Lectures on joint diseases and treatment

2021-08-13 06:15 PM

Anti-inflammatory drugs should be used with caution in patients with a history of epigastric pain, a history of allergies, nephritis and liver failure, the elderly, and pregnant women

Approaching patients with arthritis

History and physical examination are important for patients with rheumatic diseases, and laboratory and radiographic studies are often only supportive.

Optimal treatment for patients with joint disease requires a combination of skills and disciplines: rheumatologist, orthopedic surgery, physical therapy... aiming at pain relief, anti-inflammatory, maintain joint function and limit disability.

Classification of joint diseases

Diseases of the affiliated organization

Rheumatoid arthritis.

Juvenile arthritis.

Systemic lupus erythematosus.

Scleroderma.

Polymyositis/dermatomyositis.

Necrotizing vasculitis.

Sjogren's syndrome.

Duplicate syndrome (Mixed connective tissue disease).

Other autoimmune diseases.

Arthritis associated with spondylitis

Ankylosing spondylitis.

Reiter's syndrome.

Psoriatic arthritis...

Arthritis is associated with inflammatory bowel disease.

Reactive arthritis.

Osteoarthritis

Infectious joint disease

Direct.

Indirect.

Metabolic joint disease

Crystal arthritis.

Biochemical abnormalities.

Certain congenital metabolic abnormalities.

Endocrine disease.

Immune-deficiency diseases.

Proliferative disease

Vascular neuropathy

Combined bone and cartilage disease

Extra-articular disorder

Other disorders

Treatment

Internally medical treatment

Anti-inflammatory pain relievers:

Acetaminophen pain relievers: good pain relief, few side effects, a dose of 650mg every 4 hours.

Anti-inflammatory drugs: cyclooxygenase (COX) inhibitors, all of which have anti-inflammatory effects especially when used in high doses.

Salicylate (Aspirin and other Salicylate derivatives):

Aspirin (Acetylsalicylic acid): 100, 300, 500mg tablets; herbal medicine 50, 100mg.

Sodium salt.

Lysine salt.

Other non-steroidal anti-inflammatory drugs:

Classification of drugs according to chemical groups:

The pyrazole group:

Phenylbutazone.

Indol group:

Indomethacin (Indocid).

Group anthranilic:

Acid flufenamic.

Acid mefenamic.

Acid niflumic (Nifluril).            

Phenyl propionic group:

Ibuprofen (Bufen).

Ketoprofen (Profénid, Biprofenid).

Other types:

Tiaprofenic (surgram, Tiafen).

Phenylacetic: Diclofenac (Voltaren).

Phenothiazin: Métiazinic...

Oxicam: Piroxicam (felden), Tenoxicam (tilcotil), Meloxicam (Mobic) (selective inhibitor on COX2).

Nimesulide (selective COX2 inhibitor).

Celecoxib (selective COX2 inhibitor).

Some general guidelines for the use of anti-inflammatory drugs:

The drug with the least side effects should be started at the beginning and with low to high exploratory doses to probe until the maximal effect is achieved or maximal dose is reached.

If a high dose attack should only last 5-7 days, it is recommended to use the injectable form

With oral drug form: should be taken immediately before eating to avoid irritation of the gastric mucosa. Gastroprotective drugs should be used if there are signs of irritation (Misoprostol, a synthetic methyl agonist of Prostaglandin E1, which reduces the risk of NSAID-induced peptic ulcers but can cause diarrhea and miscarriage or oral administration). famotidine 40 mg twice daily, or omeprazole 20 mg once daily)

In addition to the injection and oral route, it is recommended to use the drug in the form of anal or external tablets, less causing complications

Anti-inflammatory drugs should be used with caution in patients with a history of epigastric pain, a history of allergies, nephritis and liver failure, the elderly, and pregnant women.

Complications (side effects) that need to be monitored when taking the drug:

Stomach: stomach pain, abdominal pain, dyspepsia, gastrointestinal bleeding, gastric perforation (selective COX2 inhibitors have little gastrointestinal side effects, but increase the risk of solid myocardial infarction. especially rofecoxib)

Kidney: nephritis, oliguria and edema, may cause hematuria and severe renal failure

Skin and allergic reactions: from mild pruritus to severe toxic dermatitis, allergic asthma attacks

Blood: agranulocytosis, hemorrhage, marrow failure (pyrazole group)

Liver: some drugs can cause hepatitis and liver failure

Prolong pregnancy.

Pay attention to drug interactions when taking with other drugs:

May increase the effect of some drugs: anticoagulants, insulin, sulfamide...

May reduce the effect of some drugs: digitalis, meprobamate, androgen.....

Do not use a combination of many anti-inflammatory drugs at the same time because it will increase the risk of complications (gastrointestinal, allergic, kidney).

