Orthopaedics & Rheumatology explanation

Question 1

Methotrexate

Answer 1

What does it do?

• Rheumatoid arthritis is an autoimmune disease
  
  • Your immune system - which usually fights infection - attacks the cells that line your joints, making them swollen, stiff and painful.
• Methotrexate dampens down the immune system, slowing the progression of RA

Side effects

• GI upset
  
  • Nausea, vomiting, diarrhoea, abdo pain etc
• Myelosuppression (seek advice)
  
  • Sore throat, fever, mouth ulcers
• Pneumonitis
  
  • SOB, cough, high fever
• Hepatotoxicity (folic acid)

Dose

• Co-prescribe folic acid (take on non-methotrexate days)
• One dose of methotrexate each week, same day each week
• Can take 6-12 weeks before symptomatic benefit - persevere!

Monitoring

• Baseline
  
  • FBC,LFT, U&E, urinary protein (KFT)
• Monitoring
  
  • FBC fortnightly until stable, monthly thereafter
  • LFTs 3-monthly
  • U&E 6-12 monthly

Contraindications

• Hepatic impairment
• Pregnancy
• Immunodeficient
• Active infection
• DO NOT TAKE WITH NSAID - Increases methotrexatre

Question 2

Sulfasalazine

Answer 2

What does it do?

• Rheumatoid arthritis is an autoimmune disease
  
  • Your immune system - which usually fights infection - attacks the cells that line your joints, making them swollen, stiff and painful.
• Sulfasalazine dampens down the immune system, slowing the progression of RA

Side effects

• GI disturbance
• Rash
• Orange urine, stain contact lenses
• Headache
• Dizziness
• Blood and liver
  
  • Sore throat, fever
  • Bruising

Dose

• Start on low dose and gradually increase according to the severity of disease
• Can take 12 weeks to notice any benefit

Monitoring

• Initial
  
  • FBC, U&E, LFT
• Monitoring
  
  • FBC and LFTs monthly for the first 3 months, and 3-monthly thereafter.

Complications

• Fall in sperm count (reversible)
• No problems in pregnancy/breastfeeding

Question 3

NSAIDs

Answer 3

What do they do?

• NSAIDs reduce inflammation, which helps to ease joint pain and stiffness

Dose

• Take with/after food (reduce GI SE)
• 2-4 times a day depending on strength/dose
  
  • Aspirin 300-600 mg
  • Ibuprofen 200-400 mg
• Co-prescribe PPI

Side effects

• GI upset
  
  • Damage lining of stomach and cause bleeding
• Heartburn / indigestion
• Rash
• Headache
• Wheeziness

Complications

• Slight increased risk of MI / stroke
• Interacts with methotrexate (increases serum concentrations)

Contraindications

• Allergy
• Asthma
• GI or kidney problems
• Taking warfarin
• Pregnant or breastfeeding

Question 4

Osteoporosis & Bisphosphonates

Answer 4

Osteoporosis

• Bone is a living tissue that is constantly renewing itself.
• As we get older, the balance between the breakdown of old bone and the formation of new bone changes, and our bones gradually lose density.
• This happens to everybody to some extent, but is referred to as osteoporosis when the bones become weak and fragile.
• Osteoporosis means ‘spongy’ bone

Who gets osteoporosis?

• Increases with age
• Women > men
  
  • Bone loss speeds up after menopause when the ovaries stop producing oestrogen
• Risk factors
  
  • Steroids
  • Smoking/alcohol
  • Lack of exercise
  • Poor diet
  • FHx

How is it diagnosed?

• DEXA scan (measure bone density)
  
  • If low impact fracture or presence of risk factors

Self-help

• Exercise, diet
• Smoking / alcohol

Bisphosphonates - What do they do?

• Bisphosphonates are prescribed in the treatment of osteoporosis
• They act by reducing bone erosion, thereby slowing the progression of osteoporosis

Dose

• Bisphosphonates poorly absorbed from the stomach
  
  • Take on empty stomach (at least 30 mins before food)
  • Stand upright and take with plenty of water
• Co-prescribe calcium and vitamin D

Side effects

• GI upset
  
  • Diarrhoea/constipation, abdo pain, indigestion

Complications

• Osteonecrosis of jaw (maintain good oral hygiene, regular dental check-ups)
• Small increase of oesophageal cancer

Question 5

Rheumatoid arthritis

Answer 5

What is it?

• RA is an autoimmune disease.
  
  • Your immune system helps fight infection. In RA, your immune system attacks the lining of your joints, causing swelling, pain and stiffness
• Symptoms come and go (flare ups)

Causes

• Genes
• Smoking, red meat, caffeine

Symptoms

• Common
  
  • Synovitis
    
    • Symmetrical, commonly wrists and fingers
    • Morning stiffness (>30 mins)
  • Tiredness
  • Flu-like symptoms
• Extra-articular
  
  • Eyes
  • Lungs (X-ray)
  • Blood vessels

Management

• Physio / OT
• Drugs
  
  • NSAIDs
  • DMARDs (x2)
  • Steroids (flare ups)

Question 6

Temporal arteritis

Answer 6

What is it?

• GCA is an inflammatory condition that affects blood vessels, specifically arteries (hence arteritis)
• The most commonly affected arteries are those in the head, causing pain and tenderness over the temples (hence temporal)

Symptoms

• Headache
• Temple / scalp tenderness
• Flu-like symptoms
• Loss of vision
• Pain in the jaw when chewing (claudication)
• Symptoms of polymyalgia rheumatica
  
  • Pain and stiffness proximal muscles, especially in morning

Who gets it?

• Rare below 50
• Women > men

Diagnosis

• Symptoms
• Blood tests (ESR, CRP)
• Temporal artery biopsy
  
  • Small sample of artery removed, looked at under microscope

Complications

• Blindness
• Stroke (small risk)

Management

• High-dose steroids (40-60 mg)
  
  • Everyday for 3-4 weeks
  • Gradually reduce dose
  • Low dose for 1-3 years (relapse most common in first 18 months)
  • Co-prescribe bisphosphonates, calcium and vit D, PPI