Presentation

Osteoarthritis

Commonly affects distal interphalangeal joints, hips, and knees
More common in elderly and women

SSx

Pain, worse w/ activity
AM stiffness < 1hr
Crepitus (Crackling of joints)
Asymmetric
Muscle atrophy
No systemic SSx
Boney spurs, visible in hands (Herberden’s and Bouchard’s Nodes)

Rheumatoid Arthritis

More common in women, no age preference
Shortens lifespan

SSx

Stiffness and muscle ache
Fatigue
Loss of Appetite
Most commonly smaller joints, but can involve elbow, shoulder, hip, knee, ankles
Symetrical
Extra-Articular SSx
- Rheumatoid nodules (most commonly in hands, elbows, and forearms)
- Vasculitis
- Pulmonary effusion and fibrosis
- Ocular inflammation
- Pericarditis
- Heart conduction abnormalities
- Feltys’
  - Splenomegaly
  - Neutropenia
- Lymphadenopathy
- Anemia
- Thrombocytosis

Dx

Apply following Dx procedure if pts have 1 joint w/ definite clinical swelling and clinical SSx are not better explained by another disease
RA if Score ≥ 6
- Joint Involvement
  - 1 medium-large joint (0 points)
  - 2-10 medium-large joints (1 point)
  - 1-3 small joints (2 points)
  - 4-10 small joints (3 points)
  - More than 10 small joints (5 points)
- Serology
  - Not positive for either RF or ACPA (0 points)
  - At least one of these two tests are positive at low titer, defined as more than the upper limit of normal but not higher than three times the upper limit of normal (2 points)
  - At least one test is positive at high titer, defined as more than three times the upper limit of normal (3 points)
- Duration of SSx
  - < 6wks (0 points)
  - ≥ 6wks (1 point)
- Acute Phase Inflammatory Mediators
  - Normal CRP and ESR (0 points)
  - Abnormal CRP or ESR (1 point)

Treatment

Osteoarthritis

Order determined partly by location
- Hip / Knee: APAP, PO NSAIDs, and Tramadol first, then others
- Hand: NSAIDS, topical capsaicin, and tramadol first

Non-Pharm
- Education
- Rest
- PT / OT
- Ice / Heat
- Wt loss
APAP and Topicals
- APAP
  - 650mg Q4H or 1000mg Q6H NTE 3-4g QD
- Diclofenac 1% Gel
  - QID
  - Pruritus, burning, and rash
  - Not for use w/ systemic NSAIDs
- Diclofenac 1.5% Solution
  - 40gtts QID 10gtts at a time
  - Smells like garlic
  - Pruritus, burning, and rash
- Glucosamine / Chondroitin
  - 500mg / 400mg PO TID
  - Slow onset, minimal evidence
  - May increase insulin resistance
- Capsaicin, Menthol / Camphor / Wintergreen Oil may help
NSAIDs
- All work, but Celebrex, Diclofenac / Misoprostol, and Naproxen / Esomeprazole prefered
- Trial for 1-2 wks for pain or 2-4 wks for inflammation
- Doses differ for pain and inflammation
- ADRs more common in high doses, elderly, PUD, Anticoagulant / Antiplatelet, and GC use
- Monitor
  - BP
  - Edema
  - BUN / SCr
  - Hgb
  - SSx of Dehydration
Opioids / Central Agents / Injections
- Tramadol
  - 25-50mg Q4-6H NTE 400mg QD
  - Terrible drug, I don’t care what the book says
- Other PO opioids at typical dose
- Monitor total dose of APAP if using combo products
- Duloxetine 30mg QD x1wk then 60mg QD if needed
  - Do not use w/ tramadol (Sz risk)
  - N / V / C
- Intra-articular GCs Q4-6mo
  - Peak pain relief in 7-10d
- Hyaluronate Injections weekly x3-5 wks
  - Max benefit in 8-12wks
Joint Resurfacing

