Medical Treatment for Rheumatic Diseases
Identifieur interne : 002594 ( Istex/Corpus ); précédent : 002593; suivant : 002595Medical Treatment for Rheumatic Diseases
Auteurs : H. A. BirdSource :
- The Journal of the Royal Society for the Promotion of Health [ 1466-4240 ] ; 1990-10.
English descriptors
- Teeft :
- Arthritis, Catabolic disease, Chemical structure, Clinical trials, Daily dosing, Diseased joints, Drug therapy, Early stage, Erosion formation, Full blood, Hospital prescription, Injectable gold, Lower dose, Marrow aplasia, Normochromic normocytic anaemia, Nsaid, Occupational therapist, Regional office, Rheumatoid, Rheumatoid arthritis, Rheumatoid disease, Rheumatoid factor, Self medication, Specific indication, Thiol group.
Abstract
REST, PHYSIOTHERAPY, joint protection, patient education and counselling all play an important role alongside drug therapy and sur gery in the management of a chronic disorder such as theumatoid arthritis. Patients expect their physician to take the initiative in integrating the members of the multi-disciplinary team devoted to their care. The physician will also instigate drug therapy. In early disease, an analgesic ('for pain') may supplement a non-steroidal anti-inflammatory drug ('for stiffness'). A variety of such drugs are available with various advantages and disadvantages. For more severe, progressive disease a 'second-line' or disease-modifying drug may be prescribed. Typical examples are injectable gold, penicillamine, anti malarials, sulphasalazine and methotrexate. The pres cription of any of these represents a calculated risk: the benefits of treatment have to be balanced against the likely side-effects. A variety of intra-articular treatments are also available for providing some localisation of response and sometimes obviating the need for surgery which should be the subject of close collaboration between the rheumatologists and orthopaedic surgeons.
Url:
DOI: 10.1177/146642409011000503
Links to Exploration step
ISTEX:B42BB046CB5B7AFD9BB442E75DA806227C1F5DFCLe document en format XML
<record><TEI wicri:istexFullTextTei="biblStruct"><teiHeader><fileDesc><titleStmt><title xml:lang="en">Medical Treatment for Rheumatic Diseases</title><author wicri:is="90%"><name sortKey="Bird, H A" sort="Bird, H A" uniqKey="Bird H" first="H. A." last="Bird">H. A. Bird</name><affiliation><mods:affiliation>University of Leeds, The General Infirmary at Leeds and Royal Bath Hospital, Harrogate</mods:affiliation></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">ISTEX</idno><idno type="RBID">ISTEX:B42BB046CB5B7AFD9BB442E75DA806227C1F5DFC</idno><date when="1990" year="1990">1990</date><idno type="doi">10.1177/146642409011000503</idno><idno type="url">https://api.istex.fr/ark:/67375/M70-XWXJ2N24-K/fulltext.pdf</idno><idno type="wicri:Area/Istex/Corpus">002594</idno><idno type="wicri:explorRef" wicri:stream="Istex" wicri:step="Corpus" wicri:corpus="ISTEX">002594</idno></publicationStmt><sourceDesc><biblStruct><analytic><title level="a" type="main" xml:lang="en">Medical Treatment for Rheumatic Diseases</title><author wicri:is="90%"><name sortKey="Bird, H A" sort="Bird, H A" uniqKey="Bird H" first="H. A." last="Bird">H. A. Bird</name><affiliation><mods:affiliation>University of Leeds, The General Infirmary at Leeds and Royal Bath Hospital, Harrogate</mods:affiliation></affiliation></author></analytic><monogr></monogr><series><title level="j">The Journal of the Royal Society for the Promotion of Health</title><idno type="ISSN">1466-4240</idno><idno type="eISSN">1757-9147</idno><imprint><publisher>Sage Publications</publisher><pubPlace>Sage CA: Thousand Oaks, CA</pubPlace><date type="published" when="1990-10">1990-10</date><biblScope unit="volume">110</biblScope><biblScope unit="issue">5</biblScope><biblScope unit="page" from="157">157</biblScope><biblScope unit="page" to="160">160</biblScope></imprint><idno type="ISSN">1466-4240</idno></series></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">1466-4240</idno></seriesStmt></fileDesc><profileDesc><textClass><keywords scheme="Teeft" xml:lang="en"><term>Arthritis</term><term>Catabolic disease</term><term>Chemical structure</term><term>Clinical trials</term><term>Daily dosing</term><term>Diseased joints</term><term>Drug therapy</term><term>Early stage</term><term>Erosion formation</term><term>Full blood</term><term>Hospital prescription</term><term>Injectable gold</term><term>Lower dose</term><term>Marrow aplasia</term><term>Normochromic normocytic anaemia</term><term>Nsaid</term><term>Occupational therapist</term><term>Regional office</term><term>Rheumatoid</term><term>Rheumatoid arthritis</term><term>Rheumatoid disease</term><term>Rheumatoid factor</term><term>Self medication</term><term>Specific indication</term><term>Thiol group</term></keywords></textClass><langUsage><language ident="en">en</language></langUsage></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">REST, PHYSIOTHERAPY, joint protection, patient education and counselling all play an important role alongside drug therapy and sur gery in the management of a chronic disorder such as theumatoid arthritis. Patients expect their physician to take the initiative in integrating the members of the multi-disciplinary team devoted to their care. The physician will also instigate drug therapy. In early disease, an analgesic ('for pain') may supplement a non-steroidal anti-inflammatory drug ('for stiffness'). A variety of such drugs are available with various advantages and disadvantages. For more severe, progressive disease a 'second-line' or disease-modifying drug may be prescribed. Typical examples are injectable gold, penicillamine, anti malarials, sulphasalazine and methotrexate. The pres cription of any of these represents a calculated risk: the benefits of treatment have to be balanced against the likely side-effects. A variety of intra-articular treatments are also available for providing some localisation of response and sometimes obviating the need for surgery which should be the subject of close collaboration between the rheumatologists and orthopaedic surgeons.