Chapter 10 – MSK System
SPONDYLOARTHRITIS
Chapter 10 –
Affects both axial and peripheral joints
Musculoskeletal
System Tx for axial spondylarthritis
NSAID – at lowest effective dose
TNF-alpha inhibitor
OSTEOARTHRITIS
For severe non-radiographic axial
Treatment spondylarthritis = adalimumab,
Paracetamol +/- NSAID – regularly certolizumab, etanercept
Topical NSAID or capsaicin 0.025% - esp. in
Psoriatic arthritis = local corticosteroid
hand and knee OA
injections, standard DMARDs, NSAID
Sodium hyaluronate – post ankle sprain
Reactive arthritis = after treating initial
RHEUMATOID ARTHRITIS infection, avoid long-term Tx (>4 weeks) with an
Persistent symmetrical joint synovitis AB solely to manage RA caused by a GI
typically of the small joints of hands/feet intestinal or genito-urinary infection
Synovitis = pain and prolonged stiffness Rheumatic disease – suppressing drugs
that’s worse at rest or inactivity, swelling, 1. Gold (sodium aurothiomalate) – given via
tenderness and heat, rheumatoid nodules, deep IM and area gently massaged.
malaise, fatigue, fever, weight loss Weekly doses given incl. test dose
Palindromic rheumatism – causes attacks of 2. Penicillinamine – discontinue if there’s no
joint pain and swelling improvement in 1 year
Drug Tx 3. Sulfasalazine – haematological effects may
occur in the first 3-6 months of Tx and are
1st line in newly diagnosed = DMARD reversible on cessation
(sulfasalazide, MTX or leflunomide) or 4. Antimalarials (hydroxychloroquine,
hydroxychloroquine chloroquine) – effective for mild SLE but
Bridging Tx as DMARDs have a slow onset avoid in psoriatic arthritis
of action (2-3 months) = corticosteroid
(oral, IM or intra-articular) Drugs affecting the immune response
Add-on Tx = a 2nd DMARD or hydroxy. 1. MTX – given once weekly.
Poor response to combination Tx = tumour 2. Leflunomide – therapeutic effect starts after
necrosis factor (TNF) alpha inhibitor 4-6 weeks
Severe, active RA = rituximab Juvenile idiopathic arthritis = MTX or
Pain relief = oral NSAID, paracetamol or sulfasalazine
selective COX-2 inhibitor. Use PPI to reduce
GI effects. Withdraw NSAID if not needed
If maintained Tx for at least 1 year without
corticosteroids, reduce drug dose to lowest
clinically effective dose or taper and stop at
least 1 drug if being treated with >1 DMARD
Surgery – if Tx has failed, there’s worsening of HYPERURICAEMIA AND GOUT
joint function, progressive deformity or
persistent localised synovitis Acute attacks of gout = NSAID (diclofenac,
etoricoxib, indomethacin, ketoprofen, naproxen,
SPONDYLOARTHRITIS
Chapter 10 –
Affects both axial and peripheral joints
Musculoskeletal
System Tx for axial spondylarthritis
NSAID – at lowest effective dose
TNF-alpha inhibitor
OSTEOARTHRITIS
For severe non-radiographic axial
Treatment spondylarthritis = adalimumab,
Paracetamol +/- NSAID – regularly certolizumab, etanercept
Topical NSAID or capsaicin 0.025% - esp. in
Psoriatic arthritis = local corticosteroid
hand and knee OA
injections, standard DMARDs, NSAID
Sodium hyaluronate – post ankle sprain
Reactive arthritis = after treating initial
RHEUMATOID ARTHRITIS infection, avoid long-term Tx (>4 weeks) with an
Persistent symmetrical joint synovitis AB solely to manage RA caused by a GI
typically of the small joints of hands/feet intestinal or genito-urinary infection
Synovitis = pain and prolonged stiffness Rheumatic disease – suppressing drugs
that’s worse at rest or inactivity, swelling, 1. Gold (sodium aurothiomalate) – given via
tenderness and heat, rheumatoid nodules, deep IM and area gently massaged.
malaise, fatigue, fever, weight loss Weekly doses given incl. test dose
Palindromic rheumatism – causes attacks of 2. Penicillinamine – discontinue if there’s no
joint pain and swelling improvement in 1 year
Drug Tx 3. Sulfasalazine – haematological effects may
occur in the first 3-6 months of Tx and are
1st line in newly diagnosed = DMARD reversible on cessation
(sulfasalazide, MTX or leflunomide) or 4. Antimalarials (hydroxychloroquine,
hydroxychloroquine chloroquine) – effective for mild SLE but
Bridging Tx as DMARDs have a slow onset avoid in psoriatic arthritis
of action (2-3 months) = corticosteroid
(oral, IM or intra-articular) Drugs affecting the immune response
Add-on Tx = a 2nd DMARD or hydroxy. 1. MTX – given once weekly.
Poor response to combination Tx = tumour 2. Leflunomide – therapeutic effect starts after
necrosis factor (TNF) alpha inhibitor 4-6 weeks
Severe, active RA = rituximab Juvenile idiopathic arthritis = MTX or
Pain relief = oral NSAID, paracetamol or sulfasalazine
selective COX-2 inhibitor. Use PPI to reduce
GI effects. Withdraw NSAID if not needed
If maintained Tx for at least 1 year without
corticosteroids, reduce drug dose to lowest
clinically effective dose or taper and stop at
least 1 drug if being treated with >1 DMARD
Surgery – if Tx has failed, there’s worsening of HYPERURICAEMIA AND GOUT
joint function, progressive deformity or
persistent localised synovitis Acute attacks of gout = NSAID (diclofenac,
etoricoxib, indomethacin, ketoprofen, naproxen,
