#DMARDs

[mcatmemoranda]

Management principles – Treatment of psoriatic arthritis (PsA) should be started early in disease and be coordinated among a rheumatologist, primary care clinician, and other specialists (eg, a dermatologist). Differences in response to individual therapies between the skin and joints, and among different musculoskeletal manifestations, are commonly observed. Treatment is guided initially by an assessment of disease severity, including the degree of disease activity, damage, and impact on the patient for each clinical domain. Attention to the most severely involved region, such as axial or peripheral arthritis, should help guide therapy.

●Treatment goals – A treat-to-target approach should be employed for peripheral and axial arthritis, with a target of remission/inactive disease or low/minimal disease activity.

●Pretreatment interventions – Patients should undergo pretreatment screening for comorbidities and baseline testing and appropriate vaccinations before drug administration. They should be referred as needed for prevention and medical management of comorbidities, such as cardiovascular and liver disease and related risk factors.

●Nonpharmacologic strategies – Nonpharmacologic management strategies are important in the treatment of PsA in addition to drug therapy; these include physical and occupational therapy, exercise, prescription of orthotics, and education regarding the disease and about joint protection, disease management, and proper use of medications. Patients should receive assistance in weight reduction, counseling and treatment for anxiety and depression, and management of cardiovascular risk factors and other comorbidities.

●Management of mild peripheral arthritis

•Initial management – In patients with mild peripheral arthritis, defined as disease involving less than four joints, no radiologic evidence of damage, and minimal discomfort or functional impairment, we suggest initiating treatment with a nonsteroidal antiinflammatory drug (NSAID; eg, naproxen 375 to 500 mg twice daily, or celecoxib 200 mg twice daily) rather than starting a disease-modifying antirheumatic drug (DMARD) (Grade 2C). NSAIDs can help control the mild inflammatory symptoms of PsA and may also lessen pain and stiffness in associated spondylitis. A concern that NSAIDs may aggravate the skin psoriasis remains unproven. An alternative that may be effective and safer for some patients, particularly those with multiple comorbidities, is apremilast (30 mg twice daily).

•Mild peripheral arthritis unresponsive to NSAIDs – In patients whose peripheral arthritis remains active despite the use of NSAIDs or is moderate to severe without erosions or substantial functional limitations, and who lack axial symptoms or have such symptoms as are well-controlled with NSAIDs, we suggest a conventional (small molecule) DMARD, usually methotrexate (MTX; 15 to 25 mg once weekly) rather than a biologic agent (Grade 2C). Limited randomized trial data support the use of a conventional DMARD in PsA, but its use is supported by evidence of benefit in other forms of inflammatory polyarthritis, efficacy for psoriasis, expert opinion, and clinical experience in such patients. We initiate or continue NSAIDs as bridging or adjunctive therapy as needed in patients begun on DMARDs. (See 'Choice of nonbiologic DMARD and other agents' above and 'MTX use and efficacy' above.)

•Alternative therapies for mild peripheral arthritis – Alternatives to MTX for the peripheral arthritis include leflunomide (LEF; 20 mg daily) and sulfasalazine (SSZ), which can be tried in patients unable to take either MTX or LEF. However, unlike MTX, which is also effective for psoriasis in some patients, LEF is less helpful than MTX for the skin disease, and SSZ is not effective for psoriasis and the efficacy for PsA is limited. Another alternative to MTX is apremilast, which may be particularly useful for patients who wish to avoid DMARD therapy, infusions, or injections, although only a portion of patients respond. It is also effective for psoriasis. Apremilast should not be used in patients with erosive disease, as the capacity of apremilast to prevent joint injury has not been established or adequately examined in PsA or in other forms of inflammatory arthritis. (See 'Choice of nonbiologic DMARD and other agents' above and 'Leflunomide' above and 'Apremilast' above and 'Sulfasalazine' above.)

●Management of severe peripheral arthritis

•Initial management – In patients presenting with severe disease who already have erosive disease and functional limitation, we suggest a tumor necrosis factor (TNF) inhibitor as first-line therapy, rather than a conventional nonbiologic DMARD (Grade 2B). Another biologic DMARD (eg, secukinumab, ustekinumab guselkumab) or Janus kinase/signal transducer and activator of transcription (JAK/STAT) inhibitors are acceptable alternatives to a TNF inhibitor in such patients. We prefer this approach because of the capacity of the TNF inhibitors and other biologic agents, demonstrated in multiple randomized trials and in contrast to MTX and the other conventional nonbiologic DMARDs, to limit joint damage and more rapidly restore function. (See 'Severe peripheral arthritis/adverse prognosis' above and 'Choice of TNF inhibitor' above and 'TNF inhibitor dose and administration' above.)