</div></front></TEI><istex><corpusName>sage</corpusName><keywords><teeft><json:string>rheumatoid</json:string><json:string>nsaid</json:string><json:string>rheumatoid arthritis</json:string><json:string>occupational therapist</json:string><json:string>early stage</json:string><json:string>chemical structure</json:string><json:string>marrow aplasia</json:string><json:string>rheumatoid disease</json:string><json:string>arthritis</json:string><json:string>daily dosing</json:string><json:string>rheumatoid factor</json:string><json:string>drug therapy</json:string><json:string>injectable gold</json:string><json:string>hospital prescription</json:string><json:string>specific indication</json:string><json:string>erosion formation</json:string><json:string>diseased joints</json:string><json:string>lower dose</json:string><json:string>thiol group</json:string><json:string>catabolic disease</json:string><json:string>full blood</json:string><json:string>clinical trials</json:string><json:string>normochromic normocytic anaemia</json:string><json:string>self medication</json:string><json:string>regional office</json:string></teeft></keywords><author><json:item><name>H.A. Bird M.A., M.D., F.R.C.P.</name><affiliations><json:string>University of Leeds, The General Infirmary at Leeds and Royal Bath Hospital, Harrogate</json:string></affiliations></json:item></author><articleId><json:string>10.1177_146642409011000503</json:string></articleId><arkIstex>ark:/67375/M70-XWXJ2N24-K</arkIstex><language><json:string>eng</json:string></language><originalGenre><json:string>research-article</json:string></originalGenre><abstract>REST, PHYSIOTHERAPY, joint protection, patient education and counselling all play an important role alongside drug therapy and sur gery in the management of a chronic disorder such as theumatoid arthritis. Patients expect their physician to take the initiative in integrating the members of the multi-disciplinary team devoted to their care. The physician will also instigate drug therapy. In early disease, an analgesic ('for pain') may supplement a non-steroidal anti-inflammatory drug ('for stiffness'). A variety of such drugs are available with various advantages and disadvantages. For more severe, progressive disease a 'second-line' or disease-modifying drug may be prescribed. Typical examples are injectable gold, penicillamine, anti malarials, sulphasalazine and methotrexate. The pres cription of any of these represents a calculated risk: the benefits of treatment have to be balanced against the likely side-effects. A variety of intra-articular treatments are also available for providing some localisation of response and sometimes obviating the need for surgery which should be the subject of close collaboration between the rheumatologists and orthopaedic surgeons.</abstract><qualityIndicators><score>6.924</score><pdfWordCount>2932</pdfWordCount><pdfCharCount>19352</pdfCharCount><pdfVersion>1.4</pdfVersion><pdfPageCount>4</pdfPageCount><pdfPageSize>575 x 832 pts</pdfPageSize><refBibsNative>false</refBibsNative><abstractWordCount>166</abstractWordCount><abstractCharCount>1183</abstractCharCount><keywordCount>0</keywordCount></qualityIndicators><title>Medical Treatment for Rheumatic Diseases</title><genre><json:string>research-article</json:string></genre><host><title>The Journal of the Royal Society for the Promotion of Health</title><language><json:string>unknown</json:string></language><issn><json:string>1466-4240</json:string></issn><eissn><json:string>1757-9147</json:string></eissn><publisherId><json:string>RSH</json:string></publisherId><volume>110</volume><issue>5</issue><pages><first>157</first><last>160</last></pages><genre><json:string>journal</json:string></genre></host><namedEntities><unitex><date><json:string>1990</json:string></date><geogName></geogName><orgName><json:string>Royal Bath Hospital, Harrogate ABSTRACT REST, PHYSIOTHERAPY</json:string><json:string>United Kingdom Table</json:string></orgName><orgName_funder></orgName_funder><orgName_provider></orgName_provider><persName></persName><placeName><json:string>Europe</json:string><json:string>America</json:string><json:string>Leeds</json:string></placeName><ref_url></ref_url><ref_bibl></ref_bibl><bibl></bibl></unitex></namedEntities><ark><json:string>ark:/67375/M70-XWXJ2N24-K</json:string></ark><categories><wos></wos><scienceMetrix><json:string>1 - health sciences</json:string><json:string>2 - public health & health services</json:string><json:string>3 - public health</json:string></scienceMetrix><scopus><json:string>1 - Health Sciences</json:string><json:string>2 - Medicine</json:string><json:string>3 - Public Health, Environmental and Occupational Health</json:string></scopus><inist><json:string>1 - sciences appliquees, technologies et medecines</json:string><json:string>2 - sciences biologiques et medicales</json:string><json:string>3 - sciences medicales</json:string><json:string>4 - psychopathologie. psychiatrie</json:string></inist></categories><publicationDate>1990</publicationDate><copyrightDate>1990</copyrightDate><doi><json:string>10.1177/146642409011000503</json:string></doi><id>B42BB046CB5B7AFD9BB442E75DA806227C1F5DFC</id><score>1</score><fulltext><json:item><extension>pdf</extension><original>true</original><mimetype>application/pdf</mimetype><uri>https://api.istex.fr/ark:/67375/M70-XWXJ2N24-K/fulltext.pdf</uri></json:item><json:item><extension>zip</extension><original>false</original><mimetype>application/zip</mimetype><uri>https://api.istex.fr/ark:/67375/M70-XWXJ2N24-K/bundle.zip</uri></json:item><istex:fulltextTEI uri="https://api.istex.fr/ark:/67375/M70-XWXJ2N24-K/fulltext.tei"><teiHeader><fileDesc><titleStmt><title level="a" type="main" xml:lang="en">Medical Treatment for Rheumatic Diseases</title></titleStmt><publicationStmt><authority>ISTEX</authority><publisher scheme="https://scientific-publisher.data.istex.fr">Sage Publications</publisher><pubPlace>Sage CA: Thousand Oaks, CA</pubPlace><availability><licence><p>sage</p></licence></availability><p scheme="https://loaded-corpus.data.istex.fr/ark:/67375/XBH-0J1N7DQT-B"></p><date>1990</date></publicationStmt><notesStmt><note type="research-article" scheme="https://content-type.data.istex.fr/ark:/67375/XTP-1JC4F85T-7">research-article</note><note type="journal" scheme="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</note></notesStmt><sourceDesc><biblStruct type="inbook"><analytic><title level="a" type="main" xml:lang="en">Medical Treatment for Rheumatic Diseases</title><author xml:id="author-0000"><persName><forename type="first">H.A.</forename><surname>Bird</surname></persName><roleName type="degree">M.A., M.D., F.R.C.P.</roleName><affiliation>University of Leeds, The General Infirmary at Leeds and Royal Bath Hospital, Harrogate</affiliation></author><idno type="istex">B42BB046CB5B7AFD9BB442E75DA806227C1F5DFC</idno><idno type="ark">ark:/67375/M70-XWXJ2N24-K</idno><idno type="DOI">10.1177/146642409011000503</idno><idno type="article-id">10.1177_146642409011000503</idno></analytic><monogr><title level="j">The Journal of the Royal Society for the Promotion of Health</title><idno type="pISSN">1466-4240</idno><idno type="eISSN">1757-9147</idno><idno type="publisher-id">RSH</idno><idno type="PublisherID-hwp">sprsh</idno><imprint><publisher>Sage Publications</publisher><pubPlace>Sage CA: Thousand Oaks, CA</pubPlace><date type="published" when="1990-10"></date><biblScope unit="volume">110</biblScope><biblScope unit="issue">5</biblScope><biblScope unit="page" from="157">157</biblScope><biblScope unit="page" to="160">160</biblScope></imprint></monogr></biblStruct></sourceDesc></fileDesc><profileDesc><creation><date>1990</date></creation><langUsage><language ident="en">en</language></langUsage><abstract xml:lang="en"><p>REST, PHYSIOTHERAPY, joint protection, patient education and counselling all play an important role alongside drug therapy and sur gery in the management of a chronic disorder such as theumatoid arthritis. Patients expect their physician to take the initiative in integrating the members of the multi-disciplinary team devoted to their care. The physician will also instigate drug therapy. In early disease, an analgesic ('for pain') may supplement a non-steroidal anti-inflammatory drug ('for stiffness'). A variety of such drugs are available with various advantages and disadvantages. For more severe, progressive disease a 'second-line' or disease-modifying drug may be prescribed. Typical examples are injectable gold, penicillamine, anti malarials, sulphasalazine and methotrexate. The pres cription of any of these represents a calculated risk: the benefits of treatment have to be balanced against the likely side-effects. A variety of intra-articular treatments are also available for providing some localisation of response and sometimes obviating the need for surgery which should be the subject of close collaboration between the rheumatologists and orthopaedic surgeons.</p></abstract></profileDesc><revisionDesc><change when="1990-10">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><extension>txt</extension><original>false</original><mimetype>text/plain</mimetype><uri>https://api.istex.fr/ark:/67375/M70-XWXJ2N24-K/fulltext.txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="corpus sage not found" wicri:toSee="no header"><istex:xmlDeclaration>version="1.0" encoding="UTF-8"</istex:xmlDeclaration><istex:docType PUBLIC="-//NLM//DTD Journal Publishing DTD v2.3 20070202//EN" URI="journalpublishing.dtd" name="istex:docType"></istex:docType><istex:document><article article-type="research-article" dtd-version="2.3" xml:lang="EN"><front><journal-meta><journal-id journal-id-type="hwp">sprsh</journal-id><journal-id journal-id-type="publisher-id">RSH</journal-id><journal-title>The Journal of the Royal Society for the Promotion of Health</journal-title><issn pub-type="ppub">1466-4240</issn><publisher>
<publisher-name>Sage Publications</publisher-name>
<publisher-loc>Sage CA: Thousand Oaks, CA</publisher-loc>
</publisher></journal-meta><article-meta><article-id pub-id-type="doi">10.1177/146642409011000503</article-id><article-id pub-id-type="publisher-id">10.1177_146642409011000503</article-id><article-categories><subj-group subj-group-type="heading"><subject>Articles</subject></subj-group></article-categories><title-group><article-title>Medical Treatment for Rheumatic Diseases</article-title></title-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Bird</surname><given-names>H.A.</given-names></name><degrees>M.A., M.D., F.R.C.P.</degrees><aff>University of Leeds, The General Infirmary at Leeds and Royal Bath Hospital, Harrogate</aff></contrib></contrib-group>
