RHEUMATOLOGY & ORTHOPAEDIC OPD Rx GUIDE

 RHEUMATOLOGY & ORTHOPAEDIC OPD Rx GUIDE

INTRODUCTION

In a Rheumatology or Orthopedic Outpatient Department (OPD), physicians encounter a diverse range of musculoskeletal conditions, from arthritis and joint pain to fractures and ligament injuries. This concise prescription guide serves as a quick reference for managing such cases effectively. It covers medication options for pain relief, inflammation control, and disease modification, alongside non-pharmacological interventions like physical therapy and orthopedic devices. Tailored to individual patient needs, this guide aims to optimize treatment outcomes while emphasizing the importance of patient education and multidisciplinary collaboration for comprehensive care.

OSTEOPOROSIS Rx

POSTMENOPAUSAL OSTEOPOROSIS Rx

ARTHRITIS Rx

POST CHIKUNGUNYA ARTHRITIS Rx

CONSERVATIVE Rx OF OSTEOARTHRITIS

GOUTY ARTHRITIS Rx 8  PLANTAR FASCIITIS Rx

POLYMYALGIA RHEUMATICA Rx

FIBROMYALGIA SYNDROME Rx

RHEUMATOID ARTHRITIS Rx

1 OSTEOPOROSIS Rx

Osteoporosis is characterized by a decrease in bone density and quality, leading to an increased risk of fractures. Here are some key points about osteoporosis:

Bone Density Loss: Osteoporosis occurs when bones lose minerals, such as calcium, faster than the body can replace them, causing bones to become weak and brittle.

Risk Factors: Age, gender (more common in women), family history, low body weight, smoking, excessive alcohol consumption, and certain medical conditions or medications can increase the risk of osteoporosis.

Complications: Fractures associated with osteoporosis can lead to chronic pain, disability, and decreased quality of life.

C/C:

Low back pain which radiate around the trunk or down the limb

A gradual loss of height and appearance of thoracic kyphosis

Difficulty in bearing

weight

Depression

History of fractures

Do complete baseline labs:

CBC, LFTS, TFTS

Urea, creatinine, electrolyte, serum calcium & 24hr urine Ca, vitamin-D level & Serum PTH

Do X-ray for suspected fracture

Gold standard investigation is: Dexa scan (Bone densitometry

Rx

1. Cholecalciferol (Indrop-D/Miura-D)

One injection in a glass of milk or water in the morning

Once weekly/2 weekly give acc. Serum vit.D³ level

2. Tab. Diclofenac potassium (Caflam, Dyclo-P) Two times a day/1--+--1

3. Tab Osteocare

+--+--1(OD)

4. Cap. Omeprazole 40 mg (Risek, Zoltar)

+-+-1(OD)

30 minutes before meals

5. Tab. Alendronate sodium (Drat)

Once weekly on empty stomach, one pill a week in the morning

2 POSTMENOPAUSAL OSTEOPOROSIS Rx

C/C:

postmenopausal osteoporosis

Postmenopausal women→ Estrogen stimulates osteoblasts and inhibits osteoclasts.

The decreased estrogen levels following menopause lead to increased bone resorption

Rx

Management of postmenopausal osteoporosis includes a combination of pharmacological treatments, lifestyle modifications, and sometimes calcium and vitamin D supplementation to reduce fracture risk and maintain bone health.

Monitoring: Regular monitoring of BMD and assessment of fracture risk are important to adjust treatment as needed and to prevent fractures.

1

. Inj Cholecalciferol (Indrop-D/Miura-D) One injection in a cup of milk or water in the morning by mouth Once weekly/2 weekly give acc. Serum vit.D³ level

1. Tab. Diclofenac potassium (Caflam, Dyclo-P) Two times a day/1-+-1

2. Tab. Avelia Or Ostibon Plus One tablet a day/0-0--1

3. Cap. Omeprazole 40 mg (Risek, Zoltar) 0-0-1

30 minutes before meals

4. Tab. Alendronate sodium (Drat)

Once weekly on empty stomach, one pill a week in the morning

ALTERNATIVE DRUGS

Tab. Paracetamol + Tramadol: Distalgesic, Tramal plus

Tab Paracetamol + Orphenadrine citrate: Neubrol forte, Duragesic forte

NSAIDs:

* Tab. Naproxen sodium: Synflex, Neoprox

* Tab. Diclofenac potassium: Caflam, Dyclo-P

* Tab Piroxicam + Beta Cyclodextrin: Brexin, Pirexin

Tab. Alendronate sodium 70 mg (Drat) "Bisphosphonate"

Tab. Alendronate sodium 70 mg + Cholecalciferol 70 mcg (Drat-D) Inj/Softgel. Cholecalciferol (Indrop-D, D4U)

Proton Pump Inhibitors

Cap. Esomeprazole (Nexium 20mg/40mg)

Cap. Omeprazole (Risek 20mg/40mg)

Cap. Pantoprazole (Pantop 30mg)

Supplements

Tab. Ossein mineral Complex + vit-D: Cal-one-D, Osnate-D

Tab. Calcium + Vitamin-D

Vitamin D3 + Vit-2, calcium: Tab Avelia Or Tab Ostibon plus

3 ARTHRITIS Rx

C/C:

Pain.

