Rheumatoid Arthritis: Clinical Significance Of Its Treatment (Drug Therapy And Surgical Correction)
A General Overview
Bed rest is essential during the acute phase of the disease. Local rest is ensured by splints which reduce muscle spasm and deformities. In the stage of deformity, splints are used as corrective measures. Physiotherapy to relieve muscle spasm and maintain joint mobility is an essential component of management during all stages of the disease.
There is no curative drug. Hence several groups of drugs are used symptomatically. Some also suppress inflammation and bring about resolution of the disease process.
- Analgesics, e.g. aspirin
- Analgesic anti-inflammatory drugs, e.g indomethacin, naproxen, ibuprofen, ketoprofen, fentiazac, mefenamic acid.
- Anti-inflammatory and immunosuppressant drugs- corticosteroids,
- Immunosuppressants like cyclophosphamide and azathioprine.
- Miscellaneous groups such as antimalarials (chloroquine), chelating agents (penicillamine), gold salts etc.
Aspirin: Aspirin being very effective and cheap is the drug of first choice in all cases. It is given as calcium aspirin or the other preparations in doses of 3- 6 g/day and an antacid is prescribed concurrently to reduce the gastric upset. This must be continued for at least two weeks before being discarded or substituted by the new drugs. Troublesome side effects include abdominal pain, upper gastrointestinal bleeding, allergic rashes, tinnitus and vertigo.
The Drugs And Their Doses
25- 50 mg three times daily
100 mg three times daily
400- 800 mg three times daily
250 mg four times daily
100 mg four times daily
200 mg two times daily
200 mg two times daily
100 mg two or three times daily
All of them share the same gastrointestinal side effects of aspirin but to a lesser degree and are indicated only when adequate relief is not obtained with rest, splinting and aspirin. They are several times more expensive than aspirin. Some of them like phenylbutazone have a great tendency to produce agranulocytosis.
Chloroquine diphosphate, 250 mg twice daily or once at bed time is effective in controlling pain, swelling and stiffness in chronic cases. The drug is to be used over long periods. It helps in suppressing the inflammatory process and prevent further deterioration. Serious side effects include retinopathy and deposition of the drug in the cornea. These are indications for stopping the drug.
These are effective in chronic cases. The common preparation is myocrisin (Sodium aurothiomalate). Treatment is started with 10 mg in the first week, 25 mg in the second week and thereafter, 50 mg weekly till a total dose of 1 g is reached. Toxic reactions to gold include dermatitis, stomatitis, nephritis, hepatitis, Stevens Johnson syndrome and bone marrow depression. Oral preparations are becoming available.
The chelating agent D. Penicillamine (Distamine, Cuprimine) in a dose of 150 to 250 mg twice or thrice a day orally is found to be very beneficial when given in chronic cases. The drug is quite beneficial in suppressing inflammation and bringing about resolution. The drug has to be continued for several months. Toxicity includes renal damage and bone marrow suppression. Gold and penicillamine should be considered when conventional therapy is not effective even after six months.
Performing A Surgery
Corticosteroids And Surgery
These are very helpful about dramatic relief in acute cases and during exacerbations. Due to their undesirable side effects, they should be employed only when other drugs fail and that too for short periods. Indications for systemic corticosteroids are:
- Active and progressive vasculitic disease;
- Severe incapacitation- corticosteroids give temporary relief and make the patient suitable for physiotherapy; and
- In severe and progressive radiological joint damage, use of corticosteroids helps to arrest the lesion and salvage the joint.
When systemic therapy is unsuccessful, intra=articular injections of cortisone acetate or triamcinolone hexacetonide may be given. In uniarticular disease, this may be advantageous. Intra-articular dose is 50- 100 mg of cortisone acetate for large joints and 5- 10 mg for small joints. After the acute symptoms are controlled, systemic therapy should be resumed.
Immunosuppressive Drugs: Drugs such as azathioprine, cyclophosphamide and chlorambucil may have to be employed in intractable cases.
Other agents that have been reported to be successful in rheumatoid arthritis are zinc salts and salazopyrine. These are still under evaluation.
When permanent joint deformities develop, surgical measures have to be employed. These help in relieving morbidity and hasten recovery. Occupational therapy, social rehabilitation and re-education constitute the remedial measures necessary in bring the cripple back to the stream of almost normal day-to-day activities.
© 2014 Funom Theophilus Makama