•Severe peripheral arthritis unresponsive to DMARDs – In patients whose joint counts do not improve substantially after three months of treatment with a conventional nonbiologic DMARD (eg, MTX), or who still have more than three tender and swollen joints, we recommend a TNF or interleukin (IL) 17 inhibitor rather than sequential trials of other conventional DMARDs (Grade 1B). The choice of the agent is based upon patient preferences for route (subcutaneous versus intravenous) and frequency of administration, regulatory and payor requirements and limitations, and potential cost to the patient. (See 'Resistant to nonbiologic DMARDs' above and 'Choice of TNF inhibitor' above and 'TNF inhibitor dose and administration' above.)

•Severe peripheral arthritis unresponsive to TNF inhibition – In patients with peripheral arthritis who experience an inadequate response to an initial TNF inhibitor, we use a second TNF inhibitor rather than trying a different class of biologic agent unless the patient experienced a severe adverse event (eg, sepsis, demyelination) or primary nonresponse. We prefer to switch from one of the antibody-based agents (eg, infliximab, adalimumab, golimumab, or certolizumab) to the soluble TNF receptor (etanercept) and vice versa. (See 'Choice of agent' above.)

•Severe peripheral arthritis unresponsive to multiple TNF inhibitors – In patients with peripheral arthritis who do not respond adequately to two different TNF inhibitors, we use an alternative biologic agent rather than another TNF inhibitor. We prefer secukinumab (administered by subcutaneous injection, usually with a loading dose of 150 mg given at weeks 0, 1, 2, 3, and 4, followed by 150 mg every four weeks; it may be increased to 300 mg every four weeks in patients who continue to have active arthritis). Ixekizumab is also effective (administered 80 mg every 2 weeks for 12 weeks followed by 80 mg monthly). In patients without an adequate response to secukinumab, we use guselkumab (by subcutaneous injection, 100 mg, given initially and four weeks later followed by 100 mg subcutaneously monthly). Either of these agents may be given with or without MTX. Ustekinumab, tofacitinib, upadacitinib, and abatacept are other treatment options for patients in whom other drugs have failed or have contraindications. (See 'Choice of agent' above and 'Secukinumab' above and 'Ustekinumab' above.)

●Management of axial disease

•Mild axial disease – In patients with mild symptoms of axial disease, which includes patients with inflammatory back pain that does not interfere with function, we suggest NSAIDs in antiinflammatory-dose regimens (eg, naproxen 375 to 500 mg twice daily, indomethacin 100 to 150 mg daily in divided doses, celecoxib 200 mg twice daily), rather than a biologic agent (Grade 2B). (See 'Mild axial symptoms' above.)

•Axial disease unresponsive to NSAIDs – In patients with axial symptoms that do not respond adequately to treatment with NSAIDs, such as those with prolonged morning stiffness and severe pain interfering with function, we recommend a TNF inhibitor rather than a traditional nonbiologic DMARD, as the latter have been shown to be ineffective in spondylitis (Grade 1B). The choice of agent and dosing are the same as those used for peripheral arthritis. (See 'Resistant to nonbiologic DMARDs' above and 'Choice of TNF inhibitor' above and 'TNF inhibitor dose and administration' above.)

•Axial disease unresponsive to TNF inhibition – In patients with axial symptoms that do not respond adequately to initial therapy with a TNF inhibitor, we use the same approach described for peripheral arthritis, switching to a second TNF inhibitor and, if that is inadequate, to an alternative biologic agent such as secukinumab or a JAK/STAT inhibitor. (See 'Resistant to initial TNF inhibitor' above.)

●Management of enthesitis – In patients with enthesitis or dactylitis, a response is often seen with medications used for other manifestations of PsA. In patients with enthesitis causing functional impairment who do not respond to NSAIDs and local therapy, we use a biologic agent, initially a TNF or IL-17 inhibitor. In patients with dactylitis who do not respond to NSAIDs, a response to a conventional DMARD (eg, MTX 15 to 25 mg once weekly) is sometimes seen, but if a conventional nonbiologic DMARD is inadequate, patients should be treated with a biologic agent (eg, a TNF or IL-17 inhibitor). (See 'Enthesitis and dactylitis' above and 'Enthesitis' above and 'Dactylitis' above.)

