These are a group of diverse inflammatory conditions due to different causes which affect joints and other musculoskeletal tissues.
General Guidelines
- The first-line treatment is a non-steroidal anti-inflammatory drug (NSAID). This group includes medicines like aspirin, diclofenac and Ibuprofen, (provide dosage and scientific proof) but does NOT include paracetamol
- NSAIDs should be used cautiously in pregnancy, the elderly, and patients with asthma and liver or renal impairment.
- NSAIDS should be avoided in patients with bleeding disorders
- NSAIDS increases the risk of heart failure and stroke and should be avoided in patients with cardiovascular diseases and those who are at high risk
- NSAIDs should be avoided in patients with current or past peptic ulceration.
- NSAIDs should be taken with food
- If dyspeptic symptoms develop in a patient on NSAIDs, try adding magnesium trisilicate mixture. If dyspepsia persists and NSAID use considered essential antagonist
- Physiotherapy is a useful adjunct treatment in many inflammatory joint conditions
Referral:
For patients with serious rheumatic disease and peptic ulceration should be referred to higher level health facility with adequate expertise and facilities.
17.2.1 Rheumatoid Arthritis
Rheumatoid arthritis is an autoimmune condition whereby the immune system attacks the synovial membrane of joints, initially of the small joints but progressively involving the big joints. It has a wide range of clinical presentation depending on extent of joints involvement and severity of the condition.
It is a chronic multisystem disease of unknown aetiology
Diagnostic Criteria
- In the majority of patients with RA, the onset is insidious with joint pain, stiffness and symmetrical swelling of a number of peripheral joints
- The clinical course is however, variable.
Investigations
- Rheumatoid Factor (positive in about 30% of cases)
Pharmacological Treatment
A: Acetylsalicylic acid 1.2 g PO 6 hourly with food.
OR
A: Ibuprofen 400–800 mg PO 8 hourly. Continue for a long as it is necessary
NOTE: Patients with intractable symptoms may require special treatment at specialized centre
17.2.2 Gout
Gout is a recurrent acute arthritis of peripheral joints which results from deposition, in and about the joints and tendons, of crystals of monosodium urate from supersaturated hyperuricaemic body fluids. The arthritis may become chronic.
Diagnostic Criteria
- The main clinical features are those of an acute gouty arthritis, often nocturnal, throbbing crushing or excruciating pain.
- The signs resemble an acute infection with swelling, hot red and very tender joints.
- The first metatarsophalangeal joint of the big toe is frequently involved
Investigation
- Serum uric acid level.
Non-Pharmacological treatment
- In obese patient, reduce weight
- Avoid precipitants e.g. alcohol
- Institute anti-hyperuricaemic therapy e.g.
A: Allopurinol give 100 mg daily. This may be increased up to even 600mg daily depending on response to reduce uric acid synthesis - Prevention or reversal of deposition of uric acid crystals in males
Note: Aim is to maintain serum uric acid level below 8mg/dl (0.48mmol/l)
Pharmacological Treatment For acute attack give:
A: Ibuprofen 400mg (PO) start then 200mg 8 hourly until 24 hours after relief of pain.
C: Meloxicam 7.5mg–15mg (PO) 12 hourly for 5 days
C: Piroxicam 10–20mg (PO) once a day for 5 days
17.2.3 Osteoarthritis
It is a common form of arthritis, characterized by degenerative loss of articular cartilage, subchondral bony sclerosis, and cartilage and bone proliferation subsequent osteophyte formation. Cause is unknown, but genetic, metabolic and biomechanical have been suggested. Gradual onset of one or a few joints involved.
Diagnostic criteria
- Pain is the commonest symptom
- Specific clinical features depend on the joint involved e.g. enlargement of distal interphalangeal joint (Bouchard’s nodes)
Investigation
- Plain X-ray of involved joint/ joints
Non-Pharmacological Treatment
- Rest the joint. Use crutches or walkers to protect weight bearing joints in severe cases.
- Crepe bandage or braces also can be worn during the active phase of disease.
- Reduction of weight in obese patients
- Physiotherapy–exercise to the affected joints
Pharmacological Treatment
A: Acetylsalicylicacid 900 mg (PO) 6 hourly with food
OR
A: Ibuprofen 400mg (PO) start then 200mg 8 hourly
OR
C: Diclofenac sodium 50 mg PO 8 hourly for 3–5 days
NOTE: In severe cases surgery may be indicated e.g. hip joint replacement, knee replacement