Musculoskeletal and rheumatic complaints account
for approximately 15% of the patients seen by primary care physicians.
These complaints include muscle pain and weakness, regional pain
syndrome such as back or neck pain, rheumatoid arthritis, gout,
ankylosing spondylitis and lupus erythematosus among others.
Rheumatologists are specialists in the diagnosis and management of
musculoskeletal disorders having completed three years of training in
the broad field of internal medicine and a two year fellowship in
Rheumatoid arthritis is a systemic disorder
characterized by female predominance. It is persistent, symmetric and
may be associated with systemic features such as fatigue, weight loss
and anemia. 70 - 80% of patients with rheumatoid arthritis are positive
with rheumatoid factor (an antibody against IgM). Most patients also
have an elevated sedimentation rate.
Medications are useful in managing inflammation
associated with rheumatoid arthritis. The first compounds employed are
either salicylates or other nonsteroidal anti-inflammatory drugs. These
medications exert their anti-inflammatory action by modifying
prostaglandin metabolism. They are used as initial therapies. All
share common toxicities including stomach upset, liver function
abnormality, renal dysfunction and fluid retention. About 1 - 2% of
people who take aspirin or other nonsteroidal anti-inflammatory drugs
may have peptic ulceration.
In those patients who cannot be managed with
aspirin or other nonsteroidal anti-inflammatory drugs, medications such
as golden injections, Plaquenil, penicillamine and Methotrexate are
employed in an attempt to modify the course of the disease.
Gold is a remittive agent that can prevent disease
progression. It is generally given by injection but can be taken
orally. It has some common toxicities including skin and mucous
membrane problems. About 1% of patients get kidney or blood problems
related to gold injections and/or oral ingestion.
Careful monitoring of gold therapy is very
important in patients with rheumatoid arthritis. During the duration of
the therapy complete blood counts, platelet counts and urinalyses must
be done at the time of each injection. After a prolonged period of time
without toxicity monitoring may be done every other injection. If
severe blood reactions and/or kidney problems develop then medication
should be discontinued.
Plaquenil or hydroxychloroquine is an anti-malarial
agent with anti-inflammatory properties in rheumatoid arthritis. Like
gold it is used in those patients who fail to respond to a conservative
regimen including rest, salicylates and/or other nonsteroidal anti-
inflammatory drugs. These are given orally. Ophthalmologic monitoring
is necessary to check for visual loss at an early reversible stage.
Patients should be seen by their eye doctors a minimum of once a year.
This therapy should be discontinued if any eye problems are related to
Penicillamine has been shown in controlled studies
to be effective in reducing inflammatory arthritis such as rheumatoid
arthritis. It is given orally. Like gold it may be associated with a
variety of problems including skin and mucous membrane problems, blood
disorders and/or kidney problems. It must be carefully monitored.
Complete blood counts, platelet counts and urinalyses should be done
monthly for the first six months of therapy and every other month
thereafter. Laboratory data is essential to permit early detection of
problems with the blood and/or kidneys.
Corticosteroids are among the most potent of the
anti-inflammatory agents. However they have a high incidence of
toxicity and may not change the course of rheumatoid arthritis. They
should only be used in patients with activie synovitis in many joints.
These medications are useful in incapacitating constitutional symptoms
such as fever, anemia, wieght loss, neuropathy and vasculitis (blood
Prednisone is the preferred agent because of its
cost and low potential for fluid retention. Tablets are available in 1
mg and 5 mg dosages. All patients should be educated about the side
effects of corticosteroids. Informed consent is most inportant in their
Methotrexate is a new usage of a very old
medication. In general it is given by "modified pulse" with 3 to 9
tablets administered weekly. Methotrexate should only be given by those
physicians who are knowledgeable and experienced in its usage. The use
of Methotrexate involves periodic monitoring for toxicity. Monitoring
should include complete blood counts with differential and platelet
counts. It should also involve liver and renal function tests.
Patients who are at increased risk for impaired Methotrexate elimination
(i.e., patients with kidney problems) should be monitored more
Methotrexate may be associated with a variety of
problems including liver toxicity, lung problems, mouth ulcers, stomach
pain, etc. Liver biopsies may be necessary if there is a question about
the degree of Methotrexate liver toxicity and continuation of this drug.
Rheumatoid arthritis is a manageable disorder is
patients who are treated by rheumatologists and/or experienced internal
medicine physicians. With proper education, exercise and medications
many patients may expect to lead fairly normal lives. The goals of
treatment are to maintain joint function and to prevent deformity.
Medications are available for this purpose. However, they must be used
by physicians who are knowledgeable about their use and employ the
proper monitoring techniques.
Physicians who use these medications in patients
with rheumatoid arthritis must be aware of the strong possibility of
serious side effects. All the ramifications of treatment should be
duscussed with the patient prior to initiation of these medications.
Patients using these medications should be under constant physician
* This article is presented and copyrighted by The 'Lectric Law Library
and Dr. Steven E. Lerner & Associates (www.drlerner.com)