Postgraduate Medicine

ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20

Rheumatoid arthritis J. Donald Smiley & Nadene Coyne To cite this article: J. Donald Smiley & Nadene Coyne (1975) Rheumatoid arthritis, Postgraduate Medicine, 58:5, 17-24, DOI: 10.1080/00325481.1975.11714184 To link to this article: http://dx.doi.org/10.1080/00325481.1975.11714184

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• CASE REPORT. A white woman 56 years of age first began to have pain and tenderness in both wrists in 1967. These symptoms became progressively worse, and after one year both knees also were tender, swollen, and painful. She had morning stiffness which lasted for two to three hours and which was partially relieved by a warm shower. She was given a diagnosis of rheumatoid arthritis and was instructed to take 12 aspirin tablets (4 gm) a day. Disease activity persisted, and trials of phenylbutazone and indomethacin provided little additional benefit but produced gastrointestinal upset. Beginning in 1973, the patient was given injections of gold sodium thiomalate until a total of 1,000 mg had been administered. She showed excellent improvement. After the injections were discontinued, aspirin was prescribed as the only medication. In late 1974, arthritis again became active, gold therapy was reinstituted, and she was seen by a rheumatologist in consultation. The patient was chronically ill. Her mouth was dry, and her tongue fissured. Pain and swelling were present in both ankles, effusions were present in both knees, and both wrists were tender. There was significant generalized atrophy. The hemoglobin value was 8.5 gm/ 100 ml, the erythrocyte sedimentation rate was 82 mm/hr (Westergren), a latex fixation test for rheumatoid factor was strongly positive, the serum globulin value was increased, and a stool guaiac test was positive A discussion of this case should include the management of possible peptic ulcer in patients being treated with aspirin, indomethacin, phenylbutazone, or ibuprofen. It should also include the use of gold therapy for rheumatoid arthritis and the diagnosis and management of some uncommon complications such as Sjogren's syndrome.

O+ ).

DISCUSSION It is of the utmost importance to make sure that a diagnosis of rheumatoid arthritis is correct. One criterion to be met is persistence of rhe symptoms for more than six weeks. Acute attacks of many other forms of arthritis will disappear within that time. Another point is the distribution of joint involvement. Most frequently, rheumatoid arthritis involves the small joints in the hands initially. Particularly significant is symmetry of involvement by symptoms persisting for more than six weeks. All rheumatoid arthritic patients do not have severe crippling. In 3 5 ~f of cases, including in particular many children, the initial attack may persist for two or three months and then remit spon-

Vol. 58 • No. 5 • October 1975 • POSTGRADUATE MEDICINE

rheumatoid arthritis Presenter

J. Donald Smlley University of Texas Southwestern Medical School at Dallas

consider What is the most important component of a physical therapy program for a patient with rheumatoid arthritis? In treating rheumatoid arthritis, what is the normal trial period for aspirin? Phenylbutazone? lbuprofen? Gold? Prednisolone? When should surgery for rheumatoid arthritis be considered?

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moderator's comment Rheumatoid arthritis is a model of chronic inflammatory disease. lt combines symptoms and signs of inflammation with the joint destruction and deformity which may result from the body's efforts to combat that inflammation. We do not yet know precisely the etiology and pathogenesis of rheumatoid arthritis. Dr. Smiley elucidates the state of our present knowledge, placing heavy emphasis on proper current therapy.-CMP

taneously. Years may go by before another attack occurs. Monocyclic arthritis is easily confused with other forms and may present a problem in assessment of management in that the measures taken might be given the credit for otherwise spontaneous improvement. About 50% of rheumatoid arthritic patients have polycyclic disease marked by flare-ups recurring over periods of years. In the remaining 15% of patients the disease is aggressive and progressive from onset, involving multiple joints and causing increasing disability. The latter patients are often especially difficult to manage medically. Relevance of Laboratory Tests

