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  #1  
Old 03-31-2013
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Question next step in management of rheumatoid arthritis?

guys, if a pt. is newly diagnosed with rheumatoid arthrits.....best initial treatment is.....?........NSAIDs or methotrexate(DMARD) or steroids.....?
this part confusing me alot...please give your explanations

thank you
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Old 04-01-2013
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76 views still no reply.....

do i asked a very silly question or the topic itself is confusing for all....?
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Old 04-01-2013
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Start both NSAIDs and MTX together. NSAIDs take care of acute symptoms while MTX takes 2 weeks to kick in. Steroids can be used if pain is severe during this time and not controlled by NSAIDs.
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Old 04-01-2013
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Quote:
Originally Posted by shinigami View Post
Start both NSAIDs and MTX together. NSAIDs take care of acute symptoms while MTX takes 2 weeks to kick in. Steroids can be used if pain is severe during this time and not controlled by NSAIDs.
thanks....it's a question from kaplan qbank....all 3 options were present....so according to you NSAIDs should be used to treat acute symptoms..?
i thought MTX as the initial treatment..........
qbank also gave NSAIDs as the right answer,but their explanation didnot convince me....they gave as NSAIDs as first line and MTX and steroids are for 2nd line treatment used when symptoms not resolved by NSAIDs...but i think your explanation does make sense
........thanks for your valuable reply..
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Old 04-01-2013
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Hi, the reason no one probably answered is because you can look it up on page 180 of MTB2 and uworld has a questions on this, however no worries I will help you out....

The first best thing to do after DX on MRI ALWAYS ALWAYS ALWAYS is a DMARD = METHOTREXATE (anti-metabolite=DMARD)...you can look it up in uworld/kaplan...

RA & PAIN


  • NSAIDS are for symptomatic control therapy for the pain and improve inflammation but DO NOT help in the progression of the disease...this is used on a daily basis and will be given with the methotrexate....
  • Steroids are used for those in unbearable excruciating pain and the person is agony ...because NSAIDS don't work as fast as steroids...and if they don't control the sx immediately...Also if you are waiting for Methotrexate/DMARDS to kick in then you will also give steroids (umm...this they probably won't even ask you...because if they are in so much pain you would give steroids...this is in the office and the pt didn't come in to throw back some tequila shots with you...naturally just makes sense because you want to stop the pain right away...)

SO with that being said....NSAIDS and Steroids DO NOT STOP the PROGRESSION of RA....in essence of what I'm saying is....the patient will come in and you will dx of RA on MRI....so then...

BEST INITIAL STEP:
DMARDS...which dmard you ask?? = METHOTREXATE

if they are not responding to methotrexate or intolerant of methotrexate...

TNF inhibitors : infilximab, adalimumab, etanercept

are added first line as DMARDS for those not responding to methotrexate or intolenrant of methotrexate

Q: so then question will be like patient on methotrexate + and wanting to add a anti-TNF...next best step?? what should you do???
ANS: get a PPD because it causes reactivation TB

or

the pt with RA and now has symtoms of TB + chest xray....what most likely caused it??? anti-TF agent (infliximab, adalimumab, etanercept)

Hydroxychloroquine
this can be used as monotherapy as DMARD in mild disease or when the pt has problems with methotrexate....AGAIN BEST INTIAL DMARD ALWAYS METHOTREXATE....usually it's used in combination with methotrexate...

Q: pt is dx with RA and they develop si/sx of retinopathy....what caused it? Hydroxychloroquine b/c it's toxic to the retina...

so these people should be getting regular eye exams...

Next OTHER ALTERNATIVE DMARDS...Sulfasalazine, Leflunomide, and Abatacept...

these are added to methotrexate IF anti-TNF agents do not control disease...again best initial DMARD: methotrexate

Sulfasalazine side effects: hemolysis with G6PD deficiency

Pt has RA and now develops anemia, jaundice, dark urine, hemolytic anemia, increased reticulocytes....what drug? Sulfasalazine

Rituximab
This is another DMARD agent that is used for LONG TERM therapy...but again best intial DMARD: methotrexate...

so the Q will be what will be effective for a pt in long term therapy and Rituximab is the right answer...


I guess I really hammered that best intial DMARD...you will never forget it now...everything else is a combination of drugs that is used at physician's discretion of tx and knowing the patient's hx and what will work for them or not or what to do if one drug fails and/or adding drugs together....best thing is to know side effects to the drugs...they have to make it clear as far as the drugs go otherwise we won't be able to answer the questions on the exam ...I hope this helped you!
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  #6  
Old 04-01-2013
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Quote:
Originally Posted by venky2600 View Post
thanks....it's a question from kaplan qbank....all 3 options were present....so according to you NSAIDs should be used to treat acute symptoms..?
i thought MTX as the initial treatment..........
qbank also gave NSAIDs as the right answer,but their explanation didnot convince me....they gave as NSAIDs as first line and MTX and steroids are for 2nd line treatment used when symptoms not resolved by NSAIDs...but i think your explanation does make sense
........thanks for your valuable reply..
You're welcome. According to MTB 2 -
1) NSAIDs are the best initial therapy for the pain of RA
2) DMARDs should be included in initial management of erosive RA and the best DMARD is MTX
...
So I suppose it depends on how the case presents. If you find radiographic evidence of erosion you could start the pt on MTX right away. I still think combining both right away is the right way to go.

Last edited by shinigami; 04-01-2013 at 09:00 AM.
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  #7  
Old 04-01-2013
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thanks @paresa and @shingami..for taking your time and giving valuable explanations.......i think this kaplan qbank question confused me alittle....

now conclusion is......for pain control immediate management-->NSAID(as DMARD take time to work)
for initial management----->DMARD(MTX)

thanks....
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Old 04-01-2013
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Welcome!...I hope you understand better now...honestly don't worry about the pain management....like I said you take the nsaid long term on daily basis...and steroid with uncontrollable pain and presenting with uncontrollable pain sx...and you know the rest...

if you wanna post the question...we could discuss it and help you further??....

and when in doubt when all else fails...3 tequila shots should do the trick haha jk
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Old 04-03-2013
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Quote:
Originally Posted by paresa View Post
Welcome!...I hope you understand better now...honestly don't worry about the pain management....like I said you take the nsaid long term on daily basis...and steroid with uncontrollable pain and presenting with uncontrollable pain sx...and you know the rest...

if you wanna post the question...we could discuss it and help you further??....

and when in doubt when all else fails...3 tequila shots should do the trick haha jk
apology for my late reply...took time for searching the question.....i dont know whether admins would allow me to post the question....here it as follows

q) a 28 yr old woman comes to office complaining of 8wks of morning stiffness which longs for an hour daily,which is relieved as the day progesses..she also reports 9-lb weightloss in this period along with fatigue mildly. her vitals are within normal limits....there is swelling in her PIP,MCP joints and wrists..swelling is symmetric..there is palpable effusion ...arthrocentesis findings-----> WBC-10,000/mm3
no crystals,no organisms on gram stain...

which of the following is the most appropriate first-line pharmacological intervention...?

a) MTX
b) NSAID's
c) prednisolone
d) aspirin
e) ceftriaxone
f) rasburicase
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