<pub-date pub-type="ppub"><month>10</month><year>1990</year></pub-date><volume>110</volume><issue>5</issue><fpage>157</fpage><lpage>160</lpage><abstract><p>REST, PHYSIOTHERAPY, joint protection, patient education and counselling all play an important role alongside drug therapy and sur gery in the management of a chronic disorder such as theumatoid arthritis. Patients expect their physician to take the initiative in integrating the members of the multi-disciplinary team devoted to their care.</p>
<p>The physician will also instigate drug therapy. In early disease, an analgesic ('for pain') may supplement a non-steroidal anti-inflammatory drug ('for stiffness'). A variety of such drugs are available with various advantages and disadvantages.</p>
<p>For more severe, progressive disease a 'second-line' or disease-modifying drug may be prescribed. Typical examples are injectable gold, penicillamine, anti malarials, sulphasalazine and methotrexate. The pres cription of any of these represents a calculated risk: the benefits of treatment have to be balanced against the likely side-effects.</p>
<p>A variety of intra-articular treatments are also available for providing some localisation of response and sometimes obviating the need for surgery which should be the subject of close collaboration between the rheumatologists and orthopaedic surgeons.</p></abstract><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Journal Article</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value>157 Medical Treatment for Rheumatic Diseases SAGE Publications, Inc.1990DOI: 10.1177/146642409011000503 H.A. Bird M.A., M.D., F.R.C.P. University of Leeds The General Infirmary at Leeds and Royal Bath Hospital, Harrogate ABSTRACT REST, PHYSIOTHERAPY, joint protection, patient education and counselling all play an important role alongside drug therapy and sur gery in the management of a chronic disorder such as theumatoid arthritis. Patients expect their physician to take the initiative in integrating the members of the multi-disciplinary team devoted to their care. The physician will also instigate drug therapy. In early disease, an analgesic ('for pain') may supplement a non-steroidal anti-inflammatory drug ('for stiffness'). A variety of such drugs are available with various advantages and disadvantages. For more severe, progressive disease a 'second-line' or disease-modifying drug may be prescribed. Typical examples are injectable gold, penicillamine, anti malarials, sulphasalazine and methotrexate. The pres cription of any of these represents a calculated risk: the benefits of treatment have to be balanced against the likely side-effects. A variety of intra-articular treatments are also available for providing some localisation of response and sometimes obviating the need for surgery which should be the subject of close collaboration between the rheumatologists and orthopaedic surgeons. .BARED CARE CHRONIC condition such as rheumatoid arthritis provides an excellent opportunity for the sharing of care between the general practitioner and hospital specialists who in turn will invoke the help of many paramedical colleagues. Initially, the diagnosis will be established. Features such as the persistent presence of rheumatoid factor in high titre and advancing erosions on X-ray may imply a poorer prognosis, dictating the need to move to stronger therapy early. Otherwise, initial management is likely to be conservative. If the disease becomes more aggressive, more aggressive therapy will be required to match this, probably involving the use of disease-modifying drugs. Ultimately, the disease is likely to become less active or 'burnt out', at which point rehabilitation needs will be paramount and the paramedicals, once again, will come mto their own. Based upon a lecture given at the conference on 'Rheumatic Disease' organised by the Royal Society of Health in Leeds on May 10. 1990. A well-informed patient is likely to be more compliant and the patient who has been encouraged to develop appropriate expectations is less likely to be disappointed. Many patients will go into spontaneous remission during the first two years of symptoms, allowing some cause for optimism. Otherwise, the patient should realise that there is at present no effective cure for established disease. Useful patient booklets are available from the Arthritis and Rheumatism Council and most rheumatology units delegate counselling to a trained nurse specialist or physiotherapist or occupational therapist. At an early stage, all patients should spend some time with a physiotherapist. They will be shown how to protect their joints and taught exercises that will strengthen the muscles around diseased joints in this essentially catabolic disease. Some patients benefit from applying heat to their joints and others find that cold relieves symptoms. Hot water bottles or packs of deep frozen peas respectively, both appropriately insulated, can be applied to the worst affected joints. Although there remains some doubt that these measures delay disease progression, home-spun physiotherapy of this sort will certainly allow patients a more comfortable life-style. Hydrotherapy (or swimming at the local pool) is particularly valuable when the arthritis involves large joints. A talk with an occupational