The erythrocyte sedimentation rate is characteristically elevated in active rheumatoid arthritis. It also serves as a parameter of the effectiveness of therapy. The importance of the latex fixation test for rheumatoid factor is much overemphasized. Some 5% of older persons without rheumatoid arthritis have a positive latex fixation test, and in some of these cases a physician who uses the rheumatoid factor as a sole criterion will mistake osteoarthritis for rheumatoid arthritis. Thus, clinical features must always be considered along with the positive laboratory tests. Some 10% to 20% of patients with rheumatoid arthritis have a positive antinuclear antibody test, creating confusion with systemic lupus erythematosus. In our experience, these patients usually have high titers of rheumatoid factor. LE cell tests may be positive in a small proportion of patients with rheumatoid arthritis, and again, positive results are usually associated with high titers of rheumatoid factor. Antinuclear antibody and LE cell tests are more likely to be positive in those rheumatoid arthritic patients who have rheumatoid nodules. Presence of the

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characteristic nodules gives some degree of security in the diagnosis. Analysis of synovial fluid should not be underestimated as a helpful diagnostic test in rheumatoid arthritis. Arthritic symptoms involving the knee in particular may be related to trauma, osteoarthritis, or gout. High cell count, low viscosity of the fluid, and absence of crystals are compatible with rheumatoid arthritis. X-ray changes usually are not helpful in making a diagnosis of rheumatoid arthritis early in the disease. DR. JOHNSON: Is the titer of rheumatoid factor related to severity of symptoms? DR. SMILEY: In a given case, the titer cannot be used as a predictor of improvement or worsening or of the extent of destructive joint damage. Overall, however, the patients in whom rheumatoid factor is demonstrable, particularly if the titer is high, are more likely to have joint damage. Education of Patient and Family

Once a diagnosis of rheumatoid arthritis is established, the patient and family need to be told what to expect from treatment-and what not to expect. Not all patients respond to the first therapeutic agent administered, and unresponsive patients who are unaware of this possibility often lose confidence in their physician and do not give medical treatment a fair trial. To gain the patient's confidence and cooperation, I usually sit down with him or her and go over, step by step, the possibilities for response to different kinds of treatment. Particularly if gold therapy is used, with a delay of many weeks in the response, this educational effort is very worthwhile. Emphasis should be given to the fact that most patients with rheumatoid arthritis do not become significantly crippled. Even some physicians have the mistaken idea that crippling is inevitable. Sequence of .Prug Therapy

Table 1 gives an outline of a sequence of drug therapy for rheumatoid arthritis which we find to be very successful. The agent prescribed initially is usually buffered aspirin, 4 to 6 gm/day. Careful trials have shown that 45% of patients with rheumatoid arthritis will respond satisfactorily to aspirin alone. The frequency of adverse effects, generally in the form of gastrointestinal distress, is quite low, about 5%. Many of these patients, if they continue to take aspirin, will eventually tolerate it without difficulty. Perhaps

POSTGRADUATE MEDICINE • October 1975 • Vol. 58 • No. 5

table 1.

drug therapy for rheumatoid arthritis

Recommended drug sequence

Usual adult dosage

Period of trial

Percentage of patients showing good response·

Incidence of significant toxic side effects(%)

Buffered aspirin

3.8·5.7 gm/day

30 days

45

2-5

Phenylbutazone Indomethacin lbuprofen

300-400 mg/day 75-150 mg/day 1,600 mg/day

14 days

25

10

Gold sodium thiomalate Gold thioglucose

50 mg weekly

10·20 weeks

18

25

Predmsolone

7.5-10 mg/day

7 days

10

)30

Experimental immunosuppressants Cyclophosphamide

50-150 mg/day

5-8 weeks

)70

"Percentage of the total patient population showing good response, providing that the recommended drug sequence is followed. Only 1% of the total patient population is medically unresponsive.

1% to 2% cannot. The incidence of true allergy to aspirin is about 0.2%, and most of these persons are aware of this intolerance even before the onset of arthritis. We usually try aspirin for one month before going to the second step of drug therapy. DR. JOHNSON: In deciding how high to go with aspirin dosage, do you find it helpful to measure blood salicylate levels? DR. SMILEY: No, not generally, but salicylate levels are helpful when more than 12 aspirin tablets a day is prescribed. Acetaminophen and ibuprofen are related mild analgesics which may be substituted for aspirin if gastrointestinal intolerance is persistent. If the response to aspirin alone is unsatisfactory, we go to the second step, giving phenylbutazone or indomethacin. (Other similar nonsteroid analgesics soon to become generally available may be added if the first two drugs are ineffective.) Adverse or toxic effects of these agents are more frequent and more severe than those of buffered aspirin, but anti-inflammatory effect also is greater. Usual dosage is 300 to 400 mg/day for phenylbutazone or 75 to 150 mg/ day for indomethacin. Of the entire group of patients with rheuma-

