Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + ANKYLOSING SPONDYLITIS AND SPONDYLOARTHRITIS Download Section PDF Listen +++ +++ Population ++ –Adults with ankylosing spondylitis (AS) or nonradiographic spondyloarthritis. +++ Recommendations ++ ACR/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 ++ –Recommendations for treatment of ankylosing spondylitis Scheduled NSAIDs. Tumor necrosis factor inhibitor (TNFi) therapy. Recommends addition of slow-acting anti-rheumatic drugs when TNFi medications contraindicated. Local parenteral corticosteroids for active sacroiliitis, active enthesitis, or peripheral arthritis for symptoms refractory to NSAIDs. Avoid systemic corticosteroid use. Refer to an ophthalmologist for concomitant iritis. Recommend TNFi monoclonal antibody therapy for AS with inflammatory bowel disease. Physical therapy program. Screen for fall risk, osteoporosis. –Recommendations for treatment of nonradiographic axial spondyloarthritis NSAIDs. Tumor Necrosis Factor inhibitor (TNFi) therapy. ++ Source ++ –Ward MM, Deodhar A, Akl EA, et al. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis. Arthritis Rheumatol. 2016;68(2):282-298. + ATOPIC DERMATITIS (AD) Download Section PDF Listen +++ +++ Population ++ –Adults and children. +++ Recommendations ++ AAD 2014 ++ –Generous application of skin moisturizers after bathing. –Recommend limited use of hypoallergenic nonsoap cleansers. –Consider wet-wrap therapy with topical corticosteroids for moderate-to-severe AD during flares. –Twice-daily topical corticosteroids are the first-line therapy for AD. –Topical calcineurin inhibitors (tacrolimus or pimecrolimus) can be used for maintenance AD therapy. –Recommend against topical antihistamine therapy for AD. –Phototherapy is second-line treatment for refractory cases. –Consider systemic immunomodulating agents for severe cases that are refractory to topical agents and phototherapy. ++ Sources ++ –http://www.guideline.gov/content.aspx?id=48409 –http://www.guideline.gov/content.aspx?id=48410 +++ Comment ++ Systemic immunomodulating agents that have been studied in AD are azathioprine, cyclosporine, or methotrexate. + BACK PAIN, LOW Download Section PDF Listen +++ +++ Population ++ –Adults. +++ Recommendations ++ ACP 2017 ++ –Consider nonpharmacologic treatments for acute or subacute low-back pain including superficial heat, massage, acupuncture, or spinal manipulation. –If pharmacologic treatments needed, start with NSAIDs or skeletal muscle relaxants. –For chronic low back pain, start a trial of nonpharmacologic treatments including exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, biofeedback, cognitive behavioral therapy, or spinal manipulation. –For persistent chronic low-back pain, pharmacologic therapy with NSAIDs as first-line therapy and tramadol or duloxetine as second-line therapy. –Use opiates for chronic low-back pain only if patients have failed all other therapies and only if the potential benefits outweigh the risks of dependency, addiction, overdose, and misuse. ++ Sources –http://guidelines.gov/summaries/summary/50781/noninvasive-treatments-for-acute-subacute-and-chronic-low-back-pain-a-clinical-practice-guideline-from-the-american-college-of-physicians?q=back+pain –Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. ++ NICE 2009 ++ –Educate patients and promote self-management of low-back pain. –Recommends offering one of the following treatment options: Structure exercise program. Manual therapy.a Acupuncture. –Consider a psychology referral for patients with a high disability and/or who experience significant psychological distress from their low-back pain. –Recommends against routine lumbar spine x-rays. –Recommends an MRI scan of lumbar spine only if spinal fusion is under consideration. –Consider a referral for surgery in patients with refractory, severe nonspecific low-back pain who have completed the programs above and would