Problems associated with the use of corticosteroids1
Patients are increasingly anxious about the use of corticosteroids because of adverse publicity about their potential side-effects. This must be discussed frankly and the risks of not treating them be described and balanced against the risks of the drug itself.
Patients must be warned to avoid sugars and saturated fats and to eat less because of the risk of weight gain.
The skin becomes thin and easily damaged.
Monitor for diabetes and hypertension.
Cataract formation may be accelerated.
Osteoporosis develops within six months on doses above 7.5mg, and hormone replacement therapy and/ or calcium and vitamin D or bisphosphonate is used.
Problems associated with the use of NSAID's2-3
Non-steroidal anti-inflammatory drugs (commonly known as 'NSAIDs') are widely used and effective medicines in the treatment of arthritis and many other painful conditions. There are many medicines in the NSAID class available both as prescription and non-prescription products.
NSAIDs are generally well-tolerated and most patients do not suffer side effects. The most commonly reported side effects are those relating to gastrointestinal irritation,such as abdominal pain, heartburn, nausea and vomiting. Rarely, serious side effects such as gastrointestinal ulceration or bleeding may occur, and this is more likely with high doses and prolonged use of NSAIDs. NSAIDs can also cause allergic reactions,fluid retention and a range of other rare side effects, which are listed in product information including patient information leaflets.
COX-2 selective inhibitors (commonly known as 'coxibs') are newer anti-inflammatory medicines which are thought to produce less in the way ofgastrointestinal side effects than NSAIDs. Recent evidence indicates that patients treated with 'coxibs' may be at a slightly increased risk of heart attacks and strokes. For this reason they should not be used in patients who already have these conditions. For other patients, doctors were advised of the need to carefully consider the potential balance of gastrointestinal and cardiovascular risks of using coxibs on an individual basis.
Any cardiovascular risk caused by the NSAIDs is likely to be small and associated with long-term use at higher doses. For this reason, all anti-inflammatory medicines (including the NSAIDs and coxibs) should be used at the lowest possible dose and for the shortest possible period necessary to control symptoms.
There are a variety of medications available to treat the pain and inflammation of osteo and rheumatoid arthritis. It is important to balance the potential benefit against the potential side-effects. Patients should be prescribed short courses of analgesics before NSAIDs on an intermittent basis. NSAIDs should be considered in patients unresponsive to paracetamol. In patients with an increased gastrointestinal risk, non-selective NSAIDs and effective gastroprotective agents, or selective COX 2 inhibitors should be used.
It has been suggested that some NSAIDs may increase the cartilage damage, while others are ‘chondroprotective’, but these claims remain controversial. Intra-articular corticosteroid injections produce short-term improvement when there is a painful joint effusion. Frequent injections into the same joint should be avoided.
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The guiding principle is to treat the symptoms and disability, not the radiological appearances. Education of the individual about the disease and its effects reduces pain, distress and disability and increases compliance with treatment. Psychological or social factors alter the impact of the disease.1
To view the EULAR Guidelines for knee OA, click here.(*)
Physical measures1
Weight loss and exercises for strength and stability are useful. Hydrotherapy helps, especially in lower-limb OA. Local heat, ice-packs, massage and rubifacients or local NSAID gels give some relief. Complementary medicine is commonly used and, despite lack of scientific evidence, little is lost trying it since a number of patients do seem to be helped.
Surgery1
Total replacement arthroplasty has transformed the management of severe OA. The safety of hip and knee replacements is now equal, with a complication rate of about 1%; loosening and late blood-borne infection are the most serious. These slight but definite risks make it essential that the patient is certain that surgery is wanted, when all else has been tried. For the vast majority a total knee or hip replacement reduces pain and stiffness and greatly increases function. Other surgical procedures include realignment osteotomy of the knee or hip, excision arthroplasty of the metatarsophalangeal (MTP) and base of the thumb, and fusion of a first MTP joint.
Reference:
1. Kumar, P and Clark, M: Clinical Medicine. (4th Edition). London, W.B. Saunders, Harcourt Publishers Ltd, (1998).
2. Cardiovascular Safety of NSAIDs - Review of Evidence. Available at: http://www.mhra.gov.uk/home/idcplg%3FIdcService%3DGET_FILE%26dID%3D1428%26noSaveAs%3D0%26Rendition%3DWEB+MHRA+%2B+nsaid&hl=en&gl=uk&ct=clnk&cd=1
3. Questions and Answers on non-selective NSAIDs / CHMP review of safety of non-selective NSAIDs. Available at: http://www.emea.eu.int/pdfs/human/press/pr/25042305en.pdf
(*). Jordan K M, Arden N K, Doherty M, Bannwarth B, et al.: EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis 2003;62;1145-1155. doi:10.1136/ard.2003.011742.