Vol. 58 • No. 5 • October 1975 • POSTGRADUATE MEDICINE

toid arthritis, 251/f will show a good response to this second step in drug therapy. In other words, roughly half of the patients who are unresponsive to aspirin will respond to phenylbutazone or indomethacin. DR. GRIFFITH: Do you give phenylbutazone alone or in combination with aspirin? DR. SMILEY: A patient who has shown some degree of response to aspirin should continue to take it. A trial of phenylbutazone lasts for two weeks. If there is no response, indomethacin is given for a similar period. About 100' of patients receiving phenylbutazone or indomethacin will have significant adverse effects. In a large study conducted by the American Rheumatism Association, 500' of patients treated with indomethacin had some side effects, usually in the form of mild headache that cleared even if the patients continued to take the drug. The most prominent side effect of indomethacin is severe gastrointestinal upset. Peptic ulcer has been reported in connection with use of this agent. Obviously if a patient is also taking aspirin, the combined effects may accentuate peptic ulcer. In Canada, indomethacin is no longer approved for use in children. In the United States, it is recommended for use only in

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J. Donald Smiley Dr. Smiley is professor of internal medicine, University of Texas Southwestern Medical School at Dallas.

persons 14 years of age and older. For these reasons, close observation of patients taking this agent is advisable. It is safe and effective in most adults. Phenylbutazone also has side effects, including peptic ulcer. Other adverse effects include bone marrow depression and skin rash. The bone marrow toxicity is the chief concern. When we give this drug to a patient with arthritis, we obtain a white blood cell count every week for the first six weeks of therapy and then every month. The drug is withdrawn if there is evidence of toxicity, eg, mouth ulceration, rash, or a white count dropping below 4,000/cu mm. In our 15-year experience with phenylbutazone, a number of patients have shown bone marrow depression, and we have stopped the drug promptly in these instances. So far not a single death attributable to adverse effects of this drug has occurred in our large clinic population. DR. PLOTZ: It is wonh mentioning that the Arthritis Foundation has issued a warning about the Chinese herbal medicines for arthritis which some people obtain surreptitiously and which have been found to contain phenylbutazone. DR. SMILEY: The potential risk of toxicity of phenylbutazone should not be minimized, but some 90% of patients will tolerate the agent for long periods. Let us say that a patient with rheumatoid arthritis is unresponsive to aspirin, phenylbutazone, and indomethacin. At that point it is usually our policy to go to a trial of gold therapy. The compounds used most often are gold sodium thiomalate and gold thioglucose. These agents are more toxic than the drugs tried first but also are effective in managing many otherwise unresponsive patients. Of all anhritic patients, almost 20% will respond to gold therapy. To put it another way, of the patients who are unresponsive to the first two forms of drug therapy, about 60% will respond to gold. In cases unresponsive to the first two cate-

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gories of drugs, we begin with a small dose of 10 mg of gold given intramuscularly. If there is no untoward reaction, a dose of 25 mg is given after a week, and then a dose of 50 mg each week to a total of 1,000 mg. Then, in responsive patients, we lengthen the interval between 50mg injections to three or four weeks. Gold exens beneficial effects much more slowly than do the other agents used in treatment of anhritis. Usually a favorable response is not evident until at least 500 mg of gold or more has been given. DR. RODNAN: A dose of 1,000 mg of either gold thioglucose or gold sodium thiomalate contains 500 mg of elemental gold, actually, since the gold content is 50%. Most patients who respond to chrysotherapy will begin to show evidence of improvement after the administration of approximately 250 mg of elemental gold. DR. SMILEY: I agree. Among the toxic effects of gold is minor but distressing skin rash with pruritus. This allergic reaction to gold is detectable early, and if it occurs the drug can and should be stopped promptly. However, gold is excreted slowly, and repression of severe allergic reactions with steroids may be necessary occasionally. Bone marrow depression is another possible toxic effect of gold. It occurs much less frequently than rash, but it is a danger. We obtain blood counts weekly and later monthly when we give gold. Infrequently, use of gold is associated with a glomerulonephritis which produces proteinuria. DR. PLOTZ: I wonder how the other panelists might respond to that. My experience is that proteinuria must be the most apparent reaction. At what point would you stop the use of gold? DR. SMILEY: If a patient did not have proteinuria before gold therapy was started and if it then developed, I would stop giving gold. DR. STILLMAN: Even if small doses were being