consider spinal fusion. ++ Source ++ –http://www.nice.org.uk/nicemedia/live/11887/44343/44343.pdf ++ ICSI 2010 ++ –See the below table. ++ Source ++ –https://www.icsi.org/health_initiatives/other_initiatives/low_back_pain/ +++ Comment ++ Analgesic ladder for low-back pain: Recommend scheduled acetaminophen. Add NSAIDs and/or weak opioids. Consider adding a tricyclic antidepressant. Consider a strong opioid for short-term use for people in severe pain. Refer for specialist assessment for people who may require prolonged use of strong opioids. ++ FIGURE 29-1 Evaluation and Management of Acute Low-Back Pain Graphic Jump LocationView Full Size||Download Slide (.ppt) Source: ICSI, 2010. + ++ aManual therapy includes spinal manipulation, spinal mobilization, and massage. + BREAST CANCER FOLLOW-UP CARE Download Section PDF Listen +++ +++ Population ++ –Early-stage women with curable breast cancer. +++ Recommendation ++ American Society of Clinical Oncology (ASCO) 2013 ++ –Mode of Surveillance Careful history and physical examination every 3–6 mo for first 3 y after primary therapy (with or without adjuvant treatment), then every 6–12 mo for next 2 y and then annually. Counsel patients about symptoms of recurrence including new lumps, bone pain, chest pain, dyspnea, abdominal pain, or persistent headaches. High-risk women for familial breast CA syndromes should be referred for genetic counseling—high-risk criteria include Ashkenazi Jewish heritage, history of ovarian CA at any age in the patient or any first-degree relatives; any first-degree relative with breast CA before age 50; two or more first- or second-degree relatives diagnosed with breast CA at any age; patient or relative with bilateral breast CA; and history of breast CA in male relative. All women should be counseled to perform monthly self-breast examinations. Mammography—women treated with breast-conserving therapy should have first posttreatment mammogram no earlier than 6 mo after radiation. Subsequent mammograms every 6–12 mo for surveillance (yearly preferred if stability of mammogram achieved). Regular gynecology follow-up with pelvic examination. Tamoxifen increases risk of uterine cancer, and therefore patients should be advised to report any vaginal bleeding if they are taking tamoxifen. Coordination of care: Risk of recurrence continues through more than 15 y (especially in woman who are hormone receptor positive). Continuity of care by physicians experienced in surveillance of patients and in breast examination is recommended. Follow-up by a primary care physician (PCP) leads to the same outcome as specialist follow-up. If the patient desires transfer of care to PCP, 1 y after definitive therapy is appropriate. ++ Sources ++ –NCCN Guidelines. 2015;BINV-16:27. –J Clin Oncol. 2013;31:961-965. +++ Comments ++ Reduce Routine Investigative Testing The following routine studies are NOT recommended for routine breast cancer surveillance: CBC and automated chemistry studies. Routine chest x-ray. Bone scans. Liver ultrasound. Routine CT scanning. Routine FDG-PET scanning. Breast MRI (unless patient has BRCA1 or BRCA2 mutation or previous mediastinal radiation at young age). Tumor markers including CA27.29, CA15-3, or CEA are not recommended for routine surveillance. (JAMA. 1994;27:1587-1592) Although studies have shown no survival benefit for routine surveillance testing, many oncologists will do routine blood studies including tumor markers especially in higher risk women. The most important follow-up strategy is to make certain patients know and report early signs or symptoms that may reflect recurrent disease. There is a significant difference in the behavior of hormone receptor (HR) positive vs. hormone receptor negative disease. HR-negative disease tends to recur earlier (2–3 y) than HR-positive breast cancer (>50% of relapses occur after 5 y). There is also a 3- to 4-fold increase in risk of brain metastasis