1. Rheumatology teaching session GP ST2 year 8/9/10

2. Introductions Kate Gadsby, Lead Rheumatology educator Dr. Helen Vose, GP trainer from Ashbourne

3. Overview Identifying inflammatory arthritis DMARDs & shared care protocol TEA & CAKE! Fibromyalgia

4. Diagnosing inflammatory arthritis Leena Patel ST2

5. Inflammatory arthritis Group of autoimmune diseases presenting with joint and systemic features Progressive condition Causes joint destruction and dysfunction Diagnosis of various types depends on pattern of joint involvement and certain systemic features

6. Inflammatory arthritis Rheumatoid arthritis Psoriatic arthritis Ankylosing spondylitis Reactive arthritis

7. Important message Evidence shows earlier detection and intensive treatment slows disease progression and joint destruction Do not delay referral if inflammatory arthritis is suspected

8. Quick test Which symptoms would make you think more of an inflammatory arthritis than a mechanical/degenerative joint disease?

9. History Pattern of joint involvement Pattern of stiffness(>30 mins in the morning) Presence of swelling Relationship of symptoms to use Fatigue Associations like psoriasis, uveitis, inflammatory bowel disease

10. Examination Pattern of joint involvement Presence of synovitis (soft, boggy feeling along joint line) Degree of tenderness ROM of joint Joint deformity

11. Guess the type of arthritis

12. Now.. Pick out the signs you can see in the picture that point to that diagnosis Any other joints commonly affected in this type of arthritis? What features may you find on an x-ray? Any other systems that may be affected?

13. What features can you identify?

14. Now.. Which inflammatory arthritis causes this? Which population group does it affect? What signs may you find on examination?

15. What’s the diagnosis

16. Which arthritis associated with the following eye symptoms Scleritis/episcleritis Anterior uveitis Uveitis Conjuctivitis

17. Recognising a pattern RA – symmetrical involvement of MCPs & MTPs with swelling, morning stiffness and flare ups Ankylosing spondylitis- prolonged morning stiffness of spine in young person BUT not always as straight forward!!! If in doubt, refer for further assessment

18. Investigations If history and examination suggests inflammatory arthritis, DON’T wait for results, refer straight away

19. Blood tests FBC U&E ESR CRP Rheumatoid factor

20. NOT a screening test for RA Used for classification and prognosis Can be raised in other conditions and infection High false positives Anti-CCP antibodies (more sensitive and specific for RA)

21. X-rays During early stages, normal x-rays therefore don’t rely on them for diagnosis With time, periarticular osteopenia Bony erosions Joint subluxation

22. Initial management by GP NSAID – reduced pain, swelling and inflammation Simple analgesia – paracetamol, codeine Think of gastric protection in elderly, dyspepsia symptoms Refer to secondary care early Think about quality of life, refer to OT for possible aids

23. Secondary Treatment options 1. Steroids 2. Disease modifying anti-rheumatic drugs (methotrexate, sulfasalazine, gold salts, azathioprine, ciclosporin) 3. Biological therapy ( rituximab, etanercept, infliximab) 4. Surgical options

24. Key messages Think of inflammatory arthritis when pt presents with joint pain Ask appropriate history to confirm this Refer early, don’t wait for results X-rays not useful in early stages Rheumatoid factor not diagnostic

25. References www.arthritisresearchuk.org www.rheumatology.org.uk InnovAiT; volume 2; issue 10; october 2009