Stiffness.

Swelling.

Redness.

Decreased range of motion

Rx

1. Cap. Piroxicam 20mg (Feldine)

1-0-1 (Twice daily)

2. Tab. Diclofenac Potassium 50mg (Caflam, Maxit)

1-0-1 (Twice daily)

3. Tab. Cartigen plus

1-0-1 (Twice daily)

4. Cap. Omeprazole 40 mg (Risek, Zoltar) 0-0-1(OD)

30 minutes before meals

Rx

Alternative Rx 2

1. Tab. Lornoxicam 8mg (Xika Rapid, Atcam) 1-0-1 (Twice daily)

2. Syp. Ossis

10 ml-0-10ml (10ml x Twice daily)

3. Cap. Esomeprazole 40mg (Nexum, Esso) 0-0-1(OD)

30 minutes before meals

4 POST CHIKUNGUNYA ARTHRITIS Rx

Post-chikungunya arthritis refers to a condition where joint pain and inflammation persist long after the acute phase of chikungunya virus infection has resolved. Chikungunya is a mosquito-borne viral disease that typically causes fever and severe joint pain, among other symptoms, during the acute phase of infection.

Pathophysiology: The exact mechanisms behind post-chikungunya arthritis are not fully understood. It is believed that the virus may trigger an immune response that leads to persistent joint inflammation in susceptible individuals.

Fever (sometimes as high as 104 °F)

prevention: Since there is no specific treatment, prevention focuses on avoiding mosquito bites to prevent chikungunya virus infection in the first place. This includes using insect repellent, wearing protective clothing, and using mosquito nets

c/c

joint pain

headache

muscle pain

rash

swelling around the joints

Less commonly, symptoms can be accompanied by a maculopapular rash (similar to measles or heat rash), conjunctivitis, nausea, and vomiting.

Rx

1. Tab. Lornoxicam 4mg/8mg (Xikarapid/acabel) Two time day/ BD

2.Paracetamol 325 mg + Tramadol 100mg (Distalgesic) Two time a day/ BD

3. Tab Dexamethasone (Oradexon, Kanadex) 2+0+2/2 tab. BD

4. Cap Omeprazole 40mg (Risek, Zoltar) 0+0+1 (OD) 30 minutes before food

ALTERNATIVE Rx

1. Tab. Lornoxicam 4mg/8mg (Xikarapid/acabel) Two time day/ BD

2.

Paracetamol 325 mg + Tramadol 100mg (Distalgesic) Two time a day/ BD

3. Methotrexate (Unitrex 2.5mg) Weekly 2 tablets at day 1 and 4th day Or Tab Hydroxychloroquine (Tab HCQ 200 mg) 0+0+1 (OD)

4. Cap Esomeprazole 40mg (Nexum/Esso) 0+0+1 (OD) 30 minutes before food

5 CONSERVATIVE Rx OF OSTEOARTHRITIS

Osteoarthritis (OA) is a degenerative joint disease that primarily affects the cartilage, the tissue that covers the ends of bones in a joint. It is the most common type of arthritis and typically develops gradually over time. 

C/C:

Pain on exertion, which is relieved with rest Pain worsens with use and improves with rest, commonly involves the hands, hips, and knees

Pain in both complete flexion+extension

Crepitus on joint movement

Constant pain (including at night)

Morning joint stiffness usually lasting < 30 minutes

Physical exam

Joint tenderness

Decreased range of motion

Bony swelling

swelling of the distal interphalangeal (Herberden nodes)

swelling of the proximal interphalangeal (Bouchard nodes)

Radiological signs of osteoarthritis

1. Irregular joint space narrowing

2. Subchondral sclerosis

3. Osteophytes (also: bone spurs)

4. Subchondral cysts

1st Rx of osteoarthritis

Rx

1. General: Exercise & weight loss, Physical therapy

2. Cap Celecoxib (Celbexx 100mg, 200mg) 1--+--I Two times a day)

3. Tab. Diclofenac potassium (Caflam 50mg) 1-+--1 (Two times a day)

4. Tab Cartigen plus

1--+--I (Two times a day)