●Minimal role for glucocorticoids – Use of oral glucocorticoids in patients with PsA should be avoided, and when required (eg, for severe flares), the dose should be the minimum needed, since their use is associated with an increased chance of developing erythroderma or pustular psoriasis; in addition, there appears to be interference with the effect of other drugs. It is important, however, to taper the glucocorticoids slowly and with close observation for the development of erythroderma or pustular psoriasis. Intraarticular glucocorticoids are sometimes used, and care should be taken in patients who require such injections to avoid injection through psoriatic plaques. (See 'Role of glucocorticoids' above.)

●Prognosis – PsA has variable disease expression; a significant proportion of patients may develop destructive and potentially disabling disease. Factors predicting a poor prognosis include a higher number of actively inflamed joints, an elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), failure of previous medication trials, the presence of joint damage, loss of function, and diminished quality of life. (See 'Prognosis' above.)

●Disease monitoring – Clinical monitoring of disease should include joint counts that assess both the upper and lower extremities, and the number of areas involved by enthesitis and by dactylitis. In clinical practice, plain film radiography of clinically involved peripheral joints, the sacroiliac joints, and the spine are used to assess the extent and progression of disease at these sites. (See 'Assessment for clinical care' above.)

[dmardsanddaisies]

Welp, ya girl had a pretty productive day today! 😖

1) I'm meeting with the Disability office on Wednesday to do paperwork (cross your fingers I get approved in 6 months, lol).

2) Thursday I write my midterm at 11am.

3) I went to my Rheumatologist appointment, aaaand Sulfasalazine doesn't seem to be helping me at all after 4 months, so I'm going to start Adalimunab / biologic medication to see if we can get these flare ups under control... Can't wait for the massive delays due to Insurance arguing with my doctor 🥴😖😑

4) I gotta book a chest x-ray, blood work, and a TB test.

I also had a really good sandwich today, and yet again got some of my food on a white shirt. I can't wear white. I don't know why I keep doing this to myself 😂.

[mandana-the-service-pup]

I snagged a last minute virtual appointment with Rheumatology this morning. We’re going to try another round of steroid (Medrol/Methylprednisolone) to see we if we can get this awful multi-month flare under control. Last time I took it for a week and it helped but all the symptoms came back a week later. This time I’m taking a higher dose for a week and then the original dose for a second week. If this doesn’t work then we will add an additional DMARD to my regime (most likely Imuran/Azathioprine)

Mandana wasn’t sure if she wanted to go shopping with me today. I gave her some time to decide and turns out she just wanted to make sure she could go to the bathroom first. I always give her a chance to go potty before we go but she needed to go a second time so I’m glad she made her needs known.

She was super good as always. We went to the pharmacy and then grabbed a few groceries.

My knees and back are hurting bad today. I put Mandana on a tie out in the front yard with some water and scattered kibble while I slowly brought the groceries in a little at a time.

[kiwitheft]

Give me strength to call a rheumatologist please

[criticalbread]

pain pain pain pain pain pain pain pain ow

just wanted to go of methotrexate cuz i thought it wadnt doing nothing and it made me nauseated whenever i got hungry

yeah it was doin something and now it’s not and ow ow ow ow ow ow ow

[system-splintered]

Big news guys!

Saw my Rheum today and she decided that since the methotrexate isn't helping much with the pain (although my CRP has gone down! So that's good) we needed to either add Sulfasalazine or Humira and she let me pick. I didn't know anything about Sulfasalazine but I did have a really strong negative reaction to the other conventional DMARD she gave me, hydroxychloroquine, and we'd already talked about Humira so I'd researched it between appointments, so I just went with that. I will have to use the next few years with state Healthcare to try and figure out how to get better insurance that will pay for medicines like that with a low copay. As without it, this drug is more than $7,500 *with a goodrx coupon* like wtf.

But until 2026 I have insurance that covers it completely so I'm taking the chance to use it while I can.

Any advice from folks with RA who are on or have tried Humira?

[mirabelmadrigal2310]

Treatment for Psoriatic Arthritis

Psoriatic arthritis is a chronic inflammatory condition that affects individuals with psoriasis, a skin disorder characterized by red, scaly patches. Treatment for psoriatic arthritis aims to alleviate symptoms, reduce inflammation, and prevent joint damage. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen may be prescribed to manage pain and inflammation. Disease-modifying antirheumatic drugs (DMARDs) like methotrexate or sulfasalazine are often used to slow down the progression of joint damage. In cases of more severe disease, biologic medications, such as tumor necrosis factor (TNF) inhibitors like adalimumab or etanercept, may be recommended to target specific components of the immune system responsible for inflammation. Additionally, lifestyle modifications, including regular exercise, a balanced diet, and stress management, can contribute to overall well-being and help manage symptoms of psoriatic arthritis.