in HR-negative women vs. HR-positive women. Overexpression of Her2 is found in 20% of breast cancer patients and targeted therapy in this group has significantly improved prognosis. Her2 overexpressed patients, however, are also at increased risk for brain metastasis. HR-positive patients have a 4-fold increased risk of bone metastasis compared to HR-negative patients in whom metastases to liver, lung, and brain are more common. (N Engl J Med. 2007;357:39) + GOUT, ACUTE ATTACKS Download Section PDF Listen +++ +++ Population ++ –Adults. +++ Recommendations ++ ACR 2012 ++ –Therapy options for acute gout attacks. Mild-to-moderate attacks involving 1–2 joints. NSAIDs: full-dose naproxen, sulindac, or indomethacin is preferred. Colchicine 1.2 mg PO × 1, then 0.6 mg 1 h later, then 0.6 mg daily bid. Corticosteroids: prednisone or prednisolone 0.5 mg/kg PO daily for 5–10 d. Severe attacks or polyarticular gout. Colchicine + NSAIDs. Colchicine + steroids. Expert opinion to continue urate-lowering therapy (eg, allopurinol) during acute attacks. Ice applied to affected joints can help. –Pharmacologic urate-lowering therapy. Allopurinol. Starting dose should not exceed 100 mg/d. Uptitrate dose every 2–4 wk to max of 800 mg/d, unless renal impairment exists. Desire uric acid level of <6 mg/dL. Consider adding a uricosuric agent (eg, probenecid) for refractory hyperuricemia despite urate-lowering therapy. Initiate allopurinol after an acute gout attack has resolved and continue prophylactic anti-inflammatory agents for 3 mo beyond achieving urate level <6 mg/dL. Colchicine 0.6 mg daily bid. Naproxen 250 mg PO bid. ++ Sources ++ –http://www.guideline.gov/content.aspx?id=38624 –http://www.guideline.gov/content.aspx?id=38625 +++ Comment ++ Consider HLAB*5801 testing prior to the initiation of allopurinol for patients at particularly high risk of allopurinol hypersensitivity reaction. Highest risk group are those of Korean, Han Chinese, or Thai descent, especially if Stage 3 or higher CKD is present. +++ Population ++ –Adults with suspected gout. +++ Recommendation ++ American College of Physicians 2017 –Clinicians should use synovial fluid analysis when diagnostic testing is necessary in patients with possible gout. ++ Sources ++ –http://guidelines.gov/summaries/summary/50607/diagnosis-of-acute-gout-a-clinical-practice-guideline-from-the-american-college-of-physicians?q=gout –Qaseem A, McLean RM, Starkey M, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Diagnosis of acute gout: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(1):52-57. +++ Population ++ –Adults >18 y with acute or recurrent gout. +++ Recommendations ++ American College of Physicians 2017 –Options for treatment of acute gout include corticosteroids, NSAIDs, or colchicine. –Corticosteroids should be considered first-line therapy in patients without contraindications. Prednisolone 35 mg orally for 5 d. –Recommends against using long-term urate-lowering therapy in most patients with infrequent attacks (<3 attacks per year). –Febuxostat and allopurinol are equally effective at decreasing serum urate levels. ++ Sources ++ –http://guidelines.gov/summaries/summary/50608/management-of-acute-and-recurrent-gout-a-clinical-practice-guideline-from-the-american-college-of-physicians?q=gout –Qaseem A, Harris RP, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Management of acute and recurrent gout: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(1):58-68. + HIP FRACTURES Download Section PDF Listen +++ +++ Population ++ –Elderly patients with hip fractures. +++ Recommendations ++ AAOS 2014 ++ –Recommends preoperative pain control in patients with hip fractures. –Insufficient evidence to support preoperative traction in hip fractures. –Recommends hip fracture surgery within 48 h of admission. –Do not delay hip fracture surgery for patients on aspirin +/– clopidogrel. –Recommends operative fixation for nondisplaced