5. Cap. Omeprazole 40 mg (Risek, Zoltar) 0-0-1 30 minutes before meals

Rx

2nd Rx of osteoarthritis

1. General: Exercise & weight loss, Physical therapy

2. Tab Lornoxicam (Xika Rapid 8mg/Acabel 4mg, 8mg) 1--+--I (Two times a day)

6 GOUTY ARTHRITIS Rx

Gouty arthritis, often referred to simply as gout, is a form of arthritis that occurs due to the deposition of uric acid crystals in joints and tissues. It's a type of inflammatory arthritis characterized by sudden and severe episodes of pain, swelling, redness, and tenderness in the affected joints.

Gout is primarily caused by high levels of uric acid in the blood, a condition known as hyperuricemia. Uric acid is normally dissolved in the blood and excreted through the kidneys in urine. However, when there is an excess of uric acid or the kidneys cannot excrete enough of it, crystals can form and accumulate in joints, leading to gout attacks.

C/C:

Acute onset of lower extremities joint pain (Great Toe)

Fever and chills

Intense joint pain that is most severe in the first 12 to 24 hours

Joint pain that lasts a few days to a few weeks and spreads to more joints over time

Redness, tenderness and swelling of the joints (Joint Inflammation) Asymmetric

joint involvement

Investigation:

CBC

Urea, creatinine, electrolyte

Serum uric acid

ESR

X-Ray best for chronic stage

CT/MRI best

Arthrocentesis:

Polarized light microscopy:

needle-shaped monosodium urate crystals that are negatively birefringent (crystals appear yellow when their optical axis is oriented parallel to the polarizer and blue if their axis is perpendicular to the polarizer)

Synovial fluid: WBC > 2000/μL with > 50% neutrophils

Rx

1. Tab Febuxostat 40mg/80mg (Zurig) Two times a day /1+1

2. Tab. Paracetamol + Tramadol (Distalgesic, Tramol plus) Two times a day/1--+--1

3. Cap. Omeprazole 40 mg (Risek, Zoltar) 0-0-1(OD) 30 minutes before meals

If not respond than give

4. TabPrednisolone 5 mg (Deltacortril)

3 Tablets TDS for 3 days

2 Tablets TDS for 3 days

2 Tablets BD for 3 days

1 Tablets BD for 3 days

1 Tablet OD for 3 days

ALTERNATIVE Rx

1. Tab Allopurinol 100mg, 300mg (Zyloric) 1-0-1 (BD), 0-0-1 (OD)

2. Tab. Paracetamol + Tramadol (Distalgesic, Tramol plus) 1--+--1 (BD)

3. Cap. Esomeprazole 40mg (Nexum, Esso) 0-0-1(OD) 30 minutes before meals

If not respond than give

4. TabPrednisolone 5 mg (Deltacortril) x 40-50mg dose per day in divided doses

7  PLANTAR FASCIITIS Rx

Plantar fasciitis is a common condition that involves inflammation of the plantar fascia, a thick band of tissue that runs along the bottom of the foot, connecting the heel bone to the toes. This condition causes heel pain, especially noticeable with the first steps in the morning or after prolonged periods of rest.

Causes:

Repetitive Stress: Activities that place repetitive stress on the heel and arch of the foot, such as running, walking long distances, or standing for extended periods.

Foot Mechanics: Flat feet, high arches, or abnormal walking patterns that alter the distribution of weight on the foot.

Age and Weight: Plantar fasciitis is more common in adults aged 40-60 and in individuals who are overweight or obese.

Footwear: Wearing shoes with inadequate support or poor cushioning can contribute to the development of plantar fasciitis.

C/C:

Sharp heel pain

pain is worse with first step in the morning or after a period of rest, then improves with walking

pain may be worse again at the end of the day with prolonged standing/weight- bearing

may also improve with stretching, massage, and rest

 May prefer to walk on toes

initially Relieved by ambulation Common to have symptoms bilaterally tender to palpation at medial tuberosity of calcaneus

On examination, the patient usually has a point of maximal tenderness at the anteromedial region of the calcaneus. The patient may also have pain along

the proximal plantar fascia. The pain may be exacerbated by passive dorsiflexion of the toes or by having the patient stand on the tips of the toes.