[thepictoblr]

I need it to be known that ive been on dmards for like 4-5 months now and my bitch ass now has covid and i cant for the LIFE of me work out through googling the god damn question if i should stop taking them whilst i'm unwell so this fucking infection doesnt fucking kill me

[nursingscience]

Medical Abbreviations on Pharmacy Prescriptions

Here are some common medical abbreviations you may see on pharmacy prescriptions:

qd - once a day

bid - twice a day

tid - three times a day

qid - four times a day

qh - every hour

prn - as needed

pc - after meals

ac - before meals

hs - at bedtime

po - by mouth

IV - intravenous

IM - intramuscular

subQ - subcutaneous

mL - milliliter

mg - milligram

g - gram

mcg - microgram

stat - immediately, right away

NPO - nothing by mouth

cap - capsule

tab - tablet

susp - suspension

sol - solution

amp - ampule

inj - injection

Rx - prescription

C - Celsius

F - Fahrenheit

BP - blood pressure

HR - heart rate

RR - respiratory rate

WBC - white blood cell

RBC - red blood cell

Hgb - hemoglobin

Hct - hematocrit

PT - prothrombin time

INR - international normalized ratio

BUN - blood urea nitrogen

Cr - creatinine

Ca - calcium

K - potassium

Na - sodium

Cl - chloride

Mg - magnesium

PO2 - partial pressure of oxygen

PCO2 - partial pressure of carbon dioxide

ABG - arterial blood gas

CBC - complete blood count

BMP - basic metabolic panel

CMP - comprehensive metabolic panel.

ECG - electrocardiogram

EEG - electroencephalogram

MRI - magnetic resonance imaging

CT - computed tomography

PET - positron emission tomography

CXR - chest x-ray

CTX - chemotherapy

NSAID - nonsteroidal anti-inflammatory drug

DMARD - disease-modifying antirheumatic drug

ACE - angiotensin-converting enzyme

ARB - angiotensin receptor blocker

SSRI - selective serotonin reuptake inhibitor

TCA - tricyclic antidepressant

ADHD - attention deficit hyperactivity disorder

COPD - chronic obstructive pulmonary disease

CAD - coronary artery disease

CHF - congestive heart failure

DVT - deep vein thrombosis

GI - gastrointestinal

UTI - urinary tract infection

OTC - over-the-counter

Rx - prescription

OD - right eye

OS - left eye

OU - both eyes.

TID - thrombosis in dementia

TDS - ter die sumendum (three times a day)

BOM - bilaterally otitis media (infection in both ears)

BT - body temperature

C&S - culture and sensitivity

D/C - discontinue or discharge

D/W - dextrose in water

ETOH - ethyl alcohol

FUO - fever of unknown origin

H&P - history and physical examination

I&D - incision and drainage

I&O - intake and output

KVO - keep vein open

N&V - nausea and vomiting

PERRLA - pupils equal, round, reactive to light and accommodation

PR - per rectum

QAM - every morning

QHS - every bedtime

QOD - every other day

S/P - status post (after)

TPN - total parenteral nutrition

UA - urinalysis

URI - upper respiratory infection

UTI - urinary tract infection

VO - verbal order.

XRT - radiation therapy

YOB - year of birth

BRBPR - bright red blood per rectum

CX - cervix

DVT - deep vein thrombosis

GB - gallbladder

GU - genitourinary

HCV - hepatitis C virus

HPI - history of present illness

ICP - intracranial pressure

IVP - intravenous pyelogram

LMP - last menstrual period

MRSA - methicillin-resistant Staphylococcus aureus

MVA - motor vehicle accident

NKA - no known allergies

PEG - percutaneous endoscopic gastrostomy

PRN - pro re nata (as needed)

ROS - review of systems

SOB - shortness of breath

TAH - total abdominal hysterectomy.

TIA - transient ischemic attack

Tx - treatment

UC - ulcerative colitis

URI - upper respiratory infection

VSD - ventricular septal defect

VTE - venous thromboembolism

XR - x-ray

w/c - wheelchair

XRT - radiation therapy

ASD - atrial septal defect

Bx - biopsy

CAD - coronary artery disease

CKD - chronic kidney disease

CPAP - continuous positive airway pressure

DKA - diabetic ketoacidosis

DNR - do not resuscitate

ED - emergency department

ESRD - end-stage renal disease

FFP - fresh frozen plasma

FSH - follicle-stimulating hormone.

