CHAPTER 14: MUSCULOSKELETAL CONDITIONS 11/20/2018 NATIONAL DEPARTMENT OF HEALTH AFFORDABLE MEDICINES ESSENTIAL MEDICINES PROGRAMME DISCLAIMER This slide set is an implementation tool and should be used alongside the published STG. This information does not supersede or replace the STG itself. PRIMARY HEALTHCARE 2014 Updates to the 2008 PHC STG & EML

DERMATOMYOSITIS STG for Dermatomyositis was not added to the chapter. Rationale: Not considered as a common condition that requires to be covered by the essential medicines concept in South Africa. 2014 PRIMARY HEALTHCARE 2014 IMPLEMENTATION SLIDES: MUSCULOSKELETAL CONDITIONS

Level of evidence: II RCT 14.4.1 GOUT, ACUTE Ibuprofen, oral: retained Naproxen, oral: not added Although naproxen is not associated with long-term cardiovascular adverse events, etc. this is an acute setting. A single NSAID was considered pragmatic for primary level of care. Level of evidence: III Expert opinion Prednisone, oral: dose not amended Lancet article investigated prednisolone 35 mg daily for 5 days for the treatment of gout. As the dose of prednisolone is equivalent to prednisone, prednisone, oral was retained in the STG as 40 mg daily for 5 days, for the treatment of acute gout where NSAIDS are contraindicated, e.g. peptic ulceration, warfarin therapy and renal dysfunction. Level of evidence: II RCT Ref 1 PRIMARY HEALTHCARE 2014 IMPLEMENTATION SLIDES: MUSCULOSKELETAL CONDITIONS

Level of evidence: III Expert opinion 14.4.2 GOUT, CHRONIC Colchicine 0.5mg tablets: not added Colchicine had been deleted in the previous edition (2008) and no new evidence was available to support its inclusion in the PHC EML. Level of evidence: III Expert opinion PRIMARY HEALTHCARE 2014 IMPLEMENTATION SLIDES: MUSCULOSKELETAL CONDITIONS

Level of evidence: III Guidelines 14.3 ARTHRITIS, SEPTIC Urgent referral criterion for children: amended 2008: All children with hot, swollen, joints, very painful on movement with restricted movements administered a single dose of ceftriaxone, prior to referral. 2014: Nurse to determine whether a child is septic using the IMCI Guidelines for “POSSIBLE SERIOUS BACTERIAL INFECTION” . Recommendation: Text was amended as follows: Rationale: Prevent over treatment with a broad spectrum antibiotic of children who may not have septicaemia. In addition, subsequent cultures would be negative impeding further management at secondary level. Level of evidence: III Guidelines -Children with suspected septic arthritis should be assessed for evidence of septicaemia and septicaemic shock which should be treated accordingly. -Infants up to the age of 2 months who fulfil the IMCI criteria for “POSSIBLE SERIOUS BACTERIAL INFECTION” should receive a first dose of Ceftriaxone along with other IMCI urgent care while arranging transfer. • Ceftriaxone, IM, 80 mg/kg/dose immediately as a single dose. Ref 2 PRIMARY HEALTHCARE 2014 IMPLEMENTATION SLIDES: MUSCULOSKELETAL CONDITIONS

14.5 OSTEOARTHROSIS Paracetamol, oral: dose amended Dose was amended for consistency throughout the PHC STGs, 2014: “Paracetamol, oral, 1 g, 6 hourly”. PRIMARY HEALTHCARE 2014 IMPLEMENTATION SLIDES: MUSCULOSKELETAL CONDITIONS

Slide Ref # Reference 14.4.1 GOUT, ACUTE 3 1 PREDNISONE Janssens HJ, Janssen M, van de Lisdonk EH, van Riel PL, van Weel C. Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial. Lancet. 2008 May31;371(9627):1854-60. SAMF, 2012 edition. 14.3 ARTHRITIS, SEPTIC 5 2 National Department of Health. Integrated Management of Childhood Illness Guidelines, 2014. PRIMARY HEALTHCARE 2014 IMPLEMENTATION SLIDES: MUSCULOSKELETAL CONDITIONS