Treatment

Question 1

When do you refer a patient with joint synovitis?

Answer 1

Persistent synovitis with no clear underlying cause
Refer urgently if the hands or feet small joints affected, >1 joint affected or there has been >3 months between onset and presentation

Question 2

Which members of the MDT should be involved in treatment of someone with RA?

Answer 2

Physiotherapist - encourage exercise
Specialist nurse - for coordinating care
Occupational Therapist - if function affected
Psychologist - if people struggling to live with RA
Podiatrist - for foot health needs

Question 3

What is the treatment for someone with newly diagnosed RA?

Answer 3

2 DMARDs (one of which is Methotrexate) and short term steroids

Question 4

What is the treatment for someone with established RA?

Answer 4

Remove steroids
Carefully reduce dose until relief of symptoms but prevention of side effects is acheived
At first sign of a flare return up to a disease controlling dose

Question 5

What treatments are available for pain relief in RA?

Answer 5

Paracetamol and Codeine
NSAIDs should not be used routinely and only at the lowest effective dose for the shortest possible time
NSAIDs should always be co-prescribed with a PPI

Question 6

When should RA patients be reviewed?

Answer 6

Monthly with DAS until treatment has controlled the disease
Annually with DAS thereafter
Ability to review with specialist nurse for disease flares and ongoing drug monitoring

Question 7

If the combination therapy for RA does not work, what is the next line of therapy?

Answer 7

Active disease despite combination therapy - consider biologics - Rituximab, anti-TNF, Abatacept

Question 8

What is the first line treatment in someone who has an acute attack of gout?

Answer 8

NSAIDs i.e. Naproxen
Colchicine - if NSAIDs contraindicated i.e. renal disease
Steroids - if the above both contraindicated and septic arthritis ruled out

Question 9

When do you introduce urate lowering therapy?

Answer 9

> 2 attacks of gout in 1 year
Tophi
Renal stones
CKD stage 2 or worse

Question 10

How soon after an attack do you initiate urate lowering therapy?

Answer 10

2 weeks

Question 11

What is Allopurinol?

Answer 11

Xanthine Oxidase Inhibitor
Titrate upwards from 100mg daily, not exceeding 900mg/day
Has to be continued lifelong

Question 12

What do you give alongside Allopurinol?

Answer 12

Low dose NSAID or Colchicine for two weeks prior to starting
This is because it can precipitate more gout attacks in the first 6 months - so keep taking the NSAID or Colchicine throughout this time

Question 13

What are the management options for someone with OA?

Answer 13

Conservative - physiotherapy, weight loss and patient education, involve the MDT

Medical - NSAIDs, topical analgesia or capsaicin cream, for more moderate pain - intra-articulate steroid injections

Surgical - joint replacement if symptoms significantly impact quality of life

Question 14

How do you manage musculoskeletal back pain?

Answer 14

Education and reassurance
Safety netting regarding red flags for back pain
All normal activities should be undertaken and exercise is encouraged
Avoid triggers
Physiotherapy
Local modalities i.e. heat or ice
Home environment modifications to reduce strain on the back
Weight reduction

Question 15

What pharmacological management should you use in someone with lower back pain?

Answer 15

NSAIDs - lowest dose for the shortest time possible
Then weak opioids
Consider at last resort surgical spinal decompression

Question 16

What are the principles of treating someone with a newly diagnosed small vessel vasculitis?

Answer 16

Induction of remission with high dose immunosuppressants (steroids + rituximab)
Once disease controlled, switch to a steroid sparing regime such as Azathioprine or Methotrexate
Taper the drug until the patient is in remission off the medication

Question 17

Treatment options for someone with Fibromyalgia?

Answer 17

Reassurance and education
Lifestyle changes
Avoiding triggers
Exercise
AVOID NSAIDs

Question 18

What are the treatments of the complications of fibromyalgia?

Answer 18

Depression and anxiety - Talking therapies
Severe pain - Duloxetine or Pregabalin
Severe sleep disturbance - Amitriptyline

Question 19

Methotrexate - when and how to take

Answer 19

Once a week tablet
Some people like to remember it as ‘Methotrexate Mondays’
Also have to take it with Folic Acid to reduce the side effects - again some people like to remember ‘Folic Acid Fridays’ as this helps you remember not to take them at the same time
Can be given as an injection, but this is usually later down the line if you aren’t getting the benefits from it anymore
Building up dose slowly so may be a while before you start to experience benefits

Question 20

Methotrexate - tests

Answer 20

Need regular tests of your blood cell count and liver and kidney function tests
Before you start - also need a CXR
Then every 2 weeks at your GP until stable
Then every 2 months
You can record your blood results in a little book which you should bring with you to all your Rheumatology appointments

Question 21

Methotrexate - side effects

Answer 21

Headaches
Drowsiness
Nausea and vomiting
Hair loss

Question 22

Methotrexate - complications

Answer 22

Can cause a reduction in the number of infection fighting immune cells - tell a doc if you have a sore throat or fever
Can damage the liver - think about cutting down on alcohol
Can damage the lungs