Rheumatology for the GP Abid Yusuf ST5 Rheumatology & GIM

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

History Inflammatory arthritis Connective Tissue Disease 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

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

Giant Cell Arteritis No Yes Typical History Includes Eye symptoms? 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

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

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!

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

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

Beighton Score

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

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

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

Referrals

Questions?