Investigation:

Serum uric acid

Calcium level

Vitamin-D level

X-Ray: Initially not necessary, often normal, may show plantar heel spur

CT/MRI: may be useful for surgical planning

Rx

Stretching of the foot and calf

Orthotics or night splinting

Rest and raise your foot on a stool when you can

put an ice pack (or bag of frozen peas) in a towel on the painful area for up to 20 minutes every 2 to 3 hours

Wear shoes with cushioned heels and good arch support

Use insoles or heel pads in your shoes

Try regular gentle stretching exercises

Try exercises that do not put pressure on your feet, such as swimming

Try to lose weight if you're overweight

1. Tab. Diclofenac potassium 50mg (Caflam, Maxit, Dyclo-P) 

Or Tab. Diclofenac sodium 50mg (Voltral, Voren) Or Tab. Paracetamol + Tramadol (Distalgesic, Tonoflex-P) 1-0-1 (Twice daily)

Rx

1. Tab. Naproxen sodium 500mg (Neoprox, Flexin) Or Tab. Lornoxicam 8mg (Xika Rapid, Atcam) 1-0-1 (Twice daily)

2. Cap. Esomeprazole 40mg (Nexum, Esso) Or Cap. Omeprazole 40 mg (Risek, Zoltar) 0-0-1(OD) 30 minutes before meals

8 POLYMYALGIA RHEUMATICA Rx

Polymyalgia rheumatica (PMR) is an inflammatory disorder that primarily affects older adults, typically those over 50 years old. It causes muscle pain and stiffness, particularly in the shoulders, neck, hips, and thighs.

Complications:

Corticosteroid Side Effects: Long-term use of corticosteroids can lead to complications such as osteoporosis, weight gain, diabetes, and increased susceptibility to infections.

Giant Cell Arteritis (GCA): Some individuals with PMR may also develop GCA, a related condition that causes inflammation of the arteries, particularly those in the head

C/C:

Clinical Presentation

> Proximal limb-girdle pain and morning stiffness in the appropriate host

>Constitutional manifestations include fever, malaise, and weight loss.

Diagnosis and Evaluation

> Examination reveals muscle tenderness but no true muscle weakness

Laboratory features

Elevated ESR

Elevated CRP

Normochromic

normocytic anemia

Elevated platelets

Rx

1. Tab. Prednisolone 5mg (Deltacortril, Rapicort) Initial dose: 15mg per day for 1 month

K Reducing the dose by 2.5mg every 2-4 weeks to a dose of 7.5mg to 10mg daily.

Then reducing the dose by 1mg every 4-6 weeks

Maintenance dose:

10mg by 6 months

5mg by 1 year

2. Tab. Paracetamol 500mg (Panadol, calpol)

Or Tab. Paracetamol + Tramadol (Distalgesic, Tramol plus) 1-0-1

3. Cap. Omeprazole 40 mg (Risek, Zoltar) 0-0-1(OD) 30 minutes before meals

Rx

1. Tab. Prednisolone 5mg (Deltacortril, Rapicort)

Initial dose: 15mg per day for 1 month

Reducing the dose by 2.5mg every 2-4 weeks to a dose of 7.5mg to 10mg daily.

Then reducing the dose by 1mg every 4-6 weeks

Maintenance dose:

10mg by 6 months

5mg by 1 year

2. Tab. Naproxen sodium 500 mg (Neoprox, Flexin) Or Tab. Lornoxicam 8mg (Xika Rapid, Atcam) 1-0-1(BD)

3. Cap. Esomeprazole 40mg (Nexum, Esso) 0-0-1(OD) 30 minutes before meals

Consider Bisphosphonate with long-term (>5 months) steroids therapy Tab. Alendronate 70 mg (Drat, Fosamax, Bonaparte)

Once weekly 30 minutes before breakfast on empty stomach Food and beverages (e.g., mineral water, coffee, tea, or juice) will decrease the amount of alendronate absorbed by the body.

9 FIBROMYALGIA SYNDROME Rx

INTRODUCTION:

Fibromyalgia (FM) is a neurosensory disorder characterized by chronic musculocutaneous pain.

The etiology and pathogenesis of this condition are not fully understood, but, notably, there is no identifiable inflammation that causes the musculocutaneous symptoms.

Patients typically present with functional symptoms (e.g., fatigue, unrefreshing sleep, morning stiffness) and often have a history of psychiatric disorders (e.g., depression, generalized anxiety disorder).

Physical examination reveals characteristic tender points over multiple areas of the body with no signs of inflammation (i.e., no notable swelling, deformity, or erythema).

Findings from laboratory tests are normal. Although this disorder is benign, it causes patients significant psychological strain and discomfort.

EPIDEMIOLOGY:

Prevalence: 2-3% [1

Sex:: Female > Male (2:1)

Peak incidence: 20-50 years (risk of occurrence increases with age)

ETIOPATHOGENESIS:

The pathophysiology of FM is not fully understood, but its etiology is likely multifactorial.

