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Osteoarthritis AND Rheumatoid Arthritis IN Practice

Applied Practice (University of Sunderland)

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OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS IN PRACTICE

Osteoarthritis Rheumatoid Arthritis

Characterised by loss of articular Chronic, progressive, systemic
cartilage and formation of new bone at inflammatory disorder principally
joint margins (osteophytes) affecting synovial joints
Commonly involves knee, hips, small Commonly involves hands, wrists,
hand joints, neck and lower back ankles and toes
Systemic disease Local joint destruction

Osteoarthritis
Risk Factors:
- Increasing age
- Female sex
- Family history (genetic factors)
- Congenital joint abnormalities
- Joint injury
- Prolonged overuse
- Occupation
- Obesity
- Disease that alter normal structure and function of joints e.g. RA, gout
Non-Pharmacological Management:
- Lifestyle e.g. weight loss, exercise, balance activity/rest
- Hot/cold therapies
- Physiotherapy
- Aids/devices e.g. braces, joint supports, insoles, TENS
- Surgery
Pharmacological Management i.e. optimal pain control:
- Paracetamol (first line) – take regularly
- Topical NSAID ahead of oral NSAIDs, COX2 inhibitors or opioids:
 Topical NSAID first line then
 Ibuprofen 400mg TDS (lowest CV and GI risk) then
 Diclofenac/Naproxen (CV vs GI risk)
 N.B. consider renal function and other medications patient is on
 Co-prescribe PPI
- Adjunctive therapies:
 Topical capsaicin for knee and hand OA
 Intra-articular steroids for moderate-severe pain
- Do not offer glucosamine, chondroitin or intra-articular hyaluronan injections

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Rheumatoid Arthritis

Management of Associated Conditions:

Sjörgrens syndrome
- Lubricating eye drops/ointments
- Artificial saliva replacement
Vasculitis
- Steroids
- Cyclophosphamide
Increased cardiovascular risk
- Assessment e.g. QRISK and appropriate medication initiation
Increased osteoporosis risk
- Assessment e.g. FRAX (+/- DXA) and appropriate medication initiation

RA can result in physical disability – help patients manage this via:

- Easy to open containers
- Supportive cutters
- Occupation therapists (support patients to maintain independent living)

General Advice - Vaccinations:

Immunosuppressive therapy e.g. leflunomide, methotrexate, biologics more likely to
suffer clinically significant infections
- Flu, pneumococcal recommended
- Avoid live vaccines (give 2-4 weeks before starting immunosuppressive where
possible)

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- Avoid contact with chicken pox/shingles/measles

- Ensure household contacts immune to measles: offer MMR
- Significant contact with chicken pox: VZ immunoglobulin can be given within 7
days of contact
- Measles: urgent measles IgG testing
For biologics, reactivation of latent TB is a particular concern; all patients should be
screened before commencing therapy
Initial Pharmacological Treatment
- Monotherapy (ASAP)
- Oral MTX, leflunomide or sulfasalazine (Hydroxychloroquine alternative)
- Consider bridging treatment with oral/IM/IA glucocorticoids with initiating
DMARD
If target (ideally remission or low disease activity) not reached, increase dose.
Still not sufficient, add second DMARD.
Inadequate response to conventional DMARDs: biologics (or JAK inhibitors) in
combination with MTX
General Points regarding DMARDs:
- Not analgesics, take weeks/months to work
- Most have a significant side effect profile
- Regular blood tests
- Patient counselling of recognition and awareness of signs/symptoms of
serious adverse effects
- Infections: if patient has an infection that requires antibiotic,
immunosuppressive agents (e.g. MTX) usually stopping until infection has
cleared
- Pregnancy: MTX and Leflunomide are C/I, AZA and Hydroxychloroquine –
benefit outweighs risk if these are used
MTX and NSAIDs:
- NSAIDs reduce renal excretion of MTX therefore increased risk of toxicity
- Avoid inappropriate clinical use of NSAIDs e.g. post-surgical pain relief, OTC/
self-medication
- Benefit may outweigh risk for RA pain control; some patients find it difficult to
manage without therefore commonly used for THIS indication in practice
- Monitoring of bloods and awareness of signs/symptoms of
haem/liver/pulmonary toxicity
MTX Counselling
Seek medical attention (same day):
- Unexplained shortness of breath and dry cough (can occur gradually or over a
few days)

