Arthritis: Treatment

00:01 Okay. Osteoarthritis is the most common kind of arthritis.

00:04 Let’s talk about treatment.

00:06 Once again, I’ve hit on the same theme.

00:08 Acetaminophen is generally less effective than NSAIDs moderately, but it's a lot safer.

00:13 That’s why it’s usually considered first-line.

00:16 It's amazing that tramadol or opiates are recommended or used for osteoarthritis because even in clinical research they really aren't very effective at all.

00:26 Sometimes not much more than placebo and less so than NSAIDs.

00:30 So, therefore, they don't have a strong role among patients with osteoarthritis.

00:35 But corticosteroid injections can help.

00:38 And this is the kind of ladder.

00:39 Start with acetaminophen and NSAIDs.

00:42 NSAIDs try to – I try to keep them – I’ll keep them high dose, but limit for the most severe types of pain.

00:48 If that fails, I’ll actually send the patient directly in for a corticosteroid injection.

00:54 Typically, it's going to be knees.

00:56 Sometimes, it’s going to be shoulder or hip.

00:59 But those injections are relatively safe.

01:01 There's very few systemic side effects.

01:04 And they can generally go for injections four times per year.

01:08 But say they're doing worse and the injections didn’t work anymore, if they’re getting only three or four weeks of improvement, then they need another injection.

01:18 We can’t do that many injections.

01:20 We can’t do 12 injections per year obviously.

01:23 Unfortunately, that’s the time to think about surgery.

01:25 So, when other treatments fail and the symptoms are limiting function, so that's the other key criteria, I think, for joint replacement would be not only is it painful, but it's painful and it limits what I'm able to normally do, think about surgery.

01:43 How about rheumatoid arthritis? How do we go about managing that? So, the treatment really is different and it’s that early initiation of DMARDs (or disease-modifying anti-rheumatalogic drugs), that's key.

01:56 We often start with methotrexate and hydroxychloroquine.

01:59 That's still effective.

02:00 Even though they are older agents, those are effective for a lot of patients with rheumatoid arthritis.

02:07 And with biologic therapies, there's a lot of different options out there.

02:13 Certainly, you want to initiate them sooner rather than later.

02:16 You don't want to let them linger on just methotrexate or hydroxychloroquine when they're progressing in terms of their disease, but choosing between them can be very complicated.

02:25 Their side effects can be complicated and, therefore, it's best left to the rheumatologist.

02:29 But don't forget, these patients are still going to have acute flares.

02:33 There's evidence that both NSAIDs and corticosteroids can be effective.

02:36 They work about equally well.

02:38 For most patients, the side effects of NSAIDs, while prominent, are less than that of corticosteroids.

02:44 So, try to stick to those.

02:47 How about gout? We haven't talked about that as much.

02:50 So, gout starts with lifestyle, avoiding foods and drinks associated with higher rates of uric acid and more gout.

03:00 Allopurinol or febuxostat, they're both effective for reducing the concentration of uric acid and, subsequently, the risk of flares of gout.

03:12 Colchicine is a second line drug.

03:14 And during flares itself, that’s not the time to initiate uric acid reduction therapy.

03:20 Treat till the exacerbation terminates with either NSAIDs or corticosteroids.

03:27 Again, they work about equally well.

03:29 So, for most patients, NSAIDs are a better choice.

03:32 So, that was a brief review of arthritis and, hopefully, you got a sense of avoiding the overuse of routine rheumatologic tests where there's going to be a lot of false positives that throw you off the track, but do use x-rays early in cases of osteoarthritis.

03:51 We talked about the ladder of treatment for osteoarthritis and the early initiation of DMARD therapy for rheumatoid arthritis.

03:58 Thanks very much.