The interaction of the following factors may play a role:

Genetic predisposition

>> Environmental triggers (e.g., physical or psychosocial stress)

> Dysregulation of the neuroendocrine and autonomic nervous systems

DIAGNOSIS OF FIBROMYALGIA (FM)

Fibromyalgia (FM) is a clinical diagnosis

The 2016 American College of Rheumatology (ACR) criteria take into account:

Symptom duration of at least 3 months

>> Patient self-reporting using the fibromyalgia score:

.

Widespread pain or tenderness in up to 19 different regions of the body (widespread pain

index; WPI)

Presence and severity of symptoms such as fatigue, sleep disturbance, depression, headache, and cognitive impairment (symptom severity scale)

Self-reporting criteria are met if Widespread pain index (WPI) ≥ 7 and symptoms severity scale (SSS) 25 OR WPI 4-6 and SSS ≥ 9

Presence of generalized pain, i.e., pain in 24 regions (upper left, upper right, axial, lower left, lower right)

Traditionally, a tender-point examination was performed based on the 1990 ACR diagnostic criteria:

Symptom duration of at least 3 months

*Tender points: 2 11 of 18 FM-associated localized areas of pain Pain-affected areas: all four quadrants of the body

Laboratory values and imaging findings are normal (helpful for excluding other causes or comorbidities).

C/C:

Common symptoms

Chronic, widespread pain, primarily at points where muscles and tendons attach to bone (tender

points)

Headache, fatigue

Morning stiffness

Unrefreshing sleep

Cognitive dysfunction (known as fibro fog), e.g., poor memory, difficulty concentrating, and lack of

clarity of thought

>> Paresthesias

Autonomic dysfunction: digestive problems, weight fluctuation, palpitations, sexual dysfunction, night sweats

Common associations: The following disorders can manifest with symptoms that sometimes resemble those seen in Fibromyalgia, and these conditions may occur alongside Fibromyalgia.

>> Functional somatic syndromes (e.g., chronic fatigue syndrome, irritable bowel syndrome, tension or migraine headaches, chronic pelvic and bladder syndromes)

>> Psychiatric disorders (depression, generalized anxiety disorder)

30

Sleep disorders (e.g., sleep movement disorders such as restless leg syndrome) Inflammatory rheumatic diseases (e.g., systemic lupus erythematosus, rheumatoid arthritis)

TREATMENT OF FIBROMYALGIA (FM)

Initial approach

Patient education: Explain that the condition, though painful, is benign, and recommend coping

strategies such as relaxation exercises.

Lifestyle changes: regular physical activity, dietary recommendations, sleep hygiene

Medication

>> Initially monotherapy: Low-dose tricyclic antidepressants (TCA), selective serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine), or anticonvulsants (e.g., Pregablin, gabapentin)

20 Avoid long term use of narcotic medications (e.g., opioids)

Consider comorbidities (e.g., sleep disorders) in treatment planning

Nonresponders

Multidisciplinary management (e.g., with rheumatology, psychiatry) and adequate pain management

Psychological interventions (e.g., cognitive-behavioral therapy)

Physiotherapy (e.g., stretching, hydrotherapy, and heat application)

Combination therapy with the drugs mentioned above

Rx

1. Cap. Duloxetine 30mg, 60mg (Dulan, Lyta, Cymbalta, Zenbar) 0-0-1 (Once daily), may increase up to 60mg/day Or Cap. Pregabalin 50 mg, 75mg, 100mg (Gabica, Zeegap, Syngab)

1-0-1 (Twice daily)

Or Tab. Amitriptyline 25mg (Tryptanol, Amitin)

0-0-1 (Once daily), may increase up to 50mg/day

2. Tab. Paracetamol + Tramadol (Distalgesic, Tonoflex-P) Or Tab. Diclofenac potassium 50mg (Caflam, Dyclo-P)

1-0-1 (BD)

30 minutes before meals

3. Cap. Esomeprazole 40mg (Nexum, Esso) or Cap. Omeprazole 40 mg (Risek, Ruling) 0-0-1(OD)

10 RHEUMATOID ARTHRITIS Rx

Rheumatoid arthritis (RA) is a chronic autoimmune disorder that primarily affects the joints, causing inflammation, pain, swelling, and stiffness. It can also affect other organs and systems of the body.

living with RA:

Living with RA involves ongoing management, regular medical monitoring, and adapting daily activities to minimize stress on joints. Support from healthcare providers, family, and community resources can also play a crucial role in coping with the challenges of RA.

Managing RA requires a comprehensive approach tailored to individual needs, focusing on reducing inflammation, preserving joint function, and improving overall well-being

C/C:

> Symmetric joint pain

> Tender, warm, swollen joints.