femoral neck fractures. –Recommends unipolar or bipolar hemiarthroplasty for displaced femoral neck fractures. –Recommends prolonged thromboprophylaxis to prevent venous thromboembolism after hip fracture surgery. –Recommends intensive physical therapy post-discharge to improve functional outcomes. –Recommends evaluation for osteoporosis in all patients who have sustained a hip fracture. ++ Source ++ –http://www.guideline.gov/content.aspx?id=48518 + MULTIPLE SCLEROSIS (MS) Download Section PDF Listen +++ +++ Population ++ –Adults. +++ Recommendations ++ AAN 2014 ++ –Consider oral cannabis extract or Sativex oromucosal cannabinoid spray to patients with MS with spasticity and pain (central neuropathic pain). –May consider a trial of Gingko biloba or magnetic therapy for reducing fatigue. –Recommend against a low-fat diet with ω-3 fatty acid or lofepramine use or bee venom therapy to reduce relapses, depression, or fatigue. –Reflexology may benefit paresthesias. ++ Source ++ –http://www.guideline.gov/content.aspx?id=47909 + MUSCLE CRAMPS Download Section PDF Listen +++ +++ Population ++ –Patients with idiopathic muscle cramps. +++ Recommendations ++ AAN 2010 ++ –Data are insufficient on the efficacy of calf stretching in reducing the frequency of muscle cramps. –AAN recommends that although quinine is likely effective, it should not be used for routine treatment of cramps. Quinine derivatives should be reserved for disabling muscle cramps. –Quinine derivatives are effective in reducing the frequency of muscle cramps, although the magnitude of benefit is smaller than the serious side effects. ++ Source ++ –Katzberg HD, Khan AH, So YT. Assessment: symptomatic treatment for muscle cramps (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2010;74(8):691-696. + OSTEOARTHRITIS (OA) Download Section PDF Listen +++ +++ Population ++ –Adults. +++ Recommendations ++ ACR 2012 ++ –Nonpharmacologic recommendations for the management of hand OA: Evaluate ability to perform activities of daily living (ADLs). Instruct in joint-protection techniques. Provide assistive devices to help perform ADLs. Instruct in use of thermal modalities. Provide splints for trapeziometacarpal joint OA. –Nonpharmacologic recommendations for the management of knee or hip OA–Pharmacologic options for OA: Participate in aquatic exercise. Lose weight. Start aerobic exercise program. Instruct in use of thermal modalities. Consider for knee OA: Medially directed patellar taping. Wedged insoles for either medial or lateral compartment OA. Topical capsaicin. Topical or PO NSAIDs. Acetaminophen. Tramadol. Intraarticular steroids is an option for refractory knee or hip OA. ++ Source ++ –http://www.rheumatology.org/practice/clinical/guidelines/PDFs/ACR_OA_Guidelines_FINAL.pdf +++ Comment ++ The following should not be used for OA: Chondroitin sulfate. Glucosamine. Opiates (if possible). +++ Population ++ –Adults with osteoarthritis. +++ Recommendations ++ NICE 2014 ++ –Recommends exercise as a core treatment to include muscle strengthening and general aerobic fitness. –Recommends weight loss for people who are obese. –Recommends against acupuncture, glucosamine, chondroitin, or intra-articular hyaluronan for OA. –Recommends against arthroscopic lavage and debridement unless knee OA with mechanical locking. –Recommends oral analgesics include acetaminophen and/or topical NSAIDs first line. Oral NSAIDs or COX-2 inhibitors at the lowest effective dose for breakthrough pain. Topical capsaicin can be used as an adjunct for knee or hand OA. –Consider referral for joint surgery for people with OA and severe joint symptoms refractory to nonsurgical treatments. ++ Source ++ –https://guidelines.gov/summaries/summary/47862 +++ Comment ++ For chronic NSAID use, consider concomitant therapy with a proton pump inhibitor to prevent NSAID-induced ulcers. + OSTEOPOROSIS Download Section PDF Listen +++ +++ Population ++ –Adults at risk