used? Yes. Would you stop it indefinitely? I would consider the proteinuria a reaction due to immune deposits in the kidney of antigold antibodies and the drug. DR. PLOTZ: We analyzed the effects of longterm gold therapy with reference to proteinuria and found that at one time or another this occurred in about 35% of patients-a high proportion to take off gold therapy. DR. WARD: It would be my view that excretion of more than 200 or 250 mg of protein in the urine in 24 hours is a manifestation of renal DR. SMILEY: DR. BROWN: DR. SMILEY:

POST8RADUATE MEDICINE • October 1975 • Vol. 58 • No. 5

toxicity and is an indication for cessation of gold therapy. DR. RODNAN: It is difficult to obtain 24-hour urine samples regularly. DR. SMILEY: We perform urinalysis and a white cell count at each visit before we give the next injection of gold. If a patient showed 2+ proteinuria, we would be inclined not to use more gold. DR. STILLMAN: Two plus or above, certainly. DR. WARD: Two plus by what technique? DR. SMILEY: Usually the dipstick method, which estimates a protein content of 100 mg/ 100 ml or greater. Another complaint made by patients receiving gold therapy is a metallic taste. Altogether about 25% of these patients have significant reactions to gold. Often these occur early in the course of treatment, the gold is withdrawn, and it is not possible to assess the therapeutic effectiveness of the agent. Role of Low-Dose Steroid Therapy If a patient is unresponsive to gold or if peptic ulcer develops with use of aspirin, indomethacin, or phenylbutazone, an alternative form of treatment should be considered. This situation raises the question about the use of steroid in low doses. Some active patients with arthritis, such as men who have job obligations or housewives who have children to care for, can take low doses of steroid without having major side effects. Also, there is little question that low doses of steroid are less ulcerogenic than aspirin. Other arthritic patients, such as those with diabetes, should not be given steroid. When steroid is indicated, we generally use prednisolone, usually giving 2.5 mg three times a day, or the smallest amount that will control symptoms. In our experience, alternate-day steroid therapy has not been successful in rheumatoid arthritis. Usually, patients receiving steroids also should take aspirin, as this combination can be very effective. The biggest problem is that patients usually respond so dramatically to steroids that they are reluctant to use safer forms of treatment. That is why we place steroid quite far down on the list in the sequence of drugs used. Some 80% of patients who are unresponsive to the other forms of drug therapy will respond to steroid. This still leaves an appreciable proportion of patients with severe disease, and these are the patients who probably should be referred to a rheumatologist. One of various forms of

Vol. 58 • No. 5 • October 1975 • POSTGRADUATE MEDICINE

experimental treatment might be considered, such as the use of cyclophosphamide, hydroxychloroquine, or chloroquine. DR. JOHNSON: Is cyclophosphamide approved for general use in rheumatoid arthritis? DR. SMILEY: The truth is that cyclophosphamide is being used, often incorrectly, by many physicians. I would emphasize the need for caution in selecting only those patients with severe rheumatoid arthritis unresponsive to all other forms of medical treatment for consideration of cyclophosphamide therapy, and I personally feel that these patients should be under the close observation of a physician familiar with use of the drug. DR. GRIFFITH: It seems to me from what you have said that low-dose steroid therapy, thoughtfully given, carries a better chance for success and less danger to the patient than some of the agents listed ahead of it. I wonder why steroid is so far down on the list. DR. SMILEY: The incidence of serious side effects of steroid given over a protracted period is high. Furthermore, patients receiving steroid often tend to take larger amounts than are prescribed. DR. JOHNSON: Getting back to the gold therapy and the proteinuria, it would seem to me that if gold were exerting a beneficial effect and the patient showed 2+ proteinuria, it would be tempting to try giving a small amount of prednisone to see if the proteinuria could be reversed. DR. SMILEY: I would not be tempted to do this. I have seen enough severe gold reactions. When one appears, I want to discontinue the use of gold. DR. PLOTZ: There has been a report that prednisone in combination with gold was effective in rheumatoid arthritis. I personally do not feel that prednisone protects against gold toxicity. One might use prednisone to control a severe dermatitis occurring as a side effect, but that is a different matter. Perhaps we should distinguish between the responses to prednisone and to gold in terms of effect on the disease process itself. A patient with arthritis who takes prednisone may feel better, but the question is whether the course of disease is altered materially. DR. SMILEY: I would emphasize that eight of every ten patients who are unresponsive to the first drugs on the list are going to show a favorable clinical response to steroid. However, gradual progression of arthritic deformities usually occurs. DR. PLOTZ: And probably the proportion of