Corticosteroids:

Mechanism of action:

Inhibits antibody production.

Inhibits leukocyte migration and concentration hinders phagocytosis.

Limit the release and promote the effect of digestive enzymes.

Inhibits the synthesis of prostaglandins from membrane phospholipids.

The above effects are only temporary and do not last long. Therefore, the anti-inflammatory effect of the drug is very rapid and obvious, but the disease also recurs immediately after stopping the drug, does not prevent the progressive destruction of joints, the drug has many side effects and complications, especially when used in high doses. and long.

Specified:

Chronic arthritis after using other drugs without effect.

Some specific diseases such as: acute rheumatic fever tend to inflammation of the heart.

Colloidal diseases.

There are 2 routes of use: systemic route (oral, injection) and local route.

Rules for using steroids:

Dosage: take prednisolone as standard (prednisolone 20mg # prednisone 20mg # methyl prednisone 16mg)

Low dose 5 - 20mg/24 hours.

The average dose is 20-30mg/24 hours.

High dose 1-2mg/kg body weight/day.

Drink once in the morning.

Can be taken every other day with a higher dose.

Intramuscular every 6-15 days (slow-release type).

Use high doses for 5-7 days and then gradually reduce the daily dose from 1 to 5mg. Maintain with a dose of 5mg less likely to cause complications

The drug should never be stopped abruptly when taking high and medium doses, the dose should be gradually reduced and then stopped.

Monitor closely while taking the drug because of many complications.

Side effects of steroids:

Metabolic disorder.

Water and salt retention causes edema.

Potassium loss: fatigue, mild paralysis, cardiac arrhythmia.

Increased blood sugar.

Increased protein catabolism in the body is manifested by osteoporosis, muscle atrophy at the extremities, skin atrophy and stretch marks, and long-healing scars.

Aseptic necrosis of the femoral head; disorders of bone development in children.

Cushing's syndrome: red round face, fat body, stretch marks, hirsutism.

Infections: acute bacterial infections due to reduced immunity (pneumonia, shingles, sepsis); Tuberculosis, especially pulmonary tuberculosis, develops.     

Excited-state of insomnia, tremor, eating a lot.

Glaucoma, possibly glaucoma attacks.

Presence of delusions and depression.

Complications due to drug discontinuation:

Acute adrenal insufficiency due to abrupt discontinuation without gradual dose reduction  

A relapse after stopping the drug (drug dependence)

Drug treatment according to the cause, locality, pathogenesis:

Medications to treat the cause:

Use of antibiotics (germ arthritis, rheumatic heart disease).

Medicines for Gout.

Drugs and treatment methods according to location and pathogenesis:

Synthetic antimalarials:

Hydroxychloroquine: used to treat rheumatoid arthritis, juvenile chronic arthritis, collagen disease: 200mg x 2 times/day x 6 months. Then continue to take 200mg/day if effective. 

Side effects: Gastrointestinal disturbances, corneal clouding, retinitis, darkening of the skin (need to check eyes every 3 months).

Gold salt: Used in rheumatoid arthritis (monitoring of urine, blood count and liver function).

Sulhydryl derivatives: 3 drugs are used:

D. penicillamine (dimethyl cysteine: Trolovol) v 125, 250mg dose 250mg once a day, maximum 1000mg/day.

Pyrithxin (Encephabol): less effective D. penicillamine but less adverse effects.

Tiopronin (Acadion) effects and side effects are similar to those of D. penicillamine.

Salazopyrin (sulfasalazine): ankylosing spondylitis and rheumatoid arthritis v 500mg dose 500mg x 2 times/day, maximum 3000mg/day.

Methotrexate 5% had to be stopped because of side effects:

Contraindications: hypersensitivity to the drug, renal failure, severe liver failure, alcoholism, marrow failure, pregnancy, lactation, infection, mouth ulcers, gastrointestinal ulcers, taking sulfonamides, chloramphenicol, pyrazole, indomethacin, diphenylhydantoin…

Side effects: nausea, vomiting, difficulty swallowing, stomatitis; oropharynx, digestive disorders, anuria, decreased sperm count, menstrual disorders, elevated liver enzymes, pneumonia, neurotoxicity, skin redness, tan, itching, hair loss

Drug interactions: NSAIDs, etc.

Immunosuppressive and cytotoxic drugs: recently used to treat rheumatoid arthritis, a severe colloid disease for which other drugs have not been effective these drugs inhibit the inflammatory process and allow dose reduction corticosteroids.

Method of short-term maximal dose of steroids: a drip infusion of an extremely high dose of steroid over a period of 1-3 (3-5) days such as methylprednisolone per day from 800-1200mg. Indicated in systemic lupus erythematosus, RA, very severe Chauffard-Still disease, other methods have failed.

