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Rheumatology for the GP

Rheumatology for the GP. Abid Yusuf ST5 Rheumatology & GIM. Plan. What we do The rheumatological history Key conditions Drugs Referrals Questions. History. Inflammatory arthritis Early morning stiffness Joint swelling Distribution Rashes IBD Preceding infection Iritis

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Rheumatology for the GP

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  1. Rheumatology for the GP Abid Yusuf ST5 Rheumatology & GIM

  2. Plan • What we do • The rheumatological history • Key conditions • Drugs • Referrals • Questions

  3. History • Inflammatory arthritis • Early morning stiffness • Joint swelling • Distribution • Rashes • IBD • Preceding infection • Iritis • Character of pain • Connective Tissue Disease • Raynaud’s • Mouth ulcers • Dry mouth/eyes • Myalgia • Tight skin • Fatigue

  4. Gout • Acute • NSAIDs • Colchicine • Steroids • Chronic • 4 weekly follow up • Allopurinol • Febuxostat • Etc • Investigations • U&Es • Uric acid • X ray affected areas • Diet

  5. Giant Cell Arteritis Typical History Includes Eye symptoms? No Yes Admit IV Methylprednisolone for 3 days Ophthalmology referral Vascular surgery referral for TAB Consider Aspirin 75mg Consider bone protection Refer to Rheumatology Prednisolone 40-60mg Orally +Proton Pump Inhibitor Consider Aspirin 75mg Consider bone protection Refer to Rheumatology

  6. PMR • Onset • Shoulder and hip girdles • Myalgia • Key manoeuvres • Constitutional symptoms • Investigations • FBC • U&E • CK • RF, Anti-CCP • Ig’s • Serum electrophoresis • CXR • Management • Start prednisolone 15mg PO OD • Should have excellent response within 24-48 hours • Consider bone protection

  7. Early Inflammatory Arthritis • Swollen tender joints • Back pain • Inflammatory • Mechanical • Stiff • Fatigue • Investigations • FBC • U&E • CRP, ESR • Uric acid • RF, Anti-CCP • B27 (if SpA features) • X ray hands and feet • ?erosions • Treatment • Avoid steroids if possible • NSAIDs • Refer early!

  8. Vasculitis • Purpuric rash • Preceding infection • ENT • Haemoptysis • Asthma • Neuropathy • Inflammatory eye disease • Always do urine dip • Investigations • URINE DIP • Protein:Creatinine Ratio, red cell casts • FBC • U&E • LFT • ANA, dsDNA • ANCA • RF • CXR

  9. Chronic pain/Fibromyalgia • Generalised pain • Unrefreshing sleep • Low mood • IBS • Investigations • Beighton score • FBC, U&E, Ca, Vit D • TFT • 9am cortisol • CK • ANA, dsDNA • Myeloma screen in older people • Interventions • Believe them • Graded exercises • CBT • Pain management • Pacing

  10. Beighton Score

  11. Antibodies If inflammatory arthropathy suspected • Rheumatoid factor • Anti-CCP antibodies If connective tissue disease suspected • ANA • ENA • dsDNA If Vasculitis suspected • ANCA • ANA + dsDNA • Rheumatoid Factor/Cryoglobulins • Hepatitis Screen

  12. Types of DMARD • Targeted synthetic DMARD • JAK inhibitors • Baricitinib • Tafacitinib • Biologic DMARD • Anti-TNFa • Infliximab • Etanercept • Adalimumab • Golimumab • Certolizumab • Anti-IL6 • Tocilizumab • Sarilumab • Anti-CD20 • Rituximab Nonbiologic DMARD • Methotrexate • Sulfasalazine • Leflunomide • Hydroxychloroquine • Azathioprine • MycophenolateMofetil

  13. Drug monitoring • Local set up • FBC, LFT • Blood testing schedule when initiating DMARD • 2 weekly for 6 weeks • Monthly for 3 months • 3 monthly

  14. Referrals

  15. Questions?

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