"Early patient education is Important to maintain or increase range of joint motion and strength, to prevent avoidable deformities, and to conserve energy."

21

"If gold Is as good as It Is said to be, then somehow we will have to work out ways and means of teaching family doctors how to use It and to give them confidence In supervising Its use."

patients responding would be higher if the steroid were given earlier? DR. SMILEY: Yes. DR. BLUESTONE: Cataracts may develop in a patient taking as little as 7.5 mg of prednisone a day. DR. SMILEY: Patients responding to gold will show a drop in titer of rheumatoid factor. This is usually not true of patients responding to steroid therapy. DR. STILLMAN: I think there are many disadvantages of long-term steroid therapy, with divided doses in particular. There are studies showing seriously increased morbidity and mortality after five years of steroid therapy. I am one of the physicians who sees these patients after they get into trouble-after someone else has been relieving their symptoms for two, four, or five years. I feel like the man in the black hat when I have to try to wean them from the steroid which has been so good and now is so bad. DR. JOHNSON: How do you do that? DR. STILLMAN: By a time-consuming, slow process, with decrements of 0.5 mg. If a patient is taking two or three doses of steroid a day, first I try to change the schedule to a single dose taken in the morning. Then I try to change to an alternate-day schedule. Eventually, I try gradually to bring down the dosage. Use of Hydroxychloroquine In order to wean a patient away from steroid, I feel that it is necessary to introduce another form of therapy, such as the use of gold or hydroxychloroquine. We use hydroxychloroquine a lot. I give it to about two thirds of the patients with juvenile rheumatoid arthritis whom I see, and I am surprised that so many physicians view it as a dangerous drug. This view, I think, stems from the very early experience with the agent when the proper dosage was not established. DR. SMILEY: I specifically avoided mentioning hydroxychloroquine because a cooperative study in which our institution participated showed that it was only slightly better than a placebo, not good enough to justify the risk of toxic effects. DR. STILLMAN: If you use as a guide a dosage of 3.5 mg for each pound of body weight, I think you will be on safe ground and will still be giving therapy that can be effective. There is evidence from several studies that makes me feel safe in going ahead and using hydroxychloroquine. We observe these patients carefully, examining the eyes with an ophthalmoscope and

22

checking color v1s1on with pseudoisochromatic charts at each visit. We have them see an ophthalmologist at regular intervals. DR. PLOTZ: Are you satisfied to extrapolate these observations to adults? DR. STILLMAN: Yes. In my experience, hydroxychloroquine has been an effective drug. We have not made a double-blind study, but we have observed again and again that when we discontinue using the drug there is an exacerbation of disease and that with reinstitution of treatment another response is seen. It seems to me that we ought to take another look at this form of treatment. I would use it before I would use gold. Physical Therapy DR. PLOTZ: Dr. Smiley, you said earlier that patient education is very important in management. I would like to ask Dr. Coyne what we should do in the way of providing some physical therapy when we make a diagnosis of rheumatoid arthritis. DR. COYNE: Early patient education is important to maintain or increase range of joint motion and strength, to prevent avoidable deformities, and to conserve energy. The measures used sound very simple, so patients often neglect to do them unless they are told how, when, and why to do them. Trained physical and occupational therapists working in close cooperation with the physician can provide the most satisfactory therapy and the instruction needed. Ideally the therapists and a social worker would be working in the arthritis clinic with the physician. Initial outpatient therapy, scheduled at least three times a week, can be gradually decreased in frequency and the patient transferred to a home program with periodic checkups. If trained allied health care professionals are unavailable, the physician should give exact instructions to the patient. The prescription for therapy should include immediate and long-term goals as well as any necessary precautions. The most important component is a daily program of balanced rest and activity. This usually means a change of habits, which is difficult. After a survey of a patient's activities, we usually ask him or her to spread the daily chores throughout the day and to get a half-hour rest period, lying down, at midmorning and at midafternoon. If patients will take a few minutes to move their joints slowly while still warm in bed, before arising, or will take a shower or bath on arising, they can decrease the amount of time during

