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Top tips in rheumatology

Dr Bobby Coughlan offers readers his top tips on the management of rheumatology patients in the first article in a new, six-part series

In a new six-part series, specialists offer top tips on the diagnosis, assessment and management of stroke, dyslipidaemia and heart failure, as well as bone, rheumatology and respiratory/sleep disorders. In the first instalment, Dr Bobby Coughlan, Consultant Rheumatologist at University College Hospital, Galway, sets out his top ten tips on managing patients who present to primary care with rheumatological symptoms.

Top Tip 1:
Inflammatory arthritis
To establish a diagnosis of inflammatory arthritis, one needs to enquire from the patient about the presence of pain, swelling and inactivity stiffness. The presence and degree of inactivity stiffness are strong indicators of the degree of underlying inflammation.

The distribution of the joint involvement is an indicator of the type of arthritis e.g. lower limb or upper and lower limb, symmetrical or asymmetrical, small joint or intermediate joint. It is also important to enquire about associated conditions such as psoriasis, inflammatory bowel disease, current or previous eye inflammation.

Top Tip 2: Hand pain
In a patient who complains of hand pain, it is important to establish from where exactly the pain is originating. Identify the origin by assessing each joint individually. Note the location of the pain and the distribution of the painful joints.

Involvement of the distal interphalangeal (DIP) joints is a strong indicator of nodal osteoarthritis. Involvement of the base of the thumb is an indicator of osteoarthritis at that site. Involvement of the proximal phalangeal (PIP) joints and/or the metacarpo-phalangeal (MCP) joints should bring to mind the possibility of rheumatoid arthritis (RA) or inflammatory osteoarthritis (OA).

In the case of rheumatoid arthritis, it is important to examine the feet. Tenderness or swelling at the metatarso-phalangeal (MTP) joints in both feet, together with symptoms and signs at the MCP and PIP joints, are strong indicators of rheumatoid arthritis.

Elevated C-reactive protein and/or erythrocyte sedimentation rate can help to establish the presence of inflammation. In the presence of symmetrical, peripheral inflammatory arthritis in the hands and feet, elevated rheumatoid factor and anti-CCP antibody levels are strong indicators of the presence of RA.

Treating RA aggressively and early has radically altered the outlook for patients with this disease and it is imperative that RA patients are seen and treated at an early stage in the disease process to reduce the chance of long-term damage, deformity and disability.

Top Tip 3: RA and coronary artery disease
Rheumatoid arthritis is a significant independent risk factor for the development of ischaemic heart disease. Attention should therefore be paid to other risk factors for coronary artery disease in RA patients.

In those with RA and ischaemic heart disease, the presentation can be somewhat unusual and angina may not be the presenting symptom. This may be because of the nature of the coronary artery involvement or because of the associated impairment in mobility that also reduces the patient’s ability to exert him/herself.

Top Tip 4: Gout
Patients with gout have an arthritis that is entirely treatable. Allopurinol is the drug of first choice in treating these patients and, in the majority of cases, it is the only drug needed long term. With allopurinol, it would be expected that the serum uric acid level would be reduced to the mid-normal range.

To avoid provoking attacks of gout while establishing the patient on allopurinol, it is best to increase the dose by 100mg increments every three to four weeks until the target uric acid level is reached. The target level may require the patient to be on 600mg or 700mg of allopurinol daily.

While escalating the dose, and for two or three months afterwards, one can use prophylactic colchicine (500mcg daily) or a non-steroidal anti-inflammatory agent. It is important to maintain the uric acid level within the target range for several months, or even a year or two, before attempting to reduce the dose of allopurinol.

Again, the dose should be reduced very slowly, with careful monitoring of serum uric acid level.

When reducing to maintenance dose, reductions of 100mg increments should also be used but, on this occasion, dose adjustments should be made at intervals of at least three to six months. Gout is a very gratifying condition to treat because it does respond very well to this sort of therapy. In patients with abnormal or impaired renal function, dose escalation, peak dose and rate of escalation must be greatly modified.

The use of anti-inflammatory agents requires similar modification in this patient group. Sometimes this treatment is best done in conjunction with a nephrologist or rheumatologist.

Top Tip 5: Shoulder pain
Patients with shoulder disease frequently complain of pain anterior to the shoulder or in the upper arm. In our clinic, the commonest problem is rotator cuff tendonitis, specifically shoulder tendonitis of the supraspinatus tendon.

This occurs in middle-aged and elderly individuals and is very amenable to treatment. The classical symptoms are that of pain on abduction of the shoulder, pain when lying on the shoulder and pain on elevating the arm. The pain radiates into the upper arm.

