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Analgesia is a common factor to consider in therapy for all the conditions described above. In the case of an acute gout attack, colchicines, nonsteroidal antiinflammatory drugs (NSAIDs), and glucocorticoids are the drugs mainly used. In the elderly population, one must take into account the possibility of GI complications from the above medications. To reduce these risks, intraarticular steroids, ice packs, and low-dose colchicine are more often used. In patients with recurrent gout attacks, chronic medication therapy can be used to maintain serum uric acid levels below 5 mg/dL. The maintenance therapy is usually with either probenecid, which increases the urinary excretion of uric acid, or allopurinol, which reduces the production of uric acid.

A septic joint requires surgery for drainage of infectious material followed by IV antibiotics. Methicillin-resistant Staphylococcus aureus (MRSA) will usually require vancomycin, but coverage with antibiotics is dependent on the specific organisms isolated.

Degenerative joint disease treatment involves mobility exercises, maintenance of adequate range of motion, and weight loss, if appropriate. Intraarticular corticosteroid injections may provide relief for varying amounts of time, but should only be done every 4-6 months so as to avoid cartilage destruction. Surgery, such as joint replacement, is usually reserved for people with severe disease that affects their daily functions.

Therapy for rheumatoid arthritis involves multiple modalities. Education and counseling of the patient regarding disease progression, treatment options, and implications to lifestyle is essential. Exercises, such as those that maintain joint mobility and muscle strength, are very important, as the natural course of RA is to develop a stiff joint that becomes disabling. Physical therapy and occupational therapy are important to address specific areas in which the patient may need additional devices to perform activities of daily living.

Many different categories of medications are used in RA. These include NSAIDs, glucocorticoids, disease-modifying antirheumatic drugs (DMARDs), anticvtokines, and topical analgesics. Among the DMARDs are sulfasalazine and methotrexate. Infliximab and etanercept are examples of anticytokine agents. Treatment regimens are individualized, and will often include a combination of two or three of these agents. Although effective, monitoring for hepatotox-icity must be performed.

Low Back Pain

Low back pain (LBP) is a very common complaint that will require a different work-up, depending on the patient's age, history, and clinical findings. Approximately 93% of patients will present with LBP only. If the patient is younger than 50 years old and has no "red Hag symptoms or signs" (Table 3-1), conservative treatment is recommended (NSAlDs, local heat, exercises) for 6 weeks. If the patient is older than 50 years of age. the likelihood pain being from a musculoskeletal source is still approximately 95%, but a lumbar spine x-ray is indicated. If this is abnormal, then imaging with magnetic resonance imaging (MRI) should be considered. A different picture is seen with patients who complain of sciatic nerve pain or symptoms consistent with a radiculopathy. If the involvement is unilateral and there is no bladder or bowel incontinence, then conservative treatment for 4 weeks is recommended followed by an MRI if no improvement. An urgent MRI or computed tomography (CT) scan should be obtained if symptoms are in saddle distribution or if there is involvement of bladder/bowel sphincters, as this may signal the "cauda equina syndrome," which is a surgical emergency.

Table 3-1

"RED FLAG" SYMPTOMS AND SIGNS IN PATIENTS WITH BACK PAIN

Unrelenting night pain Unrelenting pain at rest Neuromotor deficit Fever

Loss of bowel or bladder control Suspicion of ankylosing spondylitis Trauma

History or suspicion of cancer Osteoporosis

Chronic corticosteroid use Immunosuppression Drug or alcohol abuse

Comprehension Questions

Match the most likely diagnosis with the clinical vignette:

A. Rheumatoid arthritis

B. Crystal induced arthritis

C. Infectious arthritis

D. Degenerative joint disease

[3.11 A 26-year-old male with fever and left knee pain and swelling 2 weeks after his bachelor party.

[3.2] A 44-year-old female with a 5-month history of malaise and stiff hands in the morning that improve as the day goes by.

[3.31 A 52-year-old morbidly obese patient with bilateral knee pain for I year.

[3.41 A 35-year-old male with hypertension and right big toe pain that resolved spontaneously at home after 1 week of taking ibuprofen.

Answers

13.11 C. Infectious arthritis would need to be high on the differential diagnosis for two reasons in this scenario. Both the possibility of trauma that may lead to direct infection and the possibility of gonococcal arthritis from sexual activity must be considered.

[3.2] A. Morning stiffness, involvement of the hands and symmetric arthritis are three of the criteria necessary for the diagnosis of rheumatoid arthritis.

[3.3] D. Obesity is a risk factor for osteoarthritis, which is common in the knees and typically presents with a gradual onset and worsening of symptoms.

[3.4| B. Gouty arthritis often initially presents in the big toe ("podagra") and the use of HCTZ, a common treatment for hypertension, also can increase the risk.

CLINICAL PEARLS

A red. swollen joint must be aspirated to rule out a joint infection. Most low back pain can be treated conservatively. The presence of "red Hag" symptoms or signs should prompt a more aggressive work-up.

REFERENCES

Atlas, SJ, Deyo, RA. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med 20()I; 16:120.

Canoso J. Rheumatoid arthritis. In: Canoso JJ (ed.). Rheumatology in primary care. 1st ed. Philadelphia, PA: Saunders WB, 1997:59-63.

Canoso J. Crystal-induced arthritis. In: Canoso JJ (ed.). Rheumatology in primary care, lsted. Philadelphia, PA: Saunders WB, 1997: 150-8.

Helfgott SM. Evaluation of the adult with monoarticular pain. Up to Date, version 13.3, updated November 8, 2004.

Institute for Clinical Systems Improvement (ICSI). Adult low back pain. Bloomington, MN: Institute for Clinical Systems Improvement (ICSI). September 2005.

Van Tulder MW. Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions. Spine 1997:22:2128.

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