therapist is also valuable, particularly for the more severely affected patients. They can be shown catalogues displaying a wide range of appliances for simple tasks around the house that prove troublesome and patients should know the location of their nearest appliance centre where they can examine and purchase a large variety of such aids. There is a danger of flexion contracture at affected joints and this should be explained to patients at an early stage. Splints may be provided to guard against such contracture. Lightweight splints might be worn at the wrist during working hours. Firmer night-rest splints, possibly made from plaster of paris, can be used at night. These splints should keep the knee fully extended with the ankle dorsiflexed at an angle of 90° with the lower leg, mimicking the optimum walking position. The evidence that such measures improve joint position remains controversial. While controversy exists, it remains more ethical to provide such splints for the patient. A variety of materials is available for 10158 splinting and local tradition will dictate whether splints are prepared by the physiotherapist or the occupational therapist. .. If the patient is overweight, the advice of a dietitian should be sought. Extra weight implies extra mechanical strain on diseased joints. Career advice and support at work are also important. In severe cases, the disablement resettlement officer may be able to advise. Patients should also see a social worker at an early stage who will be able to advise on matters of finance and housing. DRUG TREATMENT ALL DRUGS cause side effects. Their use represents a calculated gamble that the benefit obtained will outweigh the risks. Other modalities of treatment such as physiotherapy and counselling are less invasive and consideration should be given to whether such simple measures might reduce the need for drugs. Equally, the physician should not hesitate to prescribe adequate medication if the situation demands it, though a patient should be fully educated in the most rational method of dosing to avoid side-effects. Analgesics These drugs are probably unduly neglected in rheumatoid arthritis. Most patients require an analgesic for pain, taken on an 'as required' basis to supplement their background anti-inflammatory agents. Paracetamol, in a dose of up to 4.0g/day is less constipating than codeine and is probably the initial analgesic of choice. Alternatives are dextropropoxyphene and dihydrocodeine. Although compound analgesic preparations raise theoretical problems, mainly because of an inexact match between the half-lives of the component parts, many arthritics find them particularly efficacious. Co-proxamol (dextropropoxyphene plus paracetamol) is the most commonly prescribed compound analgesic preparation in the UI~ and still remains on the restricted list of analgesics advised by the DHSS. Non-steroidal Anti-inflammatory Drugs (NSAIDs) At present these have not been subject to a restricted list so many compounds are available to the prescriber. Most patients respond to one of the first four or five drugs prescribed so it is normally possible to satisfy the needs of all patients with a handful of such compounds, selected either because of variation in half-life or because of chemical structure. Each drug should be prescribed in turn with attention to adequate dosing and half-life, bearing in mind the patient's requirements. Drugs with a longer half-life require a longer trial period than those with short half-life before they are discarded as ineffective. Drugs with a short half-life include indomethacin (two hours) and ibuprofen (three hours). A drug of medium half-life is naproxen (14 hours), a drug of a long half-life is piroxicam (45 hours). Drugs with half-lives of less than four hours need to be taken four times a day. Arguably, they are most suited to prescription on an 'as required' basis, the patient anticipating the period when arthritic symptoms will be most severe and taking a short half-life NSAID one hour before this, with an expectation that it will relieve symptoms for around three to four hours. NSAIDs of medium or long half-life are more suited to regular dosing. A drug with half-life of 12 to 18 hours requires twice daily dosing and a drug with half-life of over 30 hours implies once daily dosing, either of which has been shown to improve compliance (though patients with arthritic pain rarely forget to take their drug as might occur of patients who have symptomless hypertension). Anxieties about accumulation of drugs with longer half-life have in general been unfounded. The alternative classification is by chemical structure which is perhaps more relevant to side-effects than to efficacy. Table 1 shows a classification of non-steroidal anti-inflammatory drugs by structure, indicating both generic and proprietary names. Table 1 Non-steroidal Anti-inflammatory Drugs 'Available on hospital prescription only, for the specific indication of ankylosing spondylitis All NSAIDs share certain common side-effects, most notably gastric irritation sometimes leading to peptic ulceration with the risk of subsequent perforation or gastrointestinal haemorrhage. This is because they all inhibit prostaglandin synthetase which is probably protective in the stomach. Prostaglandin inhibition ui the kidney can also cause mild drug-related re4 impairment, as judged by a fall in creatinine clearance, though in practical terms, this is much less of a problem unless the patient is also receiving anti-hypertensive drugs when there is a risk of interaction and possible loss of hypertensive control. In addition, certain groups of drugs tend to be associated with specific side-effects. Salicylic acids, particularly aspirin, cause local gastric irritation and erosion formation. Indole and Indene acetic acids may cause fluid retention and central nervous system side-effects particularly in the elderly. Sulindac may have less effect than other NSAIDs on renal function. Phenylbutazone may be associated with marrow aplasia and for this reason has been withdrawn from general, use except for the specific indication of ankylosing spondylitis on hospital prescription only. Aryl propionic acids as a group sometimes cause skin rashes though this is usually one of the less severe side-effects encountered. 