128 PART II: PRIMARY CARE DISORDERS
Management
The goals of treatment for osteoarthritis are to improve
functionandqualityoflife.Thisinvolvesbothnonphar-
macologicandpharmacologicmanagement(Table 10–1).
Nonpharmacologic management includes patient educa-
tion, physical and/oroccupational therapy, and exercise.
Pharmacologic management should be tailored to the
patienttoavoidpotentialadverseeffects.Acetaminophen
isconsideredtherst-line treatmentand shouldbepre-
scribedas1000mgfourtimesaday,nottoexceed4000
mgtoavoidpotentiallivertoxicity.Aspirinandthenon-
steroidalanti-inammatorydrugs(NSAIDs),suchasibu-
profenandnaproxen,maybeusediftolerated.Incertain
populations,suchastheelderlyandthosewithcomorbid
medicalconditions,NSAIDsshouldbeusedwithcaution
because they may cause serious upper gastrointestinal
bleeding and potential kidney toxicity. Alternatively, the
cyclooxygenase 2 inhibitor celecoxib (Celebrex) may be
used,buttherearesomepossiblecardiovascularrisksasso-
ciated with this medication. Topical analgesics, such as
methylsalicylateandcapsaicincream,maybeusedalone
or in combination with oral medications. Corticosteroid
andsodiumhyaluronateinjectionsmaybeusedtoprovide
somelocalizedpainrelief,particularlyintheknee.Systemic
steroids and narcotics should be avoided, especially in
theelderly.Analternativemedicine,glucosaminesulfate,
hasshownsomepromisetobeeffectiveinpainreliefand
possible reversalin joint damage, but studies have been
inconclusive.
1
If both nonpharmacologic and pharmaco-
logic treatments fail, the patient may be a candidate for
surgery, and a referralto an orthopedic surgeon may be
necessary.
Lifestyle Changes: Practical Tips for Your
Patients
Because there is no cure for osteoarthritis, patients
willneedtoadjusttolivingwiththecondition.Patient
educationisimportantnotonlytothepatientbutto
anyfamilyorcaregiverwhomaybeinvolved.Activi-
ties of daily living may need to be modied, which
may necessitate the involvement of an occupational
orphysicaltherapist.Patientsshouldbeencouraged
to lose weight, and a plan of exercise should be initi-
atedinvolvingbothaerobicandstrengthtraining.
Rheumatoid Arthritis
General Characteristics
Rheumatoidarthritisisasystemicautoimmuneinamma-
torydiseasecharacterizedbysymmetricalsynovitis,joint
erosions, and extra-articular manifestations. It affects 1
percentoftheadultpopulation.
3
Womenaremoreaffected
thanmen,withthepeakonsetusuallyoccurringbetween
30 and 50 years of age.
4
Most patients with rheumatoid
arthritis experience a chronic uctuating course of the
disease that, despite therapy, may result in progressive
joint destruction, deformity, disability, and even prema-
turedeath.
3
Riskfactorsfordevelopingrheumatoidarthri-
tisincludefemalegender,apositivefamilyhistory,older
age,smoking,andprevioussiliconexposure.
4
The etiology of rheumatoid arthritisis unknown,but
the pathogenesis (Figure 10–3) of the disease is being
widely studied in hopes of developing new treatment
options.Thediseaseisinitiatedbyanabnormalinamma-
tory response that causes the secretion of cytokines, such
as interleukin-1 and tumor necrosis factor (TNF)-α.
Proliferationofthesynoviumthenbeginscausingthepro-
ductionofrheumatoidfactor,leadingtothedestructionof
cartilage and bone in the joint. Rheumatoid factor is an
autoantibody response and appears early in the disease
coursein85to90percentofpatientswithin1year.