Other drugs and methods:

Plasma filtration.

Irradiation of the whole body lymphatic system.

Treatment with a special diet.

Monoclonal antibody against CD4+ T-cell lymphoma.

Endoscopic resection of the synovial membrane.

Treatment by injection into the joint socket :

Indications and contraindications:

Rheumatoid arthritis, psoriatic arthritis, juvenile chronic arthritis, synovitis, post-traumatic arthritis... mono- or multi-joint disease

Absolutely do not use in septic arthritis, should not be injected in patients with severe osteoarthritis, do not inject more than 3 times in one joint and do not inject more than 3 joints in a single injection.

Drugs used:

Steroids: Use slow-dissolving suspensions for prolonged action: Triamcinolone hexacetonide (the longest-lasting inhibitory effect on inflammation), prednisolone teriary-butylacetate.

Other drugs:

Use 1% osmic acid.

Use radioactive isotopes with short half-lives.

Use alpha chymotrypsin enzyme.

Catastrophe:

Purulent arthritis (due to non-sterility and poor sterilization).

Crystal arthritis: pain that is prominent after 12-24 hours of injection usually resolves in a few days, does not require intervention.

Skin atrophy at an injection site: due to multiple injections.

Some specific cases

Rheumatoid arthritis

Diagnosis: based on ARA 1987 criteria:

Morning stiffness ³1 hour.

Inflammation in ³3 groups of joints.

Inflammation of the joints of the hand (wrist, metatarsal, or proximal knuckles).

Symmetrical arthritis.

Low notes.

Low factor (+).

X-ray changes (typical changes of rheumatoid arthritis in the hands such as bone defects).

Definitive diagnosis: must have 4 criteria, criteria 1-4 must be ³6 weeks.

General principles:

Persistence, continuously, sometimes for a lifetime.

Combination of many measures: internal medicine, surgery, physical therapy, orthopedics, re-education of occupational workers.

Purpose:

Fights inflammation in joints and other tissues.

Maintain the function of joints and muscles, prevent deformation.

Repair damage to joints to relieve pain or restore function.

Internally medical treatment.

Treatment of acute exacerbations (swelling, pain, fever, effusion):

Rest and nutrition: Complete rest in case of severe illness, active inflammatory phase. In milder cases, a moderate rest regimen can be given. The painful joint can be rested with a splint. Usual diet.

Use of drugs: Use one of the non-steroidal anti-inflammatory drugs mentioned above according to the principle of use, use Antacid between meals for patients with digestive symptoms. Misoprostol (Alsoben 200mcg, 2-4v/day) plus aspirin may reduce the likelihood of erosive or hemorrhagic peptic ulcers in high-risk patients. If after a week of using the drug (some authors recommend trying to use it for at least 2-3 weeks before finding it ineffective) without reversing the progression, change the drug or switch to corticosteroids.        

Using corticosteroids:

Moderate: 16mg Methylprednisolone/day (or equivalent) at 8am.

Severe cases: 40mg of Methylprednisolone IV per day, tapered and cut off when baseline therapy takes effect (after 3-6 months).

Severe acute progression, life-threatening: 500-1000 mg of Methyl-prednisolone IV 30-45 minutes/day for 3 consecutive days, then return to 1mg/kg/day and gradually reduce the dose.

Long-term treatment as needed: 16-20mg Methylprednisolone/day at 8am, then gradually reduce dose and maintain 5-7.5mg at 8am daily.

Using basic treatment drugs for specialists (Hydroxychloroquine, Methotrexate, Sulfasalazine, immunosuppressants...): can slow down or stop the progression of the disease, need long-term treatment and clinical and near-term monitoring clinical.

Injecting corticosteroid esters into the joint:

Gout

Definite diagnosis

Diagnostic criteria for acute gouty arthritis (Wallace SL et al, 1977):

History of acute monoarthritis followed by periods of complete resolution of the joint.

Inflammation responds well to colchicine (within 48 hours and no other arthritis for at least 7 days).

Hyperuricemia > 420 µmol/L (or > 7 mg/dL).

Diagnosis is confirmed when ³2 criteria are present.

Standards of ARA 1968 (Bennett PH):

Found uric acid crystals in the joint fluid during acute inflammation or urate deposits in the tissues (tophi, kidney stones).

Or have ³2 of the following criteria:

There is a solid history and/or observation of more than two episodes of acute painful swelling in a joint, which started suddenly, was severe, and completely resolved within two weeks.

There is a solid history and/or observation of an acute inflammatory episode meeting Criterion 1 in the big toe joint.

There are tophi in the ear lobes, around the joints.

Colchicine’s exceptional efficacy (within 48 hours) has been observed or questioned in history.

 The diagnosis is confirmed when a standard 1 or ³2 minor criteria in the standard 2

Treatment:

End the attack as quickly as possible.