GCS - Glasgow Coma Scale

Hct - hematocrit

Hgb - hemoglobin

ICU - intensive care unit

IV - intravenous

JVD - jugular venous distension

K - potassium

L - liter

MCH - mean corpuscular hemoglobin

MI - myocardial infarction

Na - sodium

NGT - nasogastric tube

NPO - nothing by mouth

OR - operating room

PCN - penicillin

PRBC - packed red blood cells

PTT - partial thromboplastin time

RBC - red blood cells

RT - respiratory therapy

SOA - short of air.

SCD - sequential compression device

SIRS - systemic inflammatory response syndrome

STAT - immediately

T - temperature

TPN - total parenteral nutrition

WBC - white blood cells

ABG - arterial blood gas

A fib - atrial fibrillation

BPH - benign prostatic hypertrophy

CBC - complete blood count

CO2 - carbon dioxide

COPD - chronic obstructive pulmonary disease

CPR - cardiopulmonary resuscitation

CT - computed tomography

CXR - chest x-ray

D5W - dextrose 5% in water

Dx - diagnosis

ECG or EKG - electrocardiogram

EEG - electroencephalogram

ETO - early termination of pregnancy.

FHR - fetal heart rate

GSW - gunshot wound

H&P - history and physical exam

HCG - human chorionic gonadotropin

I&D - incision and drainage

IBS - irritable bowel syndrome

ICP - intracranial pressure

IM - intramuscular

INR - international normalized ratio

IOP - intraocular pressure

LFT - liver function test

LOC - level of consciousness

LP - lumbar puncture

NG - nasogastric

OA - osteoarthritis

OCD - obsessive-compulsive disorder

OTC - over-the-counter

P - pulse

PCA - patient-controlled analgesia

PERRLA - pupils equal, round, reactive to light and accommodation.

PFT - pulmonary function test

PICC - peripherally inserted central catheter

PO - by mouth

PRN - as needed

PT - physical therapy

PT - prothrombin time

PTSD - post-traumatic stress disorder

PVC - premature ventricular contraction

QD - once a day

QID - four times a day

RA - rheumatoid arthritis

RICE - rest, ice, compression, elevation

RSI - rapid sequence intubation

RSV - respiratory syncytial virus

SBP - systolic blood pressure

SLE - systemic lupus erythematosus

SSRI - selective serotonin reuptake inhibitor

STAT - immediately

TB - tuberculosis

TIA - transient ischemic attack.

TID - three times a day

TKO - to keep open

TNTC - too numerous to count

TPN - total parenteral nutrition

URI - upper respiratory infection

UTI - urinary tract infection

V-fib - ventricular fibrillation

V-tach - ventricular tachycardia

VA - visual acuity

WNL - within normal limits

AED - automated external defibrillator

ARDS - acute respiratory distress syndrome

BID - twice a day

BP - blood pressure

BUN - blood urea nitrogen

CAD - coronary artery disease

CHF - congestive heart failure

CVA - cerebrovascular accident

D/C - discontinue

DKA - diabetic ketoacidosis.

DM - diabetes mellitus

DVT - deep vein thrombosis

EGD - esophagogastroduodenoscopy

ER - emergency room

F - Fahrenheit

Fx - fracture

GI - gastrointestinal

GTT - glucose tolerance test

HCT - hematocrit

Hgb - hemoglobin

HRT - hormone replacement therapy

ICP - intracranial pressure

IDDM - insulin-dependent diabetes mellitus

IBS - irritable bowel syndrome

IM - intramuscular

IV - intravenous

K - potassium

KVO - keep vein open

L&D - labor and delivery

LASIK - laser-assisted in situ keratomileusis.

ROM - range of motion

RT - radiation therapy

Rx - prescription

SCD - sequential compression device

SOB - shortness of breath

STD - sexually transmitted disease

TENS - transcutaneous electrical nerve stimulation

TIA - transient ischemic attack

TSH - thyroid-stimulating hormone

UA - urinalysis

US - ultrasound

UTI - urinary tract infection

VD - venereal disease

VF - ventricular fibrillation

VT - ventricular tachycardia

WBC - white blood cell

XRT - radiation therapy

XR - x-ray

Zn - zinc

Z-pak - azithromycin (antibiotic).

AAA - abdominal aortic aneurysm

ABG - arterial blood gas

ACS - acute coronary syndrome

ADL - activities of daily living

AED - automated external defibrillator

AIDS - acquired immunodeficiency syndrome

ALS - amyotrophic lateral sclerosis

AMA - against medical advice

AML - acute myeloid leukemia

APAP - acetaminophen

ARDS - acute respiratory distress syndrome

ASCVD - atherosclerotic cardiovascular disease

BPH - benign prostatic hyperplasia

BUN - blood urea nitrogen

CABG - coronary artery bypass graft

CBC - complete blood count

CHF - congestive heart failure

COPD - chronic obstructive pulmonary disease

CPAP - continuous positive airway pressure

CRF - chronic renal failure.

