Arthritis as a Manifestation of Systemic Disease Treatment & Management

A complete discussion of the medical therapy for each of these diseases that may have arthritis as a manifestation may be found in the article concerning that particular disease. See Hypothyroidism; Hyperparathyroidism; Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; Cushing Syndrome; Acromegaly; Hypercholesterolemia, Familial; Hemochromatosis; and Sarcoidosis.

• Hypothyroidism: This is easily treated with thyroid hormone by mouth, except under life-threatening circumstances (ie, myxedema coma), when an intravenous route can be used.
• Diabetes: This illness is managed medically with oral agents, like sulfonylureas, metformin, thiazolidinediones, as well as with parenteral insulin, with stress on the importance of dietary modification and weight loss.
• Acromegaly: This disorder is managed medically with a regimen that includes octreotide, pegvisomant, or bromocriptine. Initially, most patients are treated surgically.
• Hyperlipidemia: Familial hypercholesterolemia is managed with a hydroxymethylglutaryl coenzyme A (HMG CoA) reductase inhibitor, which is the mainstay of therapy and may be used in combination with other agents.
• Hemochromatosis: Patients are treated by phlebotomy in order to reduce the level of total body iron to the reference range. Therapy can be monitored by following the patient's ferritin levels. Therapy with phlebotomy has little effect on the clinical and radiologic progression of arthropathy.
• Sarcoidosis: Early or late sarcoid arthritis responds to nonsteroidal anti-inflammatory drugs.

  • Colchicine also can be used for acute sarcoid arthritis.
  • Occasionally for severe acute arthritis with or without erythema nodosum, a course of corticosteroids provides rapid relief of pain and inflammation.
  • Mucocutaneous sarcoidosis often improves with antimalarial agents.
  • Corticosteroids are used to suppress potentially serious inflammatory reactions such as uveitis, severe lung disease, neurosarcoidosis, and severe sarcoidosis of other organs.
  • Methotrexate can be used as a steroid-sparing agent in patients with chronic disease.

• Hyperparathyroidism

  • Treatment for an adenoma is surgical resection by an experienced surgeon.
  • Hyperplasia is also managed surgically, most commonly with a 3-and-one-half gland resection, sometimes followed with the implantation of a small portion of 1 gland.
  • In the hands of an experienced and knowledgeable surgeon, parathyroidectomy is curative in 98% of cases and has a low (< 1%) instance of permanent hypoparathyroidism or laryngeal nerve injury.
  • Data are clear that less experienced surgeons have substantially lower cure rates (approximately 75%) and higher complication rates.
• Cushing syndrome: Most patients are cured with resection of the pituitary tumor via transsphenoidal surgery.
• Acromegaly

  • The primary therapy of this disease remains surgical resection of the tumor.
  • Unfortunately, this procedure frequently does not result in a permanent cure. Many patients not cured by surgery go on to receive radiation therapy targeting the pituitary.

• Hypothyroidism and diabetes usually do not mandate a consultation.
• Hyperparathyroidism

  • Consultation with an endocrinologist may be useful to ensure the diagnosis is correct.
  • Consultation with a surgeon experienced in neck exploration is essential.
• Cushing disease

  • An endocrinologist likely will be needed to guide the patient through the maze of diagnostic tests that are required. These include provocative testing, such as high-dose dexamethasone suppression testing and petrosal sinus sampling.
  • An interventional radiologist experienced in petrosal sampling likely will be needed.
  • If pituitary-dependent Cushing disease is confirmed, consultation with a neurosurgeon experienced in transsphenoidal hypophysectomy is indicated.
• Acromegaly

  • In many patients, provocative testing of growth hormone will be required. An endocrinologist should supervise this testing.
  • Surgical therapy requires a neurosurgeon who is an expert in pituitary surgery.
  • Late in the disease, joint problems can cause significant morbidity, and consultation with a rheumatologist or orthopedic surgeon may be needed.
• Hyperlipidemia: In poorly controlled hyperlipidemia, especially in patients requiring multiple drugs, consultation with an endocrinologist or other lipidologist may be appropriate.
• Hemochromatosis

  • Many patients require a liver biopsy obtained by a gastroenterologist.
  • Prolonged phlebotomy is required, during which several dozen units of blood are removed over months to years. Such specialized therapy should be monitored by a gastroenterologist or hematologist with experience in this procedure.
• Sarcoidosis

  • A pulmonologist should be consulted when chest findings are abnormal. Patients may need bronchoscopic biopsy or mediastinoscopy for definitive diagnosis.
  • A rheumatologist may be consulted for the management of joint disease.
  • Patients need a thorough eye examination by an ophthalmologist to determine whether evidence of uveitis is present.