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Rheumatology for the GP
Abid Yusuf ST5 Rheumatology & GIM
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Plan What we do The rheumatological history Key conditions Drugs
Referrals Questions
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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
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Gout Acute Chronic Investigations NSAIDs Colchicine Steroids
4 weekly follow up Allopurinol Febuxostat Etc Investigations U&Es Uric acid X ray affected areas Diet
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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
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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 hours Consider bone protection
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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!
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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
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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
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Beighton Score
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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
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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
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Drug monitoring Local set up FBC, LFT
Blood testing schedule when initiating DMARD 2 weekly for 6 weeks Monthly for 3 months 3 monthly
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Referrals
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Questions?
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