CT - computed tomography

CVA - cerebrovascular accident

D&C - dilation and curettage

DVT - deep vein thrombosis

ECG/EKG - electrocardiogram

EEG - electroencephalogram

ESRD - end-stage renal disease

FSH - follicle-stimulating hormone

GERD - gastroesophageal reflux disease

GFR - glomerular filtration rate

HbA1c - glycated hemoglobin

Hct - hematocrit

HIV - human immunodeficiency virus

HPV - human papillomavirus

HTN - hypertension

IBD - inflammatory bowel disease

IBS - irritable bowel syndrome

ICU - intensive care unit

IDDM - insulin-dependent diabetes mellitus

IM - intramuscular.

IV - intravenous

LFT - liver function test

MI - myocardial infarction

MRI - magnetic resonance imaging

MS - multiple sclerosis

NPO - nothing by mouth

NS - normal saline

OCD - obsessive-compulsive disorder

OSA - obstructive sleep apnea

PCOS - polycystic ovary syndrome

PMS - premenstrual syndrome

PPD - purified protein derivative

PSA - prostate-specific antigen

PT - prothrombin time

PTT - partial thromboplastin time

RA - rheumatoid arthritis

RBC - red blood cell

RSV - respiratory syncytial virus

SLE - systemic lupus erythematosus

TB - tuberculosis.

It is important to remember that medical abbreviations can vary based on location and specialty. 

Healthcare professionals should use medical abbreviations with caution and only when they are familiar with their meanings. 

Patients should always communicate any questions or concerns they have about their medications or medical care to their healthcare provider or pharmacist to ensure they receive safe and accurate medical care.

[mcatmemoranda]

Rheumatoid Arthritis:

Refer to rheumatologist.

●Nonpharmacologic measures – Nonpharmacologic measures, such as patient education, psychosocial interventions, and physical and occupational therapy, should be used in addition to drug therapy. Other medical interventions that are important in the comprehensive management of RA in all stages of disease include cardiovascular risk reduction and immunizations to decrease the risk of complications of drug therapies.

●Initiation of DMARD therapy soon after RA diagnosis – We suggest that all patients diagnosed with RA be started on disease-modifying antirheumatic drug (DMARD) therapy as soon as possible following diagnosis, rather than using antiinflammatory drugs alone, such as nonsteroidal antiinflammatory drugs (NSAIDs) and glucocorticoids (Grade 2C). Better outcomes are achieved by early compared with delayed intervention with DMARDs.

●Tight control of disease activity – Tight control treatment strategies to "treat to target" are associated with improved radiographic and functional outcomes compared with less aggressive approaches. Such strategies involve reassessment of disease activity on a regularly planned basis with the use of quantitative composite measures and adjustment of treatment regimens to quickly achieve and maintain control of disease activity if targeted treatment goals (remission or low disease activity) have not been achieved. (

●Pretreatment evaluation – Laboratory testing prior to therapy should include a complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), aminotransferases, blood urea nitrogen, and creatinine. Patients receiving hydroxychloroquine (HCQ) should have a baseline ophthalmologic examination, and most patients who will receive a biologic agent or Janus kinase (JAK) inhibitor should be tested for latent tuberculosis (TB) infection. Screening for hepatitis B and C should be performed in all patients. Some patients may require antiviral treatment prior to initiating DMARD or immunosuppressive therapy, depending upon their level of risk for hepatitis B virus (HBV) reactivation.

●Adjunctive use of antiinflammatory agents – We use antiinflammatory drugs, including NSAIDs and glucocorticoids, as bridging therapies to rapidly achieve control of inflammation until DMARDs are sufficiently effective. Some patients may benefit from longer-term therapy with low doses of glucocorticoids.

●Drug therapy for flares – RA has natural exacerbations (also known as flares) and reductions of continuing disease activity. The severity of the flare and background drug therapy influence the choice of therapies. Patients who require multiple treatment courses with glucocorticoids for recurrent disease flares and whose medication doses have been increased to the maximally tolerated or acceptable level should be treated as patients with sustained disease activity. Such patients require modifications of their baseline drug therapies.

●Monitoring – The monitoring that we perform on a regular basis includes testing that is specific to evaluation of the safety of the drugs being; periodic assessments of disease activity with composite measures; monitoring for extraarticular manifestations of RA, other disease complications, and joint injury; and functional assessment.

