Treatment Flashcards
When do you refer a patient with joint synovitis?
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
Which members of the MDT should be involved in treatment of someone with RA?
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
What is the treatment for someone with newly diagnosed RA?
2 DMARDs (one of which is Methotrexate) and short term steroids
What is the treatment for someone with established RA?
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
What treatments are available for pain relief in RA?
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
When should RA patients be reviewed?
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
If the combination therapy for RA does not work, what is the next line of therapy?
Active disease despite combination therapy - consider biologics - Rituximab, anti-TNF, Abatacept
What is the first line treatment in someone who has an acute attack of gout?
NSAIDs i.e. Naproxen
Colchicine - if NSAIDs contraindicated i.e. renal disease
Steroids - if the above both contraindicated and septic arthritis ruled out
When do you introduce urate lowering therapy?
> 2 attacks of gout in 1 year
Tophi
Renal stones
CKD stage 2 or worse
How soon after an attack do you initiate urate lowering therapy?
2 weeks
What is Allopurinol?
Xanthine Oxidase Inhibitor
Titrate upwards from 100mg daily, not exceeding 900mg/day
Has to be continued lifelong
What do you give alongside Allopurinol?
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
What are the management options for someone with OA?
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
How do you manage musculoskeletal back pain?
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
What pharmacological management should you use in someone with lower back pain?
NSAIDs - lowest dose for the shortest time possible
Then weak opioids
Consider at last resort surgical spinal decompression
What are the principles of treating someone with a newly diagnosed small vessel vasculitis?
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
Treatment options for someone with Fibromyalgia?
Reassurance and education Lifestyle changes Avoiding triggers Exercise AVOID NSAIDs
What are the treatments of the complications of fibromyalgia?
Depression and anxiety - Talking therapies
Severe pain - Duloxetine or Pregabalin
Severe sleep disturbance - Amitriptyline
Methotrexate - when and how to take
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
Methotrexate - tests
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
Methotrexate - side effects
Headaches
Drowsiness
Nausea and vomiting
Hair loss
Methotrexate - complications
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