11159 DISEASE-MODIFYING DRUGS THE LAST decade has seen a rapid expansion in the number of compounds for which disease-modifyng action is claimed. Injectable gold and the anti-malarials have been joined in the last 15 years by D-penicillamine, sulphasalazine and auranofin (oral gold) together with cytotoxic drugs including azathioprine and most recently, methotrexate. other less frequently used drugs include cyclophosphamide, dapsone, chlorambu- cil, levamisol and busulphan. Experimental approaches have included the use of thymic hormones, thoracic duct cannulation, captopril and rifampicin. The benefit of most of these drugs in rheumatoid arthritis has been discovered by chance and some of the earlier drugs have still not been subjected to conventional and adequate dose-ranging studies to discover optimum dosage regimes. For drugs such as penicillamine, sulphasalazine and methotrexate, the dose currently recommended is substantially lower than the dose at which the drug was first introduced, reflecting experience from a series of successive trials, each utilising a lower dose than the one before. The wide diversity of chemical structure amongst these compounds attests to the lack of understanding on the mode of action though there are certain common themes. Many drugs contain a thiol group (injectable old, D-penicillamine and captopril) whilst others azathioprine, methotrexate, cyclophosphamide) share a final common pathway of immunosuppression. Yet others are effective against infecting organisms (hydroxycholoroquine, metronidazole and sulphasalazine) though some of these compounds also have immunosuppressive and anti-inflammatory properties as well. New drugs are being synthesized by pharmaceutical companies and the next five years should see the results of controlled trials for compounds specifically aimed against rheumatoid disease including blockers of interleukin synthesis, blockers of the lipoxygenase pathway of prostaglandin synthesis and blockers of collagenase. There has also been a recent tendency to experiment with these drugs used in combination, either in parallel or in series. The use of disease-modifying drugs implies the need for adequate patient and general practitioner education and treatment is probably best initiated from hospital practice though some of the drugs such as auranofin and sulphasalazine, with less severe toxicity profiles, may be suitable for general practice use. The basic armamentarium might include injectable old, penicillamine, hydroxychloroquine, sulphasalaine and methotrexate. Injectable gold is given by weekly injections, each of 50mg after two test doses. Improvement normally occurs when the cumulative total is close to 1000mg at which point the weekly injections can be reduced to 50mg monthly. Side-effects include skin rash, proteinuria and marrow aplasia so regular urine testing and monitoring of full blood and platelet counts is mandatory. This drug is one of the slowest but arguably, most effective of the disease-modifying drugs and probably exerts its actions through its thiol group rather that through its elemental gold. D-penicillamine shares side-effects with gold but these tend to be less severe though regular urine monitoring for protein and full blood and platelet monitoring for marrow aplasia are essential. The normal maintenance therapy is 500mg/day which is reached after eight weeks, response normally occurring in three to four months. The main risk from hydroxy- choloroquine is of retinal involvement though this risk is minimal providing daily dose is kept at 200mg/day or only increased to 400mg/day for a period of up to two years. After this, or if the dose, exceptionally, needs to be increased to 600mg/day, regular ophthalmological examinations should be instituted and it is a wise precaution for all patients embarking on therapy to have a baseline ophthalmological examination. Sulphasalazine, arguably, has the least side effects. Normal maintenance of dosage is 2.Og/day though even with the use of the enteric-coated formulation (which-is essential in rheumatoid disease) up to 30% of patients have to discontinue the drug because of dyspepsia, though this can sometimes be controlled by temporarily stopping therapy and reintroducing at a slightly lower dose. The recommendation of monthly full blood counts during the first three months of treatment may err on the side of caution. Methotrexate is fast supplanting other immunosuppressive agents, particularly since clinical trials in America have shown that it remains effective in rheumatoid arthritis at doses as low as 10mg orally every week. Full blood counts are still recommended and the risk of hepatic fibrosis at this dose (the presence of which does not correlate with abnormal liver function tests) still has to be established. DRUG INTERACTION IN GENERAL, there are no interactions when analgesics are prescibed together with non-steroidal anti-inflammatory agents. It is safest not to mix analgesics (except for the prescription of those compound preparations currently available on the restricted list) because of the risk of habituation rather than the risk of interaction which is negligible. If two NSAIDs are prescribed simultaneously, the risk of interaction is greater, though where interaction occurs, normally as a result of drugs competing for protein binding sites, the clinical relevance remains uncertain. The main rheumatologi- cal interactions that trap the physician are the prescription of NSAIDs with anticoagulants and with oral antil-diabetic drugs. In both cases, there is competition for biding sites in the plasma (NSAIDs being heavily protein bound) leading to loss of anticoagulant or anti-diabetic control respectively. There are no significant interactions between NSAIDs and disease-modifying drugs which should in any case be prescribed together in view of the slow mode of action of the second line agents (though ultimately the requirement for NSAIDs may be reduced). The principal interaction for disease-modifying drugs is that between penicillamine and iron where the two chelate in the stomach if ingested simultaneously, leading to loss of circulating penicillamine and anti-rheumatoid control. Penicillamine should also be taken separately from food that contains large amounts of heavy metals. SYSTEMIC MANIFESTATIONS OF RHEUMATOID ARTHRITIS THE DISEASE initially involves the synovium proceeding to secondary changes in cartilage and bone with erosion formation at affected joints. Because the tendon sheaths have a comparable structure, tendon damage is also a problem in the early stages and a proliferative synovium may cause nerve entrapment as when the median nerve is compressed in the carpal tunnel. The disease can also affect a variety of organs within the body and the physician will need to investigate and provide symptomatic treatment where appropriate. Thus, in the heart, pericardial effusion and nodule 12160 formation in the myocardium leading to conducting defect can both occur. In the lungs, isolated rheumatoid nodules can mimic tuberculous or neoplastic lesions and pleural effusion may occur. A widespread vasculitis can cause skin rash and peripheral neuropathy. Felty's Syndrome is splenomegaly with neutope- nia in association with rheumatoid arthritis and Cap- lan's Syndrome is rheumatoid arthritis associated with pneumoconiosis. In the haemopoietic system, the normochromic normocytic anaemia of rheumatoid disease needs to be distinguished from the hypochromic microcytic anaemia associated with gastrointestinal blood loss from NSAIDs. The estimation of serum iron, iron binding capacity and serum ferritin may help distinguish the two though some patients with a normochromic normocytic anaemia, particularly those with a low ferritin, benefit from iron supplements. Initially these should be given orally though if there is no response, intramuscular injections of iron preparations may be required. The thrombocytosis of untreated rheumatoid disease often responds to the introduction of disease-modifying drugs and a fall in platelet count, together with a rise in haemoglobin concentration, are both good indices of response. A variety of systemic parameters in the blood can be used to monitor disease progression. These include a raised ESR and a raised plasma viscosity (both of which fall with disease response). Acute phase proteins, produced by the liver, which fall as the disease comes under control, together with the serial titre of rheumatoid factor, provide additional methods for the physician to monitor progress. Rheumatoid arthritis is a catabolic disease associated with tiredness for which periods of rest and pacing of activities may be required. patients understandably become depressed and occasionally need anti-de~res-' sant drug support though side-effects from the tncylic anti-depressants such as a dry mouth, can summate with the dry mouth caused when rheumatoid arthritis is complicated by Sjogren's Syndrome (keratoconjunctivitis sicca) as a result of lymphocytic infiltration of salivary and lacrimal glands. Rheumatoid arthritis is associated with a slightly increased incidence of infection, particularly in the joint and may be associated with some reduction in longevity. LOCAL CORRECTIVE JOINT THERAPY IF THE rheumatoid disease is pauci-articular or if a single joint is causing particular problems compared to the others, local treatment may be more appropriate. This may be surgical (de-compression of nerves or synovec- tomy) or medical when the judicious use of intra-articular or intra-lesional injection may postpone the need for surgery, sometimes indefinitely. The choice amongst steroids is now wide ranging from hydrocortisone (the most soluble but least effective), through the prednisolone salts (with prednisolone t-butylacetate the most consistently effective in clinical trials) to the depot preparations (methylprednisolone) and the even more effective fluorinated preparation triamcinolone (the, least soluble and most potent of all). The risks of injudicious steroid use include tendon rupture if the injections are misplaced into the substance of tendons rather than their synovial sheaths, local joint infection and the slight