5
Signs, Symptoms, and Diagnosis
Painandswellingofthejointsarethemostcommonlyseen
symptomsinpatientswithrheumatoidarthritis.Theproxi-
mal interphalangeal joints and the metacarpophalangeal
jointsofthehandsarecommonlyinvolved,withthedistal
interphalangealjointsbeingspared,distinguishingitfrom
osteoarthritis.Otherjointsaffectedarethewrists,elbows,
shoulders,cervicalspine,knees,hips,ankles,andmetatar-
sophalangealjointsofthefeet.Thearthritisissymmetric
with a morning stiffness of longer than an hour usually
reported.Constitutionalsymptoms,suchasfever,fatigue,
andweightloss,mayalsobeseen.Onphysicalexamina-
tion, affected joints will be boggy, tender to palpation, and
warm.Ulnardeviation,swanneck,andboutonnièredefor-
mities,aswellasextra-articularmanifestations,including
rheumatoidnodules,maybeseen.Cardiopulmonaryinvolve-
mentwithcomplicationssuchaspericarditisorpleuritis
mayoccur,aswellasotherextra-articularmanifestations,
such as carpal tunnel syndrome, Sjögren syndrome, and
vasculitis.
Rheumatoid arthritis can be diagnosed clinically, but
classicationcriteriahavebeendeveloped(Table 10–2)to
helpwiththediagnosingprocess.
6
Morningstiffnesslonger
Table 10–1
Osteoarthritis Management
Nonpharmacologic:
• Patienteducation
• Physicaloroccupationaltherapy
• Exercise:Aerobicandstrengthening
Pharmacologic:
• Acetaminophen
• Aspirin
• NSAIDs:Ibuprofen,naproxen
• COX-2inhibitor:Celecoxib(Celebrex)
• Topicalanalgesics:Methylsalicylate,capsaicin
cream
• Injections:Corticosteroid,sodiumhyaluronate
• Glucosaminesulfate
• Surgery
Chapter 10: Rheumatologic Disorders 129
than1hour,swellinginthreeormorejoints,swellingin
thehandjoints,andsymmetricswellingshouldbepresent
foratleast6weekstodismissthepossibilityofsepticor
other inammatory arthritis.The other criteria are rheu-
matoidnodules,apositiveserumrheumatoidfactor, and
radiologicchangesconsistentwithrheumatoidarthritis.
Baseline laboratory tests should include a complete
blood count, rheumatoid factor, and ESR or C-reactive
protein(CRP).
4
Rheumatoidfactorispresentinapproxi-
mately80percentofpatientswithrheumatoidarthritis.
7
However, its presence or absence does not indicate that
the patient has the disease. It lacks both sensitivity and
specicityinwhichitispositivein5to10percentofthe
generalpopulationandnegativeinapproximately20per-
cent of patients with rheumatoid arthritis.
8
An elevated
ESRorCRPandamildanemiaofchronicdiseasemayalso
beseen.Synovialuid,ifcollected,willbeinammatory.
X-raysmayshowsofttissueswelling,periarticularosteope-
nia,jointspacenarrowing,andbonyerosions.
Management
Thetreatmentgoalsofrheumatoidarthritisaretoprevent
or control joint damage, prevent loss of function, and
decrease pain. Nonpharmacologic management includes
patient education; occupational and/or physical therapy,
withpossiblemodicationoftheactivitiesofdailyliving;
andanexercisecomponenttohelpwithstrengtheningand
jointrangeofmotion.
3
Pharmacologictreatment(Table 10–3)
involvesthreecomponents.Therstcomponentisusedfor
jointpainandswellingreliefandconsistsoftheNSAIDs,
such as ibuprofen or celecoxib (Celebrex). The second
component is oral corticosteroids (<10 mg prednisone
daily),whicharemainlyusedforjointpainandswelling
reliefbutmayhavesomeeffectsonslowingjointdamage.
4
Thesemedicationsshouldbeusedwithcautionduetotheir
potential side effects, such as osteoporosis, weight gain,
avascular necrosis, and elevated glucose and cholesterol.
Thethirdcomponentisthemainandmostimportantcom-
ponentfor the treatmentofrheumatoidarthritis,the dis-
ease-modifying antirheumatic drugs (DMARDs). These
Table 10–2
Classication Criteria for Rheumatoid Arthritis
Morningstiffnesslongerthan1hour
Arthritis in three or more joints
Arthritisofthehandjoints
Symmetricarthritis
Rheumatoid nodules
Rheumatoidfactor+
Radiographic changes
Source: DatafromArnettFC,EdworthySM,BlochDA,etal.TheAmeri-
canRheumatismAssociation1987revisedcriteriafortheclassication
ofrheumatoidarthritis.Arthritis Rheum. 1988;31:315–324.
Figure 10–3 Rheumatoid arthritis.
Fibrous adhesions
Inflammation of
synovium
May be irregular
bone union

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