POSTGRADUATE MEDICINE • October 1975 • Vol. 58 • No. 5

which they have early morning aches and stiffness. Heat, or occasionally cold, is also beneficial before exercise. The exercise goal may be range of motion, strength, endurance, relaxation, or a combination of these. Whatever the goal, the exercises should be done slowly and in frequent short bouts rather than in one long and perhaps exhausting session a day. Maintaining or increasing range of motion should be primary, with balancing strength on the two sides of a joint of almost equal importance if deformities are to be prevented and energy conserved. Repetition of a movement against gradually increased resistance or isometric exercises will increase strength and endurance. Isometric exercises should be recommended selectively so they do not put additional stress on involved joints. Patients should also be taught the easiest method of doing their ordinary activities of daily Jiving, either by altering their methods or by being provided with assistive devices. This not only makes patients more independent but also decreases the stress on painful joints and conserves energy. DR. GRIFFITH: What are some ways of finding out if cold rather than heat should be used? DR. COYNE: A flexible pack of crushed ice may be applied or a small can of frozen juice rubbed slowly over the local area. DR. SLEDGE: Do you have qualms about applying heat? There is evidence indicating that elevation of the joint temperature can escalate the destruction. DR. COYNE: Yes, I do. I would not recommend the use of any device that produces deep heat. DR. PLOTZ: Is it a rule not to apply heat to an inflamed area? DR. COYNE: Yes, an inflamed area does not benefit from additional heat. DR. PLOTZ: What are some simple aids that can be employed to prevent progressive deformity? DR. COYNE: A good example is the resting splint, which is most useful in preventing flexion contractures of the knee and to counteract the tendency for malposition of the wrist and fingers. Assistive devices that spare the lower extremities and allow function include modifications of canes, crutches, and walkers to suit the individual patient's needs and limitations. There are many other assistive devices to allow the patient more independent activity or to relieve stress on joints. Most of the useful assistive devices and their sources are listed in publications available

Vol. 58 • No. 5 • October 1975 • POSTGRADUATE MEDICINE

Nadene Coyne Dr. Coyne is associate professor of medicine, Case-Western Reserve University School of Medicine, and director, physical medicine and rehabilitation, Metropolitan General Hospital, Cleveland.

through local chapters of the Arthritis Foundation. DR. PLOTZ: What do you tell patients who ask whether they can have sexual intercourse? DR. COYNE: Unless the doctor brings up the subject, many patients will not ask about this. DR. SLEDGE: The physician should bring it up. Whether sexual intercourse will be possible is a major concern of patients with arthritis, particularly of the hip. DR. BLUESTONE: The problem is pretty well limited to the hip joints. Role of Surgery DR. SMILEY: I would like to hear comments, from Dr. Sledge particularly, about the role of surgery in selected cases of rheumatoid arthritis. DR. SLEDGE: In some cases, when satisfactory remission is not obtained with adequate drug therapy and when functional limitation persists, it is worthwhile to consider synovectomy. This is a controversial subject, and a definitive answer to the question of its effectiveness will be hard to find. Double-blind cooperative trials of synovectomy are doomed. There cannot be a "doubleblind" surgeon. A surgeon either believes in synovectomy, and does it, or does not believe in it. In the literature are a number of well-documented cases that point to the potential benefit of synovectomy in carefully selected patients, ie, those in whom one fears secondary destruction of a joint. In the hand, for example, persistence of swelling for only a few months can lead to irreversible stretching of collateral ligaments. So-called chemical synovectomy, being carried out in Great Britain and France, appears to hold promise. If destruction is still relatively mild, ie, not sufficient to produce serious mechanical problems, one can still consider the use of synovectomy. If damage is moderate, one can consider re-

