Rheumatoid Arthritis for GPs

Examples - RhA, Psoriatic arthropathy, AnkSpond

Inflammatory arthritis falls into several broad categories:

  1. Early undifferentiated arthritis - arthritis which is difficult to categorise because very early stages
  2. Rheumatoid arthritis - chronic autoimmune disease  joint inflammation and deformity.
  3. Sero-negative rheumatoid arthritis - arthritis behaves exactly like RA but negative RhF anti-CCP
  4. Spondyloarthropathy- includes psoriatic arthropathy, reactive arthritis, arthritis associated with inflammatory bowel disease and ankylosing spondylitis
  5. Gout and crystal arthropathies- managed in primary care because the drugs used to treat it aren’t as risky as DMARDs. Treat promptly but ONLY refer if difficulties in management.

RHEUMATOID ARTHRITIS

  • One new RhA every year. Prevalence 1% (muscskel disorders 12% of GP consults)
  • Peak 30-40s but also 70s.

DIAGNOSIS

Confusingly, osteoarthritis can also present with hot, swollen joints because it too is an inflammatory process, especially in the hands.

Pointers to OA

  1. Middle aged to elderly with evidence of OA in other joints, e.g. Heberden's, knee and spine OA
  2. DIP joint involvement
  3. Persistent (use related) pain with limited stiffness
  4. Crepitus or reduced movement
  5. Bony enlargement

Pointers to an inflammatory diagnosis

  1. Sudden onset
  2. Bilateral symptoms
  3. Systemic disturbance, fever, sweats, fatigue and weight loss
  4. Raised inflammatory markers/normocytic anaemia
  5. Family history of auto-immune disorders
  6. Morning stiffness lasting >30 minutes or new onset stiffness after rest
  7. Pain on MTP/ MCP squeeze

INVESTIGATIONS

  • FBC, ESR, CRP, U&E, LFT, bone profile (ESR & CRP can take a while to go up)
  • Urate - for gout – do urate at least 2w after acute attack. Think in people on thiazide or metabolic syndrome (diabetes, obesity, high BP = DOB mnemonic).
  • RhF: Sensitivity 70% (in other words 30% of –ve results are wrong). Specificity 80% (or 20% of +ve results wrong); costs £7 (compare with FBC = £2.50)
  • AntiCCP similar sens as RhF. But better specificitythan RhF (95%). Like RhF, 30% of –ve results are wrong, but only 5% (as opposed to 20% in RhF) of +ve are wrong. costs £8.50 (RhF = £7)
  • Xrays only if symptoms >6m because it takes this long for changes to be seen.

EARLY REFERRAL & TREATMENT

There is a window of opportunity in the first 12 weeks of the illness when treatment with DMARDs may actually switch off the disease, thus improving the patient's prognosis. Hence refer ASAP if you suspect the diagnosis to improve prognosis. Rheumatologists will start DMARD & Steroid and gradually reduce dose to control levels. DMARDs to start within 12w of onset = better prognosis long terms. Ring them if you need to.

If there is going to be a long wait, low dose steroids – 10mg od prednisolone for 2w; 7.5mg aftercontinue to reduce ORIMmethylpred 120mg stat (preferred route). Tell the Rheum you have done this.

OTHER THINGS

  • QRISK2 on all RhA patients. (10y risk) - high risk of CV disease (as bad as diabetic patients).
  • Modify BP, obesity, smoking.
  • FRAX toolBMD – risk of osteoporosis; 30% will get Osteoporosis (even worse if on steroids).
  • Give advice on exercise, Ca in diet,vit D supplementation. Reduce steroids use to minimum levels.

DMARDS

  • DMARDs need monitoring – bone marrow suppression. Also liver and kidney impairment risk.
  • Therefore do regular FBC, U&E LFTs

BIOLOGIC THERAPIES

•Prescribed by hospital. Add to GP record so you know they are on it. Can be serious drugs because they are immunomodulatory. Mark as hospital prescribed only on the record.

•Examples – adalimubab (Humira), ritumab (Mabthera), Etanercept (Enbrel)

SPECIFICALLY METHOTREXATE

  • Rare side effects methotrexate = lung fibrosis, liver fibrosis, pneumonitis.
  • Methotrexate normal dose = 7.5-25mg once a WEEK; prescribe 2.5mg tabs (not 10mg).
  • Increase/Decrease every 2-6w.
  • Also add Folic acid 5mg once a week 24h after the methotrexate;Caution: NEVER prescribe trimethoprim to people on methotrexate – both folate antagonists FATAL bone marrow suppression.
  • Before Rx: FBC U&E LFT, CXR (within last 6m), Spirometry
  • During Rx: FBC U&E LFT every 2w until dose stable for 6w., Thereafter monthly until stable dose for 1y. Thereafter – depends on clinical judgement. Once every 2-3 months?

Stop methotrexate if…

•If a patient has an infection – talk to specialist first.

•WCC <2 or Neutrophils <1

•FBC – downward trend in all parameters (bone marrow aplasia)

•AST ALT rise 3x normal

•Unexplained fall in albumin in the absence of liver disease

•New or increasing shortness of breath with a dry cough (fibrosis?)

•Patient has a rash

Side Effects DMARDs

•N&V, D, mouth ulcers, rashes.

•Sulfasalazine – headaches. Rarely settle.

•Rash – withdraw drug, slowly reintroduce. If recurs, stop.

FLARE UPS

•= acute joint pain, stiffness, loss of function. Heat ++ Sore in a few places. Feel unwell and exhausted.

•Before altering medication, check:

  1. Compliance with medication
  2. Patient has not injured joint recently
  3. Not septic arthritis - one joint flare up is RARE in RhA – think septic arthritis esp if on immunosuppressive Rx.

•What GP should do in flare up:

  • Ring Rheum hotline if you need to (or ask patient to)
  • Increase analgesia & advise test. Both these usually do the trick.
  • If not, short course oral steroids (10mg predod, reducing rapidly over 2w) or IMmethodpred 120mg stat. IMinj preferred – works within 40h, last 6w. Ask patient to tell rheum deptyou have done this.

QOF

•Register of RhA patients

•QRISK done on all 30-84 y olds – done every year (15m in QOF)

•FRAX assessment of 50-90y olds every 2 years (27 m in QoF = 2y +3m)

•Face to face annual review (QoF 15m)

THE FACE-FACE REVIEW

•Med Review – side effects, compliance check, DMARD monitoring – shared care?

•Control of disease – joint activity counts, pain scores, joint damage, functional ability, review of diagnoses, extra articular disease

•Review bloods over the year - any downward spiral esp in FBC parameters. Review CRP, ESR

•Depression screen

•Contraceptive/Preconception advice for patients of child bearing age

•Pneumococcal and seasonal flu vacs for those on DMARDs

•Co-morbidities

  • Work on cardio-vasc health - BP, obesity, smoking, QRISK every year (30y+)
  • Work on bone health - exercise, ca in diet, vit D sup, FRAX every 2 years (50y+)