Rested.

Drink plenty of water with Bicarbonate (alkaline urine to keep urine pH >7).

Use Colchicine-specific anti-inflammatory 1mg x 3 tablets/day for the first day, 2 tablets for the second day, then take 1 tablet per day. NSAIDs can be used during an acute attack, or oral or intra-articular corticosteroids (corticosteroids should only be used when these drugs are ineffective or contraindicated).

Relapse prevention:

Low-purine diet: avoid fatty fish, heart, liver, kidney, veal thymus, brain, peanuts, juice....

Calorie reduction in obese patients.

Maintain abundant diuresis and alkalinize the urine.

Prevent complications by preventing crystal deposition.

Using drugs to increase uric acid excretion: probenecid 250mg x 2 times/day (partial inhibition of reabsorption in the proximal tubules (indications: increased uric acid due to decreased secretion, patient <60 years old, good renal function, uric aciduria) < 500 mg/24 hours, no history of kidney stones)

Or use drugs that inhibit uric acid synthesis: Allopurinol v: 100; 200; 300mg dose of 100- 300 mg/day, orally for several months, depending on the amount of adjusting the amount of uric acid (keeping uric acid levels <5 mg% or <300 mmol / L) with Colchicine 1 mg/day or oral NSAIDs prevent recurrent gout attacks while taking uric acid lowering drugs.

Avoid favorable factors.

Treatment of secondary causes of hyperuricemia.

Osteoarthritis

Diagnose:

Clinical: Muscular joint pain, limited range of motion, signs of joint destruction, no systemic signs.

Subclinical: Routine tests within normal limits, X-ray: narrowing of joints but never leading to ankylosing spondylitis, osteophyte growth, subchondral thickening

Treatment:

Symptomatic treatment and rehabilitation are important, must combine medical, physical, and surgical.

Purpose: relieve pain, maintain activity, limit disability.

Medical:

Pain relievers, anti-inflammatory drugs.

Slows down the degenerative process and fosters joint cartilage.

Glucosamine (Viartril–S, Bosamin, Golsamine) v: 250; 500 mg x 2-3 times/day orally 15 minutes before meals. Treatment should be repeated every 6 weeks – 4 months, if necessary, repeat the course after 6 months.

Oztis (Glucosamine sulfate 750mg + Chondroitin sulfate 250mg) 1-2v/ngày.

Diacerein (Artrodar) 50mg x times/day with main meals.

Inject drugs into joints only when necessary (specialist doctor appoints and performs).

Surgical treatment:

Correction of joint deformities.

Treatment of herniated disc.

Stiffening of ankylosing spondylitis in the functional position.

Artificial joint graft.

Prevention:

Prevention plays an important role by preventing and limiting excessive mechanical stress in the joints and spine which can prevent the outcome of degenerative joint disease.

In daily life:

Prevent bad posture in living and working.

Avoid too strong impact, sudden wrong posture when carrying, pushing, carrying heavy.

Periodically check people who do heavy labor who are prone to osteoarthritis for early detection and treatment.

Fight obesity with proper exercise nutrition.

Early detection of malformations of joints and spine to have orthopedic measures prevent secondary osteoarthritis.

Children checkup, early treatment of rickets, knee joint defects...

Systemic lupus erythematosus

90% of cases are women, often of childbearing age.

Symptom:

Clinical Manifestations:

Body as a whole: fatigue, fever, malaise, weight loss.

Skin and subcutaneous tissue: facial erythema, photosensitivity, vasculitis, alopecia, oral flashes.

Symmetrical arthritis.

Hematologic: anemia (possibly hemolytic), leukopenia, thrombocytopenia, lymphadenopathy, splenomegaly, arterial and venous embolism.

Cardiopulmonary: pleurisy, pericarditis, myocarditis, endocarditis.

Kidney disease.

Gastrointestinal: peritonitis, vasculitis.

Neurological: epilepsy, psychosis.

Subclinical:

Complete blood count, erythrocyte sedimentation rate.

Antinuclear antibodies and nuclear components. . .

Treatment:

Non-steroidal anti-inflammatory drugs.

Synthetic antimalarial.

Corticosteroids: in severe, life-threatening cases.

Cytotoxicity: In severe diseases, corticosteroids are ineffective.

Anticoagulation if the patient has thromboembolic complications.

Ankylosing spondylitis

Common in young men (20-30 years old).

Diagnose:

Back pain, limited movement of the lumbar spine, limited expansion of the thoracic cavity

HLA- B27 (+), the image of lesions on X-ray of sacroiliac joints and spine

Treatment:

Practice.

Non-steroidal anti-inflammatory.

Sulfasalazine.

Do not take corticosteroids and immunosuppressants.

Surgery for joint deformity.