> Swelling of small peripheral joints

> Morning joint stiffness of variable duration (Joint stiffness that is usually worse in the mornings and after inactivity)

> Fever and weight loss.

> Other diffuse aching, Fatigue, Malaise and Depression may proceeds other symptoms by weeks or months

Investigation:

CBC, LFTS, RFTS

CRP and ESR

Anti-CCP (more specific)

Rheumatoid factor

Antinuclear antibodies (ANA)

Synovial fluid analysis: fluid is collected by joint aspiration.

X-ray of affected joint

Dorso-palmar x-ray of both hands

Early: soft tissue swelling, demineralization (juxta-articular)

Late: joint space narrowing, erosions of cartilage and bone, demineralization (generalized)

MRI: (with or without contrast), especially if cervical spine involvement is suspected or in early stages

Ultrasound: joint effusion, formation of pannus

Nonsteroidal anti-inflammatory drugs (NSAIDs) play only a minor role, if any, in slowing progression of RA and, therefore, should not be used as the sole therapy for RA. The role of NSAIDs in RA is limited to symptomatic relief.

Intra-articular injections of glucocorticoids can suppress joint inflammation for several months and can be a useful addition to DMARD therapy, especially when there is residual activity in large joints (eg, wrists, knees).

(Minodrem, Minogen) Tab Minocycline, 100mg twice daily, is an effective treatment for RA, particularly when used in early seropositive disease. The mechanism of action in RA is uncertain but probably is independent of its antibacterial effects. Long-term therapy (more than 2 years) may lead to cutaneous hyperpigmentation.

Managing Comorbidities

Optimal care of patients with RA requires recognition of the comorbid conditions that are associated with RA. These include increased risk of cardiovascular death, osteoporosis, infections, and certain cancers.

Glucocorticoids in low doses (e.g., prednisolone 5-10 mg daily) can provide rapid, symptomatic improvement of articular disease and significantly slow the radiographic progression of RA. Glucocorticoids should be used rarely, if ever, as monotherapy for RA but can help control synovial inflammation while initiating therapy with the slow-acting synthetic DMARDs or when the response to DMARDs is suboptimal Long-term therapy with prednisolone in doses of 27.5 mg/d orally is associated with an increased risk of both vertebral and hip fractures → Prevented by alendronate sodium.

The use of concomitant misoprostol or proton pump inhibitors should be considered in all patients with rheumatoid arthritis who are taking NSAIDS.

Rx  

1. General measures

For acute episodes of inflammation: cryotherapy Physical and occupational therapy- range of motion exercises, joint protection, and assistive devices.

- Physical activity/exercise and rest

2. Tab. Leflunomide 10mg or 20mg (Lefona, Lefora) 0-0-1(OD)

3. Tab. Diclofenac sodium 50mg or 100mg (Voren, Voltral) Or Tab. Naproxen sodium 500 mg (Flexin, Neoprox) Or Cap. Celecoxib 100mg or 200mg (Celbexx, Celebrex) 1-0-1 (BD)

4. Cap. Omeprazole 40 mg (Risek, Zoltar) 0-0-1(OD) 30 mg before meals

Rx alternative

1. Tab. Leflunomide 10mg, 20mg (Lefona, Lefora) 0-0-1(OD) (LEF Causes Gl symptoms) Or Tab. Methotrexate 2.5mg (Cytotrexate, Unitrexate) Three tablets of MTX = 7.5mg Once weekly (CMDT-22)

MTX Dosage: 7.5mg to 10mg/week (maximum 20-25mg)

Before initiation, check CBC, LFTs and Renal function, monitoring should be done every three months

To minimize side effects, folic acid is recommended 24-48 hours after taking methotrexate (MTX)

Do not give NSAIDs on the same day as Methotrexate, as they can worsen the side effects of Methotrexate by inhibiting its renal excretion.

Contraindications to methotrexate include pre existing liver disease, infection with hepatitis B or C, ongoing alcohol use, and renal impairment (creatinine clearance <30 mL/minute) and in pregnancy

2. Tab Folic acid 5mg (Folic acid)

0-0-1 (Oral folate 1-5 mg daily reduces side effects and should be administered concomitantly.