##Rheumatoid Arthritis

Non-Pharm
- Wt reduction
- Surgery
- Splints
- PT / OT
- Rest
Adjuncts
- NSAIDs
  - Celecoxib 100-200mg PO BID
  - Does not alter disease progression
GCs
- Burst in acute flares, bridge for DMARd, low-dose chronic for hard-to-treat cases, use in extra-articular manifestations
- Not mono therapy
- Low-Dose: 10mg prednisone QD
- High Dose: 10-60 mg prednisone QD
- Intra-Articular: 10-25mg hydrocortisone q2-3mo
Traditional DMARDs
- See DMARDs for full SEs, CIs, and monitoring parameters
- Methotrexate
  - 7.5mg weekly PO or IM NTE 15-20mg
  - Onset in 1-2mo
  - Give 1 mg QD folic acid to reduce SSx
  - Teratogen, wait 3 mo after D/C before conceiving
- Leflunomide
  - 100mg PO QD x3d then 20mg QD
  - Caution if also using MTX due to hepatotoxicity
  - Onset in 1mo
  - Teratogen in males and females
- Sulfasalazine
  - 500mg BID titrated to 1g BID or TID
  - Onsets in 1-2mo
- Hydroxychloroquine
  - 200mg PO BID
  - Onset 2-4mo
  - No hepatic or renal toxicity, no myelosuppression
Biologic DMARDs
- Etanercept
  - 50mg SubQ weekly
  - Use alone or w/ MTX
  - No monitoring except initial TB test
- Infliximab
  - 3 mg/kg at 0, 2, and 6 weeks then q8wks NTE 10 mg/kg q4wks
  - Indicated w/ inadequate response to MTX alone; must use w/ MTX
  - No monitoring except initial TB test
  - Do not use in pts w/ CHF III or IV
- Adalimumab
  - 40mg SubQ every other week NTE 40mg SubQ weekly
  - Alone or in combination with other DMARDs
  - No monitoring except initial TB test
- Golimumab
  - 50mg SubQ monthly, can be administered at home
  - Use w/ MTX
- Certolizumab
  - 400mg SubQ at 0, 2, and 3 wks then 200mg q2wks or 400mg q4wks
  - Moderate to severe RA, alone or in combo with traditional DMARDs
  - No monitoring except initial TB test
- Anakinra
  - 100mg SubQ QD
  - CrCl < 30 then 100mg SubQ QOD
  - Moderate to severe RA failed previous DMARD, alone or w/ any DMARD that is not a TNF antagonist
  - Do not use w/ TNF inhibitors (Etanercept, Infliximab, Adalimumab, Golimumab, Certolizumab) or Abatacept due to infection risk
- Abatacept
  - Wt based dosing at 0, 2, and 4 wks then q4wks
  - < 60kgs: 500mg IV over 30min
  - 60-100kg: 750mg IV over 30min
  - > 100kg: 1g over 30min
  - In pts who have failed one DMARD, alone or in combination with DMARD that is not TNF antagonist or anakinra
  - No monitoring
  - Avoid in COPD
- Tocilizumab
  - 4 mg/kg IV over 1hr q4wks NTE 8 mg/kg or 800mg
  - Black box for serious infections
  - Causes lipid abnormalities
  - Use alone or in combination with DMARD after failing one DMARD
- Rituximab
  - 1g IV q2wks x2 doses
  - Can repeat q6mo
  - Pretreat w/ Methylprednisolone 100mg IV over 30min before infusion, can also give APAP and antihistamines
  - In combination with MTX, after failing TNF antagonist
  - Black Box: Fatal infusion reactions, tumor lysis syndrome, and mucocutaneous reactions
- Tofacitanib
  - 5mg PO vid or 11mg XR QD
  - Alone or in combo with other traditional DMARDs after failing MTX alone
  - Not for use w/ biologic DMARDs or azathioprine or cyclosproine
  - Do not use if Hgb < 9, ANC < 1000, or Lymphocytes < 500
Common Combinations
- MTX + HCQ, SSZ, or all three
- MTX + Leflunomide
- MTX + Biologic DMARDs

Monitoring

Osteoarthritis

Pain
Joint function
Fall risk
ROM
X-ray
ADRs
Wt
QOL

Rheumatoid Arthritis

Drug-specific monitoring
SSx