●Other factors affecting target and choice of therapy – Other factors in RA management that may influence the target or choice of therapy include the disabilities or functional limitations important to a given patient, progressive joint injury, comorbidities, and the presence of adverse prognostic factors.

Osteoarthritis

General principles – General principles of osteoarthritis (OA) management include providing continuous care that is tailored to the patient according to individual needs, goals, and values and should be patient-centered. Treatment can be optimized by OA and self-management education, establishing treatment goals, and periodic monitoring.

●Monitoring and assessment – The management of OA should include a holistic assessment which considers the global needs of the patient. Patient preferences for certain types of therapies should also be assessed, as compliance and outcomes can be compromised if the care plan does not meet the patient's preferences and beliefs.

●Overview of management – The goals of OA management are to minimize pain, optimize function, and beneficially modify the process of joint damage. The primary aim of clinicians should include targeting modifiable risk factors. Due to the modest effects of the individual treatment options, a combination of therapeutic approaches is commonly used in practice and should prioritize therapies that are safer.

●Nonpharmacologic therapy – Nonpharmacologic interventions are the mainstay of OA management and should be tried first, followed by or in concert with medications to relieve pain when necessary. Nonpharmacologic therapies including weight management and exercises, braces and foot orthoses for patients suitable to these interventions, education, and use of assistive devices when required.

●Pharmacologic therapy – The main medications used in the pharmacologic management of OA include oral and topical nonsteroidal antiinflammatory drugs (NSAIDs). Other options include topical capsaicin, duloxetine, and intraarticular glucocorticoids. Our general approach to pharmacotherapy is described below.

•In patients with one or a few joints affected, especially knee and/or hand OA, we initiate pharmacotherapy with topical NSAIDs due to their similar efficacy compared with oral NSAIDs and their better safety profile.

•We use oral NSAIDs in patients with inadequate symptom relief with topical NSAIDs, patients with symptomatic OA in multiple joints, and/or patients with hip OA. We use the lowest dose required to control the patient's symptoms on an as-needed basis.

•We use duloxetine for patients with OA in multiple joints and concomitant comorbidities that may contraindicate oral NSAIDs and for patients with knee OA who have not responded satisfactorily to other interventions.

•Topical capsaicin is an option when one or a few joints are involved and other interventions are ineffective or contraindicated; however, its use may be limited by common local side effects.

•We do not routinely use intraarticular glucocorticoid injections due to the short duration of its effects (ie, approximately four weeks).

•We avoid prescribing opioids due to their overall small effects on pain over placebo and potential side effects (eg, nausea, dizziness, drowsiness), especially for long-term use and in the older adult population.

•We do not routinely recommend nutritional supplements such as glucosamine, chondroitin, vitamin D, diacerein, avocado soybean unsaponifiables (ASU), and fish oil due to a lack of clear evidence demonstrating a clinically important benefit from these supplements. Other nutritional supplements of interest that may have small effects on symptoms include curcumin (active ingredient of turmeric) and/or Boswellia serrata, but the data are limited.

●Role of surgery – Surgical treatment is dominated by total joint replacement, which is highly effective in patients with advanced knee and hip OA when conservative therapies have failed to provide adequate pain relief.

●Factors affecting response to therapy – The discordance of radiographic findings to pain supports the notion that the mechanisms of pain are complex and likely multifactorial. The placebo effect is also known to impact response to therapy.

●Prognosis – Although there is great variability among individuals and among different phenotypes of OA, courses of pain and physical functioning have been found to be predominantly stable, without substantial improvement or deterioration of symptoms over time.

[disabled-dinosaur]

Monday, I noticed as I was typing, that my fingers were slower. My typing speed was 80 in high school and has pretty much been the same since. I type really fast and I loved that I had that skill. But Monday, no matter how fast my brain wanted to type, my fingers would not go as fast as my brain wanted to. I recently had an issue with my DMARD medicine. I found myself in a drunken state and rather light headed. Others around me have noticed, even though I tried so hard to hide it that I was limping. My left leg tends to experience muscle weakness. I can still hide it with the help of my right leg and walking a certain way, but there are times that I can’t. Lately, I haven’t been able to hide it as well as I used to. So if you see me with a cane, I’m using it for balance, as I’ve been tripping more lately.

[mandana-the-service-pup]

My Rheumatology appointment was great. The dramatic improvement on Methotrexate was the final piece of the puzzle. My Rheumatologist was able to confirm a Spondyloarthritis diagnosis based on my improvement and the X-rays, blood tests, etc. She said my presentation is not typical (probably bc of the EDS & dysautonomia) so Lupus will always need to be on the table and I’m supposed to inform doctors of my increased risk for drug-induced Lupus.