for osteoporosis or who have confirmed osteoporosis. +++ Recommendations ++ ICSI 2011 ++ –Evaluate all patients with a low-impact fracture for osteoporosis. –Advise smoking cessation and alcohol moderation (≤2 drinks/d). –Advise 1500-mg elemental calcium daily for established osteoporosis, glucocorticoid therapy, or age >65 y. –Assess for vitamin D deficiency with a 25-hydroxy vitamin D level. Treat vitamin D deficiency if present. –Treatment of osteoporosis. Bisphosphonate therapy. Consider estrogen therapy in menopausal women <50 y of age. Consider parathyroid hormone in women with very high risk for fracture. –Fall prevention program. Home safety evaluation. Avoid medications that can cause sedation and orthostatic hypotension, or affect balance. Assistive walking devices as necessary. ++ Source ++ –https://www.icsi.org/_asset/vnw0c3/Osteo.pdf +++ Comments ++ All patients should have serial heights and observed for kyphosis. Obtain a lateral vertebral assessment with DXA scan or x-ray if height loss exceeds 4 cm. DXA bone mineral densitometry should be repeated no more than every 12–24 mo. +++ Population ++ –Postmenopausal women. +++ Recommendations ++ NAMS 2010, AACE 2010, ACOG 2012 ++ –Recommend maintaining a healthy weight, eating a balanced diet, avoiding excessive alcohol intake, avoiding cigarette smoking, and utilizing measures to avoid falls. –Recommend supplemental calcium 1200 mg/d and vitamin D3 800–1000 international units (IU)/d. –Recommend an annual check of height and weight, and assess for chronic back pain. –DXA of the hip, femoral neck, and lumbar spine should be measured in women age ≥65 y or postmenopausal women with a risk factor for osteoporosis.a –Recommend repeat DXA testing every 1–2 y for women taking therapy for osteoporosis and every 2–5 y for untreated postmenopausal women. –Recommend against measurement of biochemical markers of bone turnover. –Recommend drug therapy for osteoporosis for: Osteoporotic vertebral or hip fracture. DXA with T score ≤ –2.5. DXA with T score ≤ –1 to –2.4 and a 10-y risk of major osteoporotic fracture of ≥20% or hip fracture ≥3% based on FRAX calculator, available at http://www.shef.ac.uk/FRAX/ –Consider the use of hip protectors in women at high risk of falling. ++ Sources ++ –http://www.guidelines.gov/content.aspx?id=15500 –https://www.aace.com/files/osteo-guidelines-2010.pdf –http://www.guidelines.gov/content.aspx?id=38413 +++ Comments ++ Options for osteoporosis drug therapy: Bisphosphonates: First-line therapy. Options include alendronate, ibandronate, risedronate, or zoledronic acid. Potential risk for jaw osteonecrosis. Denosumab: Consider for women at high fracture risk. Raloxifene: Second-line agent in younger women with osteoporosis. Teriparatide is an option for high fracture risk when bisphosphonates have failed: Therapy should not exceed 24 mo. Calcitonin: Third-line therapy for osteoporosis. May be used for bone pain from acute vertebral compression fractures. Vitamin D therapy should maintain a 25-OH vitamin D level between 30 and 60 ng/mL. ++ aPrevious fracture after menopause, weight <127 lb, BMI <21 kg/m2, parent with a history of hip fracture, current smoker, rheumatoid arthritis, or excessive alcohol intake. + OSTEOPOROSIS, GLUCOCORTICOID-INDUCED Download Section PDF Listen +++ +++ Population ++ –Glucocorticoid-induced osteoporosis. +++ Recommendations ++ ACR 2010 ++ –All patients receiving glucocorticoid therapy should receive education and assess risk factors for osteoporosis. –FRAX calculator should be used to place patients at low risk, medium risk, or high risk for major osteoporotic fracture. –If glucocorticoid treatment is expected to last >3 mo, recommend: Weight-bearing activities. Smoking cessation. Avoid >2 alcoholic drinks/d. Calcium 1200–1500 mg/d. Vitamin D 800–1000 IU/d. Fall risk assessment. Baseline DXA test and then every 2 y. Annual 25-OH vitamin D. Baseline and annual height