Treatment options for rheumatoid arthritis
Eamonn Brady is a pharmacist and the owner of Whelehans Pharmacy, Pearse St, Mullingar. If you have any health questions e-mail them to firstname.lastname@example.org
This is the second of three articles on rheumatoid arthritis (RA). There are self-help activities to help your arthritis; for more information on these ask in Whelehans.
A number of RA sufferers will develop irreversible joint or tendon damage. For these, surgery can provide a return of functional ability, a decrease in symptoms and pain, and avoid deformity and disability. Typically, surgical interventions involve joint replacement (commonly hip, knee, shoulder, elbow and hand joints).
Current guidelines recommend early diagnosis and early referral (within 3 months of symptom onset) to a rheumatologist for the introduction of disease modifying anti-rheumatic drugs (DMARDs).
Although DMARDs may be introduced at time of diagnosis, they have slow onset of action and can take weeks for an improvement. Most patients will require at least initial courses of analgesics or non-steroidal anti-inflammatory drugs (NSAIDs). The need for painkillers may be reduced once the DMARDs start to exert their effect after a few weeks.
Paracetamol on its own is seldom sufficient to control acute pain in RA; however, there is evidence that regular dosing of paracetamol enhances the painkilling effects of NSAIDs in RA.
Opioid analgesics such as tramadol may be used during acute attacks of RA, especially in elderly patients who may not be able to tolerate NSAIDs. Continuous / long-term use is not recommended due to risk of addiction and cognitive impairment (eg) Memory loss, confusion, constipation, respiratory depression.
Corticosteroids such a prednisolone (Deltacortil®) are useful for managing of acute pain and have disease-modifying properties. Their efficacy diminishes over time. The preferred method of administration of corticosteroids is intra-articular injection (directly into the joint) (eg) Depo-Medrone® injection. This produces rapid symptom relief and has fewer side effects than oral corticosteroids such as stomach irritation. However, effects of intra-articular steroid injections can wear off within a month so they are not a long term solution. Where there is multiple joints involved, local injection directly into the joints is not possible, so an intramuscular injection (e.g. 120mg methylprednisolone) may be given, while waiting for DMARDs to take effect. Long-term use of even low-dose corticosteroids may result in osteoporosis and other steroid-related side effects such as weight gain, thinning skin, easy bruising and high blood pressure.
NSAIDs reduce swelling and stiffness in addition to providing pain relief. Side effects can include gastric irritation, kidney damage, fluid retention and skin reactions, as well as evidence linking selective COX-2 inhibitors (eg. Arcoxia®, Celebrex®) to increased risk of heart attack. Diclofenac should be avoided in those with health problems. Long-term use of NSAIDs is not recommended, especially in those with heart and stomach problems.
Educate yourself about your condition
Whelehans Pharmacy, in conjunction with Arthritis Ireland (Westmeath Branch) host a Rheumatoid Arthritis Information event on Wednesday Oct 12th at 6:45pm in Greville Arms Hotel Mullingar. Admission is free.
Guest speaker for the evening is Consultant Rheumatologist from Midland Hospital Tullamore, Killian O’Rourke MD MSc FRCP FRCPI. Dr O’Rourke will give first-hand information on RA along with self-help tips including information about surgery and aftercare. He will take questions from attendees.
Chartered physiotherapist Kevin Conneely MISCP of HealthStep Physiotherapy Mullingar will discuss the role of physiotherapy in Rheumatoid Arthritis (RA), such as the benefits of manual therapy, the importance of a tailored and comprehensive exercise program. The final speaker is pharmacist Eamonn Brady MPSI who will discuss medication.
To be continued….Next week
This article is shortened to fit within Newspaper space limits. More detailed information and leaflets is available in Whelehans