Methotrexate has improved 4-5 years of symptom development but it’s not enough on its own. Hydroxychloroquine and Methotrexate are both dosed based on weight so they can’t be increased. I’m supposed to stay on both medications and use steroids for acute flares (2 pills in the morning every day for a week) If the steroids don’t help then we might move on from Methotrexate to the next DMARD.

I’m so incredibly grateful to finally have a diagnosis that can be treated effectively. I’ve had symptoms my whole life, disabled for the last ten years and have had red flag symptoms for the last several years. To finally have treatment options is such a relief. My Cardiologist follow-up is next week and I can’t wait to finally quell their doubts in me.

[allie-p-medicalstuff]

Howdy! It’s 8:00am.

Here are my notes for the Diagnosis and Treatment of the Musculoskeletal system!! I abbreviated it as MS.

The app I use to take my notes is called Procreate! It’s very cool. I’ll have more notes to share after today, but for now here’s my todo list!

Complete text book assignments(there are only two left)

Summarize what I’ve gotten out of the assignments(knowledge, expectations, etc.)

Re-read my lessons chapter(pages 35–68) and summarize.

Start my pro-quest project!!!

!!! So, I have to create my own medication/pharmaceutical company. My medication will be able to treat Mixed Connective Tissue Disease (MCTD), which in turn will make it a Disease Modifying Anti-Rheuatic Drug (DMARD). It’s pretty cool if you ask me.

Thank you very much for reading! Have a wonderful day, and do your best!!

[luckynein]

Fuck RA seriously. Just really really fuck it. This is another flare up and I’m just frustrated as hell about it. What am I taking my DMARDs for?!

[minha-amiga-artritereumatoide]

A artrite reumatoide (AR) é uma doença autoimune que afeta principalmente as articulações, mas pode também afetar outros órgãos e sistemas do corpo. Essa condição crônica e progressiva pode causar dor, inchaço e rigidez nas articulações, além de fadiga e outros sintomas que podem impactar significativamente a qualidade de vida dos pacientes.

Apesar de não ser uma condição rara, muitas pessoas ainda não compreendem completamente a artrite reumatoide e seus efeitos no corpo. Neste artigo, vamos explorar as causas, sintomas e tratamentos da AR, bem como fornecer algumas dicas importantes para ajudar os pacientes a gerenciar a doença e melhorar sua qualidade de vida.

Causas da artrite reumatoide

A causa exata da artrite reumatoide é desconhecida, mas sabe-se que a condição é causada por uma resposta autoimune do corpo, na qual o sistema imunológico ataca as próprias células do corpo, especialmente as articulações. Como resultado, ocorre inflamação crônica nas articulações, o que pode levar à destruição do tecido articular e à incapacidade de realizar atividades diárias simples.

Sintomas da artrite reumatoide

Os sintomas da artrite reumatoide podem variar de pessoa para pessoa, mas geralmente incluem dor nas articulações, inchaço, rigidez matinal, fadiga e perda de mobilidade nas articulações afetadas. Além disso, pode haver sintomas não articulares, como febre, perda de peso e fadiga crônica.

À medida que a doença progride, pode ocorrer deformidade articular e outras complicações, como doenças cardíacas, problemas respiratórios e problemas neurológicos.

Tratamentos para artrite reumatoide

Embora não haja cura para a artrite reumatoide, existem tratamentos que podem ajudar a controlar a dor e a inflamação, retardar a progressão da doença e melhorar a qualidade de vida das pessoas com a condição. Esses tratamentos podem incluir medicamentos, terapia ocupacional e física, mudanças no estilo de vida e, em alguns casos, cirurgia.

Medicamentos: existem diferentes tipos de medicamentos que podem ser usados para tratar a artrite reumatoide, como anti-inflamatórios não esteroides (AINEs), corticosteroides, medicamentos modificadores da doença (DMARDs) e agentes biológicos. O tratamento com medicamentos deve ser feito sob a orientação de um médico, que avaliará a eficácia e os possíveis efeitos colaterais.

Terapia ocupacional e física: a terapia ocupacional e física pode ajudar a melhorar a mobilidade, a força e a flexibilidade das articulações afetadas. Um terapeuta ocupacional pode ajudar o paciente a realizar atividades cotidianas com mais facilidade, enquanto um fisioterapeuta pode prescrever exercícios específicos para ajudar a melhorar a função articular.

Mudanças no estilo de vida: manter um estilo de vida saudável pode ajudar a gerenciar a artrite.

[wellmedcenter061]

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