Management of Common Rheumatic Diseases

RHEUMATOID ARTHITIS (RA): [Top of page]

Management: [Top of page]

• Use familiar NSAIDs. Titrate dose if required or if concerned about toxicity.
• Avoid oral corticosteroids if possible - they make the diagnosis difficult in early disease.
• Second-line drugs (e.g. sulphasalazine) may be added in those with active RA. A management plan should be established after initial consultations with a rheumatologist.
• Many patients with RA can be managed in Primary care rather than attending the hospital for frequent review appointments. Those with aggressive disease often need regular hospital reviews and involvement of other health professions.

Aims of Review by GP: [Top of page]

• Assess clinical conditions e.g. disease activity, presence of secondary degenerative changes and psychosocial adjustment to disease. ESR / CRP aid assessment of disease activity.
• Side effects and tolerance of medication. Appropriate monitoring of drugs where required.
• Assess other medical needs and drugs interaction in those with significant co-morbidity.
• Assess needs for surgical aids, involvement of occupational therapist, physiotherapist, and social worker.
• Establish dialogue with hospital rheumatolgoist if inadequate disease control or other cause for concern.

OSTEOARTHRITIS [Top of page]

• Common sites are: knee, hip, base of thumb, DIP and PIP joints. < li > Diagnosis: insidious onset, pain worse with activity, crepitus, bony enlargement or joint deformity at some sites, limited movements and functional limitation.
• Signs and symptoms are usually local - occasionally more generalized.
• Clinical features usually correlate with x-ray but considerable discrepancy possible.
• Joint stiffness is relatively short lived.
• Acute inflammatory flares with synovitis ± effusions occur due to trauma or crystal synovitis (Pseud-gout). Self-limiting inflammatory. Flares common at DIPs and PIPs.
• Blood tests are usually normal except during an attack of pseudo-gout.

Management - is symptomatic[Top of page]

• Patient education, weight reduction, exercise to improve muscles e.g. quad for knee OA, splints and aids e.g. for OA at base of thumb (OTs or physios can advise). Appropriate footwear to accomodate feet and reduce lower limb impact.
• Drugs: Simple analgesia. Topical agents (e.g. counter-irritants which are cheaper than NSAIDs) have a significant placebo effect but may be useful in some cases. Over-the-counter NSAIDs or prescription NSAIDs if this fails.
• Intra-articular steroid injections most useful for inflammatory flares: Effects are otherwise short-lived, in established oA.

POLYMYALGIA RHEUMATICA [Top of page]

Diagnosis

• Is a diagnosis of exclusion: Consider sero-negative rheumatoid arthritis, hypothyroidism, malignancy including myeloma, osteoarthritis, bone disease, myositis (check CPK).
• Very rare below age 50. Characterized by symmetrical aching and stiffness of shoulders, neck, lower back and hips often with anorexia, fatigue and weight loss. Muscle tenderness is unreliable and muscle weakness not a typical feature. New headaches, visual symptoms, temporal artery tenderness - consider associated temporal arteritis.

Management [Top of page]

• Steroids are usually required - starting dose in PMR 10-20 mg / day. In suspected cranial arteritis 40 mg / or up to 80 mg/day if ocular symptoms.
• Temporal artery biopsy if temporal arteritis suspected. This may be arranger through rheumatalogy, ophthalmology or the RMO. Do not delay steroids until this is done.
• Reduce steroids by 2.5 mg every 2-4 weeks until 10 mg / day reached. Then reduce by 1 mg every 2-6 weeks.
• Treatment for 2-4 years. 30-50% able to stop steroids after 2 yr. but relapse common in the first 18 months of treatment and in the first year off steroids. ESR and CRP are unreliable in judging relapse and decisions about steroid therapy should rely on presence and recurrence of typical symptoms.
• Beware steroid related side effects. Fracture prevention prophylaxis is recommended from the outset in those over 70. This group has the highest risk of fracture (see section on osteoporosis).
• Difficulty reducing steroids? Re-examine diagnosis e.g. missed serolegative rheumatoid arthritis.

GOUT [Top of page]

Diagnosis

• Attacks of severe joint pain, of sudden onset, especially in males >40 yr. and females >60 yr., which usually resolve after a few days. Initial attack monoarticulur in 90% of cases.
• May be obvious e.g. big toe in over weight beer drinker. Other common sites include foot, ankle, or knee and olecranon bursitis. Accompanying crystal-induced cellulitis possible.
• Blood urate is commonly normal during acute attack but should be raised at other times.
• Hyperuricaemia is a risk factor for gout. Gout is not inevitable and ~ 10% of the population have a raised urate intermittently.
• Joint pain with hyperuricaemia is not necessarily due to gout.
• Where possible examine synovial fluid for urate crystals.
• Identify risk factors e.g. alcohol, diuretics, obesity, renal disease, hyperlipidaemia especially raised triglycerides.

Management [Top of page]

• Patient education and lifestyle advice especially alcohol consumption.
• Medical modification of risk factors e.g., re-assess need for diuretics, treat hyperlipidaemia.
• Diets (e.g. low purine diets) rarely lead to a sustained fall in blood urate. Concentrate on weight and alcohol reduction.
• Acute attack: as with any suddenly painful joint - rest, analgesia and full dose NSAIDs (it does not have to be indomethacin). Colchicine works less quickly but may be preferred in renal disease, anti-coagulant use or poor tolerance of NSAIDs. Suggest 1 mg initially followed by 500 mcg four or five doses over 24 hours. Then reduce to 500 mcg t.d.s. / q.d.s. for 2 days and wean off over 7-10 days. Colchicines may be continued for several weeks at a dose of 500 mcg b.d. or t.d.s., as prophylactic treatment, if allopurinol is being introduced.
• Prophylactic treatment: consider if recurrent attacks (despite addressing risk factors). Options are:

1.   Low dose NSAIDs
2.   Allopurinol - start when acute attack resolved and with NSAID or colchicine cover (see above). Titrate allopurinol dose usual maintenance 200-600 mg per day. Beware renal dysfunction.
3.   Colchicine 500 mcg twice or three times a day.

ANKYLOSING SPONDYITIS [Top of page]

Diagnosis

• Disease of late adolescence or early adulthood. Symptom onset rare after age 40.
• Chronic relapsing and remitting low back pain, sometimes unilateral and associated with radiation along the back of the thigh to the knee. Sleep disturbance common at times of active disease.
• Stiffness of lower back with inactivity and in the early morning associated with difficulty getting out of bed.
• Extra-spinal features include heel and rib pain, hip, knee and shoulder disease, and anterior uveitis. Symptoms in some of these sites may pre-date spinal pain.
• Diagnosis is clinical and HLA typing is not required.

Management [Top of page]

• Patient education and physiotherapy in order to provide specific advice on mobilizing exercises and maintenance of a normal spinal curvature.
• NSAIDs: Often full doses of more potent agents are required and in some individuals for very prolonged periods.
• There is little evidence that second-line drugs help spinal disease in AS but sulphasalazine and other second-line drugs may benefit peripheral joint disease.

Aims of regular review [Top of page]

• Assess symptom control including psychosocial adjustment. ESR/CRP help to assess disease activity.
• In those with long term disease assess hips, heart sounds and ask about eye symptoms.
• Assess functional  difficulties e.g. with driving in those with cervical spinal disease.
• Evaluate side effects, tolerance of medication and drug interactions. Drug monitoring where required e.g. a periodic check on FBC if long term NSAIDs.
• Assess needs for review by rheumatologist or physiotherapist.