Treatment of Rheumatoid Arthritis and Osteoarthritis

Treatment of Rheumatoid Arthritis and Osteoarthritis.
A Guide to the General Practitioner / Family Physician

by drdoc on-line

The assessment of any arthritis disease requires clarification of the specific disease as well as assessment of the stage, activity of the disease and an assessment of function. In doing so one can assess prognosis. Thereafter therapy is aimed at symptomatic therapy, specific disease modifying therapy and rehabilitation with restoration of function.
Non-pharmaceutical therapy is applicable as an essential part of treatment, and a multidisciplinary approach is ideal. This encompasses physiotherapy, occupational therapy and education, aimed at empowering the patient to understand all aspects of a chronic disease process.

Osteoarthritis (OA) is perhaps the model degenerative disease, whilst Rheumatoid Arthritis (RA) is a classic inflammatory arthritis. Both diseases warrant symptomatic therapy, consisting of anti-inflammatory therapy and analgesic therapy. However, in addition, a disease modifying approach is applicable to both diseases, particularly for RA, where it is now demonstrated to have revolutionised treatment and improved outcome in patients.

Ideally, treatment of these diseases should occur by or in consultation with a rheumatologist, but this is not always possible for logistic reasons. The General Practitioner should be seen as part of the team, and should endeavour to acquire skills of diagnosis, and a sound understanding of disease modifying drugs and their potential side effects, and requirements for monitoring.

Non pharmacological therapy
This is provided by Physiotherapists, Nurses, Educators, Occupational therapists, Orthotists, Dieticians, Social workers, and the families and patients themselves.
The Physical Therapist plays a role in assessing function and activity and implementing a program to help pain relief initially and a rehabilitation program in the long term. Acute management includes resting or immobilising acutely inflammed joints, and maintaining joint range of movement by active movement and passive stretch exercises. Heat, laser and ultrasound provide relief to the soft tissues. Hydrotherapy plays role in mobilising and provides exercise in a non-impact, buoyant environment to restore muscle tone and power. As the joints become less inflammed, movement is encouraged with active exercises against progressive resistance.
The Occupational Therapist looks at the function of the patient in the context of their disability. They teach and provide joint protection advice. They provide assistant devices and splints. Resting Splints are used during acute phase and thereafter, serial splints are used with semi-static, resting splints progressing to dynamic splints. The use of assistant devices and education about the activities of daily living is invaluable.
The Dietician provides advice regarding a balanced diet and weight control, a major problem especially in disease of large weight bearing joints, especially in OA. There is no specific diet for arthritis. Red meat is reduced and fish and vegetable intake is encouraged. In some patients aggravation by certain foodstuffs may be noted and advice is given to avoid these in individual cases.
The Orthotist provides a vital service especially by providing orthotics, such as arch supports for ankle and subtalar disease and metatarsal domes for metatarsal disease.

Pharmacological Therapy
Symptomatic therapy is useful to relieve discomfort. However, other than helping to maintain mobility and joint range of movement, it has no influence on actual disease control or influence on outcome. Analgesia was previously seen as first line therapy in disease, but recent advances have changed the classical teaching. In RA, the early use of disease modifying drugs (DMARDs) have changed disease outcome. It is not considered sufficient to treat RA with analgesics or anti-inflammatories alone. In OA, the first line approach of analgesics has also been challenged. Evidence suggests that OA is a heterogeneous condition with significant inflammation present, and not a simple mechanical or degenerative disease. Evidence suggests that anti-inflammatories are more efficacious than analgesics in OA. Previous guidelines for therapy of OA, advocating analgesia as first line have been heavily influenced by the side effects of nonsteroidal anti-inflammatory drugs (NSAIDs). The advent of specific COX-2 inhibitor drugs have made effective, safer, use of anti-inflammatories possible, even in the higher risk elderly patient population seen in OA.