measurement. Assessment of prevalent fragility fractures. X-rays of spine. Assessment of degree of osteoporosis medication compliance, if applicable. –For postmenopausal women or men age >50 y: Low-risk group. Bisphosphonate if equivalent of prednisone ≥7.5 mg/d. Medium-risk group. Bisphosphonate if equivalent of prednisolone ≥5 mg/d. High-risk group. Bisphosphonate for any dose of glucocorticoid. –For premenopausal women or men age <50 y with a prevalent fragility (osteoporotic) fracture and glucocorticoid use ≥3 mo: For prednisone ≥5 mg/d, use alendronate or risedronate. For prednisone ≥7.5 mg/d, use zoledronic acid. Consider teriparatide for bisphosphonate failures. ++ Source ++ –http://www.rheumatology.org/practice/clinical/guidelines/ACR_2010_GIOP_Recomm_Clinicians_Guide.pdf +++ Comments ++ Clinical factors that may increase the risk of osteoporotic fracture estimated by FRAX calculator: BMI <21 kg/m2. Parental history of hip fracture. Current smoking. ≥3 alcoholic drinks/d. Higher glucocorticoid doses or cumulative dose. IV pulse glucocorticoid use. Declining central bone mineral density measurement. Bisphosphonates recommended: Low- to medium-risk patients. Alendronate. Risedronate. Zoledronic acid. High-risk patients. Same + teriparatide. + PRESSURE ULCERS Download Section PDF Listen +++ +++ Population ++ –Adults at risk for pressure ulcers. +++ Recommendations ++ NICE 2014 ++ –Regular documentation of ulcer size. –Debride any necrotic tissue if present with sharp debridement or autolytic debridement. –Nutritional supplementation for patients who are malnourished. –Recommend a pressure-redistributing foam mattress. –Negative pressure wound therapy, electrotherapy, or hyperbaric oxygen therapy is not routinely recommended. –Antibiotics are only indicated for superimposed cellulitis or underlying osteomyelitis. ++ Source ++ –http://www.guideline.gov/content.aspx?id=48026 +++ Population ++ –Patients with pressure ulcers. +++ Recommendations ++ ACP 2015 ++ –Recommends nutritional supplementation with protein and amino acids to reduce wound size. –Use hydrocolloid or foam dressings to reduce wound size. –Use electrical stimulation as adjunctive therapy to accelerate wound healing. ++ Source ++ –https://guidelines.gov/summaries/summary/49050 +++ Comment ++ Moderate-quality evidence supports the addition of electrical stimulation to standard therapy to accelerate healing of Stage II–IV ulcers. + PSORIASIS, PLAQUE-TYPE Download Section PDF Listen +++ +++ Population ++ –Adults. +++ Recommendations ++ AAD 2009 ++ Topical Therapies ++ –Topical therapies are most effective for mild-to-moderate disease. –Topical corticosteroids daily—bid: Cornerstone of therapy. Limit Class I topical steroids to 4 wk maximum. –Topical agents that have proven efficacy when combined with topical corticosteroids: Topical vitamin D analogues. Topical tazarotene. Topical salicylic acid. –Emollients applied 1–3 times daily are a helpful adjunct. ++ Source ++ –http://www.aad.org/File%20Library/Global%20navigation/Education%20and%20quality%20care/Guidelines-psoriasis-sec-3.pdf +++ Comments ++ Approximately 2% of population has psoriasis. Eighty percent of patients with psoriasis have mild-to-moderate disease. Topical steroid toxicity: Local: skin atrophy, telangiectasia, striae, purpura, or contact dermatitis. Hypothalamic–pituitary–adrenal axis may be suppressed with prolonged use of medium- to high-potency steroids. +++ Recommendations ++ AAD 2009 ++ –Systemic Therapies ++ Indicated for severe, recalcitrant, or disabling psoriasis. Methotrexate (MTX): Dose: 7.5–30 mg PO weekly. Monitor CBC and liver panel monthly. Cyclosporine: Initial dose: 2.5–3 mg/kg divided bid. Monitor for nephrotoxicity, HTN, and hypertrichosis. Acitretin: Dose: 10–50 mg PO daily. Monitor: liver panel. ++ Source ++ –http://www.aad.org/File%20Library/Global%20navigation/Education%20and%20quality%20care/Guidelines-psoriasis-sec-4.pdf +++ Comments ++ MTX contraindications: pregnancy, breast-feeding, alcoholism, chronic liver disease, immunodeficiency syndromes, cytopenias, hypersensitivity reaction. Cyclosporine contraindications: CA, renal impairment, uncontrolled HTN. Acitretin contraindications: pregnancy, chronic liver, or renal disease. + PSORIASIS AND PSORIATIC ARTHRITIS Download Section PDF Listen +++ +++ Population ++ –Adults. +++ Recommendations ++ AAD 2010 ++ –Treatment options for patients with limited plaque-type psoriasis. First-line therapy: Topical corticosteroids. Topical calcipotriene/calcitriol. Topical calcipotriene/steroid. Topical tazarotene. Topical calcineurin inhibitors (flexural surfaces and face). Targeted phototherapy. Second-line therapy: Systemic agents. –Treatment of extensive plaque-type psoriasis. First-line therapy: UVB phototherapy ± acitretin. Topical PUVA. Second-line therapy: Acitretin + biologic. Cyclosporine + biologic. Cyclosporine + methotrexate. Methotrexate + biologic. UVB + biologic. –Treatment of palmoplantar psoriasis. First-line therapy: Topical corticosteroids. Topical calcipotriene/calcitriol. Topical calcipotriene/steroid. Topical tazarotene. Second-line therapy: Acitretin. Targeted UVB. Topical PUVA. Third-line therapy: Adalimumab. Alefacept. Cyclosporine. Etanercept. Infliximab. Methotrexate. Ustekinumab. –Treatment of erythrodermic psoriasis. Acitretin. Adalimumab. Cyclosporine. Infliximab. Methotrexate. Ustekinumab. –Treatment of psoriatic arthritis. First-line therapy: Adalimumab. Etanercept. Golimumab. Infliximab. Methotrexate. Tumor necrosis factor (TNF) blocker + methotrexate. Second-line therapy: Ustekinumab and methotrexate. ++ Sources ++ –http://www.guideline.gov/content.aspx?id=15650 –http://www.aad.org/File%20Library/Global%20navigation/Education%20and%20quality%20care/Guidelines-psoriasis-sec-2.pdf +++ Comment ++ Use of potent topical corticosteroids should be limited to 4 wk duration. + RHEUMATOID ARTHRITIS (RA), BIOLOGIC DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) Download Section PDF Listen +++ +++ Population ++ –Adults. +++ Recommendations ++ ACR 2008 ++ –Anti–TNF-α agents A tuberculosis (TB) skin test or IGRA must be checked before initiating these medications. Any patient with latent TB needs at least 1 mo treatment prior to the initiation of a TNF-α or biologic agent. Recommended for all patients with high disease activity and presence of poor prognostic features of any duration of disease. –Recommended for patients with disease ≥6 mo who have failed nonbiologic DMARD therapy and have moderate-to-high disease activity, especially if poor prognostic features are present. –Abatacept has same indications as anti–TNF-α agents. –Rituximab has same indications as anti–TNF-α agents. –Recommends withholding all biologic DMARDs 1 wk before or after surgery. +++ Comment ++ Anti–TNF-α agents, abatacept, and rituximab all contraindicated in: Serious bacterial, fungal, and viral infections, or with latent TB. Acute viral hepatitis or Child’s B or Child’s C cirrhosis. Instances of a lymphoproliferative disorder treated ≤5 y ago; decompensated congestive heart failure (CHF); or any demyelinating disorder. +++ Recommendations ++ ACR 2012 ++ –Target low disease activity or remission. –MTX or leflunomide monotherapy may be used for patients with any disease severity or duration. –Hydroxychloroquine or minocycline monotherapy recommended if low disease activity and duration ≤24 mo. –Sulfasalazine recommended for all disease durations and without poor prognostic features.a –MTX plus either hydroxychloroquine or leflunomide recommended for moderate-to-high disease activity regardless of disease duration. –MTX plus sulfasalazine recommended for high disease activity and poor prognostic features. + ++ aFunctional limitation, presence of rheumatoid nodules, secondary Sjögren syndrome, RA vasculitis, Felty syndrome, and RA lung disease.