3. Tab. Diclofenac sodium 50mg or 100mg (Voren, Voltral) Or Tab. Naproxen sodium 500 mg (Flexin, Neoprox) 1-0-1 (BD)

4. Cap. Omeprazole 40 mg (Risek, Zoltar)

0-0-1(OD)

Rx alternative

1. Tab Methotrexate 2.5mg (Cytotrexate, Unitrexate) One tablets every 3rd day

2. Tab Sulfasalazine 500mg (Salazopyrin, Salazodine EC) 1-0-1 (BD), 2 tablets BD/TDS (1-3g daily is effective for RA)

3. Tab. Folic acid 5mg (Folic acid)

0-0-1

4. Tab. Diclofenac sodium 50mg or 100mg (Voren, Voltral) Or Tab. Naproxen sodium 500 mg (Flexin, Neoprox) 1-0-1 (BD)

5. Cap. Esomeprazole 40mg (Nexum, Esso) 0-0-1(OD) 30 mg before meals

Rx alternative

1. Tab Prednisolone 5mg (Deltacortril) 1-0-1(BD) (Low-dose steroid 5-10 mg/day) Steroids use for synovial disease, 2-15 mg/d in 1-4 doses For extra-articular disease (vasculitis), 20-60 mg/d according to response

2. Tab Leflunomide 10mg, 20mg (Lefona, Lefora) x0-0-1(OD) Or Tab. Methotrexate 2.5mg (Cytotrexate, Unitrexate) Three tablets of MTX = 7.5mg Once weekly Tab. Folic acid 5mg (Folic acid) x OD

3. Tab. Diclofenac sodium 50mg or 100mg (Voren, Voltral) Or Tab. Naproxen sodium 500 mg (Flexin, Neoprox) 1-0-1(BD)

4. Cap. Esomeprazole 40mg (Nexum, Esso) 0-0-1(OD) 30 mg before meals

OTHER IMPORTANT TOPICS

11  HICCUPS (SINGULTUS) Rx 

Definition: Hiccups refer to a sudden, involuntary contraction of the diaphragm that results in abrupt inhalations of air followed by a characteristic "hic" sound.

Singultus (hiccup) is common, usually transient, and only rarely indicative of disease.

If it persists, it can be highly bothersome, potentially interfering with sleep and leading to depression and physical exhaustion. It is presumed to be due to a disturbance in a reflex arc that includes the brainstem, the phrenic nerve, the vagus nerve, and the sympathetic chain.

CAUSES OF HICCUPS

Transient Hiccups (Second to minutes)

   > Stomach distension

      Swallowed air

   > Smoking

     Alcohol and carbonated beverages

     Intense emotion (excitement/stress)

Persistent Hiccups (>48 hours)

    General anesthesia

    Intubation

Chronic hiccups (> 1 month)

     Pericarditis

     Laryngitis

     Inflammation from the stomach from H.pylori

     GERD

     Space occupying lesions

     Metabolic & CNS disorders

     Medications

     Idiopathic

Non-pharmacological remedies used in the Emergency Department

Stimulation of the nasopharynx by applying forcible traction to the tongue, swallowing granulated sugar, gargling with water, sipping ice water, drinking from the far side of a glass, biting on a lemon, or inhaling noxious agents (e.g., ammonia)

C3-5 dermatome stimulation by tapping or rubbing the back of the neck, coolant sprays

Direct pharyngeal stimulation by a nasal or oral catheter (90% effective)

Direct uvular stimulation by a spoon or cotton-tip applicator

Removal of gastric contents by means of emetics or a nasogastric tube

The following remedies lead to vagal stimulation (only one should be used at any given time

> Iced gastric lavage

> Valsalva maneuver: an individual strongly exhales while holding their mouth and nose closed, generally effective for reducing the duration of transient hiccups, but they rarely resolve persistent or chronic hiccups.

> Carotid sinus massage (performed only by experienced personnel after exclusion of contraindications)

>> Digital ocular globe pressure (performed only by experienced personnel after exclusion of contraindications)

>>> Digital rectal massage

Various techniques are used that interfere with normal respiratory function, such as the following:

>>Holding one's breath for several seconds

>> Hyperventilation

Gasping (as in fright)

39 Breathing into a paper bag:

Which increases arterial carbon dioxide tension (PaCO2) 1. Tightly press a small paper bag around your mouth

2. Breath slowly and deeply into it

3. Repeat this several times, while keeping the paper bag in place.

>> Drinks upside down:

1. Fill a glass with cold water

2. Bend down at the waist and put your head down

3. Slowly drinks water from the opposite side of the glass, if required repeat it again.

Pulling the knees up to the chest and leaning forward

> Using continuous positive airway pressure

>> Rebreathing 5% carbon dioxide

>> Mental distraction sometimes works. For example, the patient may be asked to "think of a loved one remembering you." An inventive naval doctor achieved success by offering $10 if the patient could continue to hiccup immediately.