and mainly theoretical risk of cartilage damage if too many injections are given to a single joint in rapid succession. This risk has to be balanced against the damage that would accrue if the joint was left untreated. "Failed injection treatment" implies the need to refer to an orthopaedic surgeon since joint replacement therapy is now available and satisfactor 'I for an ever increasing number of joints. As the patient embarks on a programme of surgery, it behoves the physician to ensure that the general medical condition is satisfactory and that the anaesthetist is warned of the risk of atlanto axial subluxation if an X-ray of the cervical spine prior to operation reveals substantial joint damage. The physician may also be requested to organise post-operative convalescence, particularly if more than one joint has been replaced. The increased capacity for exercise sometimes places additional strain on intact joints. In an age of increasing specialisation, it is now not uncommon for a single patient to pass through the care of several orthopaedic surgeons, each operating on the joint that falls within their own area of expertise. In this Situation, the rheumatologist tends to fill a co-ordinat- ing role in deciding the order of surgical priorities.</meta-value></custom-meta></custom-meta-wrap></article-meta></front></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Medical Treatment for Rheumatic Diseases</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>Medical Treatment for Rheumatic Diseases</title></titleInfo><name type="personal"><namePart type="given">H.A.</namePart><namePart type="family">Bird</namePart><namePart type="termsOfAddress">M.A., M.D., F.R.C.P.</namePart><affiliation>University of Leeds, The General Infirmary at Leeds and Royal Bath Hospital, Harrogate</affiliation></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="research-article" authority="ISTEX" authorityURI="https://content-type.data.istex.fr" valueURI="https://content-type.data.istex.fr/ark:/67375/XTP-1JC4F85T-7">research-article</genre><originInfo><publisher>Sage Publications</publisher><place><placeTerm type="text">Sage CA: Thousand Oaks, CA</placeTerm></place><dateIssued encoding="w3cdtf">1990-10</dateIssued><copyrightDate encoding="w3cdtf">1990</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><abstract lang="en">REST, PHYSIOTHERAPY, joint protection, patient education and counselling all play an important role alongside drug therapy and sur gery in the management of a chronic disorder such as theumatoid arthritis. Patients expect their physician to take the initiative in integrating the members of the multi-disciplinary team devoted to their care. The physician will also instigate drug therapy. In early disease, an analgesic ('for pain') may supplement a non-steroidal anti-inflammatory drug ('for stiffness'). A variety of such drugs are available with various advantages and disadvantages. For more severe, progressive disease a 'second-line' or disease-modifying drug may be prescribed. Typical examples are injectable gold, penicillamine, anti malarials, sulphasalazine and methotrexate. The pres cription of any of these represents a calculated risk: the benefits of treatment have to be balanced against the likely side-effects. A variety of intra-articular treatments are also available for providing some localisation of response and sometimes obviating the need for surgery which should be the subject of close collaboration between the rheumatologists and orthopaedic surgeons.</abstract><relatedItem type="host"><titleInfo><title>The Journal of the Royal Society for the Promotion of Health</title></titleInfo><genre type="journal" authority="ISTEX" authorityURI="https://publication-type.data.istex.fr" valueURI="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</genre><identifier type="ISSN">1466-4240</identifier><identifier type="eISSN">1757-9147</identifier><identifier type="PublisherID">RSH</identifier><identifier type="PublisherID-hwp">sprsh</identifier><part><date>1990</date><detail type="volume"><caption>vol.</caption><number>110</number></detail><detail type="issue"><caption>no.</caption><number>5</number></detail><extent unit="pages"><start>157</start><end>160</end></extent></part></relatedItem><identifier type="istex">B42BB046CB5B7AFD9BB442E75DA806227C1F5DFC</identifier><identifier type="ark">ark:/67375/M70-XWXJ2N24-K</identifier><identifier type="DOI">10.1177/146642409011000503</identifier><identifier type="ArticleID">10.1177_146642409011000503</identifier><recordInfo><recordContentSource authority="ISTEX" authorityURI="https://loaded-corpus.data.istex.fr" valueURI="https://loaded-corpus.data.istex.fr/ark:/67375/XBH-0J1N7DQT-B">sage</recordContentSource></recordInfo></mods><json:item><extension>json</extension><original>false</original><mimetype>application/json</mimetype><uri>https://api.istex.fr/ark:/67375/M70-XWXJ2N24-K/record.json</uri></json:item></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
EXPLOR_STEP=$WICRI_ROOT/Sante/explor/ChloroquineV1/Data/Istex/Corpus
HfdSelect -h $EXPLOR_STEP/biblio.hfd -nk 002594 | SxmlIndent | more
Ou
HfdSelect -h $EXPLOR_AREA/Data/Istex/Corpus/biblio.hfd -nk 002594 | SxmlIndent | more
Pour mettre un lien sur cette page dans le réseau Wicri
{{Explor lien
|wiki= Sante
|area= ChloroquineV1
|flux= Istex
|étape= Corpus
|type= RBID
|clé= ISTEX:B42BB046CB5B7AFD9BB442E75DA806227C1F5DFC
|texte= Medical Treatment for Rheumatic Diseases
}}
| This area was generated with Dilib version V0.6.33. |  |