23

placement of one side of the articular surface. If in spite of medical measures the disease has progressed to a stage of gross destruction or deformity where function is severely impaired or lost, one can consider total joint replacement. The classic example is total hip replacement. After more than 12 years' experience with this procedure, the high rate of success in relieving pain and restoring function is established. Application of the same principles has yielded more than 300 designs for replacement of other joints. Virtually every joint in the body is being examined with a view toward replacing it with an artificial one. The concept is sound. I would like to dispel a common misconception concerning patients with rheumatoid arthritis-that they present a greater surgical risk than do patients with other forms of arthritis. DR. PLOTZ: Unless they are taking steroid. DR. SLEDGE: Even then, I am not certain that the risk is increased if the doses are small. There is published evidence that more than minimal doses of steroid do sometimes increase the risk of surgery. In our hands, mortality and the frequency of complications are no greater among patients with rheumatoid arthritis undergoing operation than among patients with osteoarthritis. DR. COYNE: The statement is often made that medical therapy should be tried for six months before surgery is considered. Would you agree? DR. SLEDGE: All of us, I think, who do this kind of surgery have seen arthritic patients in whom we thought there was every indication for surgical intervention except time. And with the passage of time we have seen remission which made surgery unnecessary. It is wise to delay surgery until one is sure that there is structural damage that is irreversible. In the case of a child, delay is even more appropriate and probably should be a minimum of six months. Referral of Patients to Rheumatologists DR. GRIFFITH: I would appreciate an expression from the panelists of their recommendations as to when a family physician should refer an arthritic patient to a rheumatologist. DR. JOHNSON: I would certainly like to have a rheumatologic consultation before giving steroids, gold, or antimalarials. DR. GRIFFITH: One reason why family physicians may be reluctant to use gold and tend to use steroid instead may be the fact that they have had experience with steroids in other disease states. Again and again they have seen dramatic responses to steroid given for other problems. If gold is as good as it is said to be, then

24

somehow we will have to work out ways and means of teaching family doctors how to use it and to give them confidence in supervising its use. I agree with Dr. Johnson about using gold or antimalarial or steroid. I would want someone to share the responsibility. DR. WARD: The importance of communication between referring physician and consultant deserves emphasis. The family physician should communicate clearly to the rheumatologist the reasons for referring a patient. DR. JOHNSON: It is important, I think, to ask specific questions of the consultant and to include past diagnostic and therapeutic data. DR. SMILEY: In many parts of the country, getting a patient an appointment with a rheumatologist can be very difficult. Rheumatologists in Texas are booked for six to eight months. So it falls on the primary physicians to make some of these decisions, including the difficult ones such as whether to use gold. DR. RODNAN: That is correct. All the rheumatologists now available, working full time, cannot possibly see even 10% of the patients with rheumatic disease. We have to do a better job of educating primary physicians in care of these individuals. DR. GRIFFITH: We have said that one of the important things to do for patients with arthritis is to teach them. We pay lip service to this concept, but I wonder how many physicians take short cuts and give only the briefest oral instructions. DR. PLOTZ: The Arthritis Foundation makes available an abundance of educational material that is very helpful to patients. Summary DR. PLOTZ: Dr. Smiley's discussion emphasizes the pyramidal nature of treatment for rheumatoid arthritis, a concept first promulgated by Dr. Charley J. Smyth. Building on the base of a good physician-patient relationship, simple home physiotherapy, and aspirin (a regimen that achieves control in about half the cases), the pyramid goes on through more potent anti-inflammatory agents, gold, hydroxychloroquine, and corticosteroids to the dangerous, narrow peak-immunosuppressive and cytotoxic drugs. These last require specialized consultation, but much of the earlier therapy can be administered by the family physician. •

CME credit quiz on rheumatic disease begins on page

62.

POSTGRADUATE MEDICINE • October 1975 • Vol. 58 • No. 5

Rheumatoid arthritis.

Postgraduate Medicine ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20 Rheumatoid arthritis J. Don...
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