Pharmacological treatment for persistent hiccups

Tab. Baclofen 10 mg (Lioresal, Baclast, Baclin, Liorex)

>> Dose range: 5mg twice daily, to 10mg x four time daily

>> Maximum daily dose: 60mg/day

Or Cap. Gabapentin 300mg (Neogab, Gabix) x TDS >> Dosage: 900mg to 1200mg in three divided doses

Or Cap. Pregabalin 75 mg (Gabica, Zeegap) x BD

> Dosage: 75mg to 150mg/day in 2 divided doses

*Or Tab Metoclopramide 10mg (Maxolon, Metoclon) x PO x TDS Or Inj. Metoclopramide 10mg (Maxolon, Metoclon) x IV x TDS

Dosage: 10mg every 8 hourly up to 80mg/day

Or Tab. Domperidone 10mg (Motilium, Domel) x TDS

*Or Tab. Chlorpromazine 25mg (Largactil) 25mg to 50mg per orally x TDS Or inj. Chlorpromazine 25mg (Largactil) 25mg to 50mg x IV, repeated 2-4 hours

* Or Tab. Haloperidol 1.5mg, 5mg (Serenace, Dosik) x initially 1.5mg x TDS, then 5mg x BD

Or Tab. Amitriptyline 25mg (Tryptanol, Amyline, Amitin) x HS > Dosage: 25mg to 100mg/day

12  APPROACH TO THE MANAGEMENT NAUSEA & VOMITING Rx

C/C:

ABDOMINAL

  Red flags for nausea and vomiting Abdominal

  Persistent vomiting

  Hematemesis

  Feculent vomiting

  Melena

  Hematochezia

  Acute and/or severe abdominal pain

  Progressive dysphagia

  Unintentional weight loss

Neurologic

   Altered mental status

   Focal neurological deficit

   Meningeal signs

Pulmonary/cardiovascular

>> Dyspnea

>> Chest tightness

>> Feeling of impending doom

Immediately life-threatening causes

Hemorrhagic stroke

CNS infection: meningitis, encephalitis

Myocardial infarction

Acute pancreatitis

Bowel obstruction

Bowel perforation

Diabetic ketoacidosis

Adrenal crisis

Drug overdose/withdrawal

Poisoning (ingestion of toxins)

Investigation:

>> Routine Investigation: CBC, ESR, Serum glucose, Urea, creatinine & electrolytes, LFTs, Beta HCG urine test.

>> In patients with severe and sustained vomiting: ABGs and Urine ketones.

>> Specific Ultrasound & X-Ray according to localization of symptoms

> Further diagnostic testing to consider based on localization of symptoms

Inpatient Treatment

Rx

ABCD&E survey

Maintain intravenous line (IV cannula)

Keep patient NPO and Consider NPO diet.

A nasogastric suction tube for gastric or mechanical small bowel obstruction improves patient comfort and permits monitoring of fluid loss.

Perform screening examination and targeted diagnostics to rule out life-threatening & other causes (see below table).

Once life-threatening causes have been ruled out:

Conduct a detailed patient history and clinical examination.

Consider further diagnostic testing.

Identify and treat hypovolemia: Inj. 0.9% Normal saline

Identify and treat electrolyte imbalance: IV 0.45% NS with 20 mEq/L of potassium chloride is given in most cases to maintain hydration.

Identify and treat acid-base disorders.

Identify and treat the underlying cause.

Minimize or discontinue any contributing medications.

Administer antiemetic therapy.

Inj. Metoclopramide 10mg/2ml (Metoclon) x IV/IM X stat/every 6-8 hourly.

Or Inj. Dimenhydrinate 50mg/1ml (Gravinate) x IV/IM x stat/every 6-8 hourly. (Maximum 400 mg/day)

If not controlled/severe/Postoperative/chemotherapy induced vomiting, consider:

Inj. Ondansetron 8mg/4ml (Onset, Onseron) x dilute in 100ml 0.9% N/S x IV x Stat

Consider Inj. Dexamethasone 4mg/ml (4-8mg) x IV x stat

Rx

Outpatient Treatment

General measure: Most causes of acute vomiting are mild, self- limited, and require no specific treatment. Patients should ingest clear liquids (broths, tea, soups, carbonated beverages) and small quantities of dry foods (soda crackers). Ginger may be an

effective non-pharmacologic treatment.

Pharmacological Treatment

Tab. Dimenhydrinate 50mg (Gravinate) Or Tab. Metoclopramide 10mg (Metoclon, Maxolon) Or Tab. Prochlorperazine 10 mg (Stemetil) Or Tab. Domperidone 10mg (Motilium, Domel) 1-1-1(TDS)

If not controlled/severe/Postoperative/chemotherapy vomiting, consider: induced

Tab. Ondansetron 4mg (Onset, Onseron) x 4-8 mg twice daily