THM1) The three most commonly used disease modifying drugs for rheumatoid arthritis are methotrexate, HCQ and sulfasalazine. One or more can be used at a time. Though traditionally not considered disease modifiers, steroids in a low dose may retard progression of bone erosions enhancing the effect of DMARDs.
Methotrexate is usually the 1st choice DMARD because of its relatively rapid onset of action & tolerability. Maximum improvement occurs after 6 months of treatment. Methotrexate use should be monitored by doing CBC, SGOT, and SGPT periodically. HCQ is a weaker DMARD & is usually combined with methotrexate or sulfasalazine.
THM2) Ankylosing spondylitis should be thought of only if a young patient (<40 years) presents with insidious onset, chronic (>3 months) low-back pain with morning stiffness in the back which improves with activity. HLA B27 is positive in 90% of patients with AS.
THM3) Fibromyalgia is an under-diagnosed condition that can be recognized by looking for the characteristic tender points. Drugs used with partial success include amitriptyline, pregabalin & duloxetine.
THM4) In an osteoarthritic patient, the use of a walking stick in the hand opposite to the affected knee or hip joint can help reduce weight-bearing on the affected side. Each kilogram of body weight increases the loading across the knee six fold. Hence a substantial weight loss may lessen the symptoms of knee OA. Paracetamol is the drug of choice for symptomatic relief of OA pain. Dose up to 4gm/day may be used on a long-term basis.
THM5) NSAID use can cause elevation of blood pressure, especially in hypertensive patients, even with a short course.
THM6) COX 2 inhibitors (like etoricoxib) as compared to other NSAIDs
a) have significantly lesser GI side effects
b) have similar nephrotoxicity or worsening of asthma
c) have similar ability to cause fluid retention & hypertension
d) increase the risk of MI & stroke especially in high doses
THM7) In patients with recurrent gout, long term therapy can be with allopurinol (Zyloric) if urinary uric acid is >800 mg/24 hours & otherwise with daily colchicine (Goutnil); both can be given for life. Febuxostat (40 to 120 mg) is a xanthine oxidase inhibitor which has lesser cutaneous side effects than allopurinol.
THM8) In rheumatologic disorders, stiffness in inflammatory diseases is worse at rest. This explains the morning stiffness of RA. On the other hand, the stiffness in degenerative diseases is worsened by exertion. Thus the pain of knee osteoarthritis is more after walking.
THM9) Think of SLE if a female patient comes with more than 1 of these –
- Malar rash
- Discoid rash
- Oral ulcers
- Pleuritis or pericarditis
- Proteinuria or cellular casts.
If SLE is suspected ANA is the best screening test.
THM10) Poncet’s disease is an acute polyarthritis (probably reactive) that occurs in patients with visceral/pulmonary TB. The joints are not infected with tuberculosis. Another cause of polyarthralgia in a patient with tuberculosis is pyrazinamide. Here the cause is hyperuricemia and the symptoms don’t respond to colchicine.
THM11) Zoledronate (5mg IV once a year) is the most potent bisphosphonate available and may become popular as the first-line treatment for fracture prevention. Cost of Indian brands is about 2800/-. Side effects include flu-like symptoms.