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- If whites of eyes become yellow or you develop severe itching

- You have fever, chills or severe sore throat/mouth
- You have severe mouth ulcers, bleeding gums, bruising or skin ulcers
- You experience severe sickness or upset stomach
- If you have never had chickenpox and come into close contact with someone
who has chickenpox or shingles
- You think you/your partner have become pregnant whilst on treatment

MTX Rescue Therapy

- Acute toxicity with MTX may require folinic acid (given as calcium folinate)
rescue therapy
- Folinic acid counteracts anti-folate activity of MTX, speeds recovery of
myelosuppression/mucositis etc.
- Granulocyte-colony stimulating factors (G-CSF) e.g. SC filgrastim may be
considered if severe neutropenia (specialist)
- Fluid & electrolyte balance, blood products etc.

Leflunomide
- Dose: 100mg OD for 3 days then 10-20mg OD (most patients do not get
loading dose as poorly tolerated
- C/I in liver impairment or hypoproteinaemia
- Monitoring: blood tests, BP and weight monitoring
- Interactions: increased risk of toxicity with MTX, caution with phenytoin,
warfarin and tolbutamide

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Leflunomide Wash-out
- In case of serious event or before conception
- Colestyramine 8mg TDS for 11 days (or activated charcoal 50g QDS for 11
days)
- Can measure concentration of active metabolite (should be < 20 microg/L on
two occasions, two weeks apart)
Hydroxychloroquine
- Dose: 200mg OD or BD (depending on weight – max 6.5mg/kg IBW)
- Side effects: GI disturbances, headache, skin reactions, ocular disturbances
- Caution in epilepsy, severe GI disorders, may exacerbate psoriasis
- Assess renal/liver function before therapy but no routine blood monitoring
(unlike other DMARDS)
- Visual acuity tested annually; referral to ophthalmologist if any ocular
problems occur e.g. reduced vision
- Interactions: amiodarone, moxifloxacin (increased risk ventricular arrthymias),
digoxin (increased dig level), ciclosporin (increased ciclo levels), some
antimalarials
Sulfasalazine
- Dose: 500mg OD 7/7, 500mg BD 7/7, 1g OM and 500mg ON 7/7, 1g BD (can
go up to 3g OD if needed)
- Usually EC, take with water, swallow whole
- Can turn urine and tears orange coloured and soft contact lenses can be
stained yellow
- Side effects: nausea, diarrhoea, stomach upset, dizziness, headache, skin
rash
- Bloods: FBC, LFTs, U&E – regularly in first two years
- Haematological/liver toxicity: report unexplained cough, breathlessness,
abnormal bruising/bleeding, severe sore throat, severe
nausea/dizziness/headache, unexplained acute widespread rash, oral
ulceration
Steroids
- May be used to bridge therapy during flare (but reduce/stop where possible)
- Reduces inflammation, suppresses symptoms
- Oral: prednisolone OM CC
- Steroid injection (IM/IA): not given more often than once per year
- Long term risks:
 Osteoporosis
 Diabetes
 Weight gain
 Fluid retention
 High BP
 Stomach ulcer (infection risk)

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Biologics
Anti-TNF drugs:
- Adalimumab (SC), Etanercept (SC), certolizumab pegol (SC), golimumab
(SC)
- Infliximab (IV), Others
Others
- Rituximab (IV), tocilizumab (IV), abatacept (IV/SC), sarilumab (SC)
- Anakinra (SC- not recommended unless part of a clinical trial)

N.B. most SC products delivered to patients via Homecare service for injection at
home, IV infusions usually given hospital day unit
- Not painkiller
- Use anti-TNFs in combination with MTX; if intolerant of MTX, some can be
used as monotherapy
- Side effects: infection risk, often withheld for surgery (2 weeks before and
after), reactivation of TB is a concern (screen all patient before initiation)
Biosimilars
- Exists for infliximab, etanercept, rituximab and adalimumab (2018)
- Cost saving, increasing use
- Similar to existing biologics but not exactly the same (large molecules so note
that even within biologic batches there will be some variation)
- NICE guidance applies to biosimilars that have a MA allowing the use of the
biosimilar for the same indication
JAK inhibitors
- Oral immunomodulatory drugs
- E.g. Tofacitinib, Baricitinib
- Can be used according to NICE guidance if severe disease activity if criteria
met
- Withdraw after 6 months if insufficient benefit

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