On clinical examination, passive shoulder movements are usually near normal and the pain is reproduced by resisted shoulder abduction. Most patients respond very well to treatment with corticosteroid injected into the subacromial space. This is one of the most common intra-articular procedures undertaken in rheumatology and can be done in primary care.

Persisting or recurring episodes of tendonitis warrant further investigation with either a plain film x-ray or MRI scan of the shoulder, with a view to possible surgical intervention.

Top Tip 6: Spondylitis
Patients with back pain who have early-morning wakening and prominent inactivity stiffness should always be considered for the possibility of anklosing spondylitis. The diagnosis is usually confirmed with an x-ray of the sacroiliac joints. On rare occasions, there is no sacroiliac involvement and/or sacroiliac joint is normal on x-ray.

In such cases, a rheumatology assessment is important. The outlook for patients with spondylitis has radically altered with the advent of biological treatments and again, early intervention will frequently maintain normal function.

Top Tip 7:
Raynaud’s phenomenon
In patients with Raynaud’s symptoms, it is important to establish if the disease is primary or secondary in nature. It goes without saying that these patients should avoid cigarette smoking. The presence of antinuclear antibodies or anticentromere antibodies should heighten the suspicion of an underlying connective tissue disease. The absence of these antibodies is reassuring. The presence of normal capillaroscopy is a strong indicator of primary (benign) Raynaud’s disease.

Top Tip 8: Fibromyalgia
Fibromyalgia is a common cause of widespread musculoskeletal pain. It is usually associated with poor sleep pattern, daytime fatigue and other conditions such as irritable bowel syndrome. There is no serological or imaging technique that can provide a definitive diagnosis.

Fibromyalgia is essentially a clinical diagnosis and a diagnosis of exclusion. In patients with fibromyalgia, it is important to encourage conditioning exercises in spite of fatigue and this usually takes the form of a structured exercise programme.

The patient should exercise vigorously once or twice daily and this will often improve the quality of sleep, reduce daytime fatigue and reduce pain. Some agents, such as anticonvulsants or tricyclic antidepressants, will help matters but are not curative.

Top Tip 9: Osteoporosis
There are few indications for doing bone-density scans in patients who are premenopausal or under the age of 55. The focus in the assessment, management and treatment of osteoporosis is on fracture prevention. Patients with low bone mineral density (BMD) who are under 50 have a very low incidence of fracture and so the issue of treatment does not arise.

Most of the evidence is based on the treatment of patients in the postmenopausal years. All patients over the age of 50, with a low trauma fracture, need to be assessed for future risk of fractures.

Measuring BMD is a key component of this assessment. Where BMD is in the osteoporotic range, there is no doubt that treatment is indicated. In younger patients and premenopausal women, there is little or no indication for doing bone-density scans. The risk of fracture in this age group is very small and is not greatly increased by low BMD.

Standard bisphosphonate therapy is used and tolerated by the vast majority of patients with osteoporosis. Poor compliance can be addressed by using either parental annual (zolendronate) or three monthly (ibandronate) preparations.
Increasingly, we are finding that patients on multiple medications find an annual zolendronate infusion to be useful from the point of view of reducing oral medications and reducing any risks from oesophagitis.

Paradoxically, some compliance issues can be addressed by giving the patient daily treatment (strontium or a bisphosphonate). Strontium is also suitable for patients who are intolerant of bisphosphonates or who have oesophageal disease.

In patients who are elderly and have sustained a fragility fracture, treatment can be initiated even in the absence of a DEXA scan. It might be useful in these patients to obtain a serum vitamin D level, as many will have vitamin D deficiency, which also increases the risks of falls and complicates the underlying bone disease. Confounding vitamin D deficiency can be treated with simple dietary supplementation.

Top Tip 10: Falls
Osteoporosis is responsible for an increased risk of fracture in certain patients. These ‘low trauma fractures’ usually involve a fall. So, in addition to addressing the patient’s bone density with pharmaceuticals, it is important to address the patient’s risk of falls.

This includes simple strategies like ensuring the patient does not have postural hypotension related to antihypertensive, cardiac or psychotropic medicines.

Exercise can prevent further decline in patients with impaired mobility. It is important therefore that these patients are encouraged to partake in regular simple exercises such as supervised walking, so that the remaining neuromuscular function is exercised and ‘trained’ as best as possible to reduce the risk of falls.

Falls prevention should include assessment of the patient’s environment for contributory factors such as loose carpets and obstructions on the floor as well as lighting and steps.

Dr Bobby Coughlan, Consultant Rheumatologist at University College Hospital, