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Arthritis: Treatment

by Charles Vega, MD
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    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.


    About the Lecture

    The lecture Arthritis: Treatment by Charles Vega, MD is from the course Chronic Care.


    Included Quiz Questions

    1. Affects large joints first.
    2. Symmetrical distribution.
    3. Worse symptoms in the mornings.
    4. X-rays are typically negative.
    5. As a diagnosis of exclusion, it requires negative ANA and RF serologic markers to rule out other types of arthritis.
    1. Referral to orthopedic surgeon for knee joint replacement surgery.
    2. Increase the frequency of intraarticular corticosteroid injections to every 1-2 months.
    3. Initiate long term opiate therapy.
    4. Start alternating regimen of Tramadol and high dose NSAIDs in addition to synovial fluid injections every 3 months.
    5. Evaluate for evidence of autoimmune connective tissue disease.
    1. Oral indomethacin (NSAID) therapy until the flare subsides.
    2. High dose allopurinol therapy.
    3. Colchicine and allopurinol combined therapy.
    4. Methotrexate therapy.
    5. Long term corticosteroid therapy.
    1. Start methotrexate.
    2. Avoid use of DIsease Modifying Anti-Rheumatologic Drugs (DMARDs) until symptoms interfere with daily function.
    3. First line analgesia with acetaminophen.
    4. Open a long term opiate therapy contract with the patient.
    5. Refer to specialist for biologic therapies.

    Author of lecture Arthritis: Treatment

     Charles Vega, MD

    Charles Vega, MD


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