W. Carson Dick

Pharmacology of the Drugs Used in the Treatment of Chronic Arthritis

This section is devoted to description of the drugs used in this field beyond the context of individual diseases. Apart from certain unusual instances such as the deployment of the appropriate antibiotic in a patient with infectious arthritis or the prescription of allopurinol in gout, most of rheumatology consists of the management of patients with chronic incurable disease on a symptomatic basis. The drugs prescribed do not exert a specific effect upon the pathological basis of the disease but rather are prescribed to relieve symptoms and thereby hopefully to improve function and the patient’s ability to cope with the presence of the disease. Much of this concept has been stressed beforehand in the context of the individual diseases. It is on this basis that the doctrine of primum non nocere becomes central.

The Seronegative Spondarthritides

“Seronegative spondarthritides” is a clumsy expression yet it embodies much that is important in clinical rheumatology. The original concept was developed upon a secure basis of solid long-term clinical documentation, notably in the Leeds unit and in Taplow. At an early stage it was recognised that the term “seronegative rheumatoid arthritis” represented a destructive concept, lumping patients together and forcing them to fit the outdated textbook. The development of rheumatology from that time when this false standard was lowered has been one of unfettered advance.

Connective Tissue Disorders

This is a difficult and controversial area where the exotic may fascinate to deceive. Ironically patients with one of the more common chronic arthritides are often neglected while patients with equally incurable but rare connective tissue disorders may suffer from a surfeit of attention. Thus patients with one of the multisystem diseases such as SLE are often overinvestigated, overdoctored and overtreated.

Antimalarials and Other Second-Line Drugs

The use of antimalarials in rheumatoid arthritis has had a chequered history since the publication of controlled studies in the 1950s.

The General Principles of Management of Chronic Arthritis in the Context of a Patient with Rheumatoid Arthritis

The bland statement “there is nothing more to be done” is frequently made to the patient with chronic arthritis and reflects observer ignorance and indifference. There is much palliative, supportive and reconstructive care which can and should be provided at each stage in the disease. If a medical practitioner feels unable to offer constructive aid, consultation with medical and paramedical colleagues is mandatory. There is always something which can be done, and a disabled patient who is looking for help should not be disappointed. The following points are relevant (and should be read in conjunction with relevant sections in Chaps. 2, 3 and 4).

Pain in the Neck, Low Back Pain and Degenerative Disc Disease

Pain in the neck is common and is the cause of considerable morbidity. This clinical syndrome has various causes: 1. Infection: pyogenic, tuberculosis, meningitis 2. Inflammation: seronegative spondarthritides, rheumatoid arthritis 3. Degenerative: osteoarthritis, degenerative disc disease 4. Structural: cervical rib, cervical canal stenosis 5. Metabolic: osteopenia, osteomalacia 6. Trauma: fracture, non-articular strain, “whiplash injury” 7. Non-specific pain: soft tissue rheumatism, postural, “psychogenic” 8. Referred pain: retropharyngeal pathology 9. Neoplastic: secondary, primary (intra- or extramedullar lesion)

General Principles and Approach to the Patient in the Context of Osteoarthritis

Osteoarthritis has a venerable history, having been recorded in Egyptian mummies and in dinosaurs of the Pleistocene era. It is now obvious that the term osteoarthritis represents a syndrome, not a disease. Furthermore the term means different things to different people. To the pathologist it implies fibrillation and destruction of the cartilage surface with clustering of chondrocytes around the bases of deep clefts, remodelling and sclerosis of subchondral bone, changes in the composition and characteristics of synovial fluid and the development of marginal osteophytes. To the radiologist the word suggests loss of joint “space” (reflecting cartilage destruction), osteophytosis, bone cysts and increased density of subchondral bone. To the clinician the word conjures up a picture of a very common clinical problem where the patient complains of pain more than stiffness, and of functional disability but where the disease process is confined essentially to one or to a few affected joints.

Infective Arthritis and Polymyalgia Rheumatica/Giant Cell Arteritis

Despite the variety of organisms which are responsible for infecting bones and joints, the possible responses to these agents by the host is limited and hence the symptoms and signs of an infective arthritis are relatively stereotyped (Table 11.1). Where differences do occur they are differences in emphasis rather than in basic pathophysiology.

General Medical and Metabolic Diseases

Both haemophilia A (factor VIII) and haemophilia B (factor IX) are inherited as X-linked recessive diseases and in both the functional defect is in the intrinsic pathway, the extrinsic tissue-factor-dependent pathway being the only mechanism left intact to subserve haemostasis. The most important consequence of haemophilia is arthritis and it is interesting that synovial tissue is deficient in tissue factor, which may explain this association. Arthritis occurs only in those patients who are severely affected, with concentrations of circulating antihaemophiliac globulin of less than 5%, and onset is usually in childhood. The knee and the elbow joints are most commonly involved and may become swollen acutely either spontaneously or after only the most minor trauma. Range of movement, usually preserved after the first episode, is progressively lost with subsequent attacks and severe joint destruction and deformity may follow. Extra-articular bleeding is also common.

Juvenile Chronic Arthritis

This is one of the most exciting areas of medicine at the moment, and recent developments have forced us to change our views in this more than in most other areas. The foundation of these changes in attitude are soundly based on the most reliable long-term data available in rheumatology. At Taplow in England a large group of thoroughly documented children have now been followed up through three generations. This is the epitome of the best of clinical research and serves as a standard for other clinical work in this and in other fields. The eponymous term “Still’s disease” should be restricted to patients presenting with a systemic illness, lymphadenopathy, polyserositis, polyarthritis and a distinctive skin rash and should not be used as a ragbag term to conceal the need for thorough clinical documentation. This is said with all respect to George Frederick Still, who himself recognised the heterogeneity of the cases which he described.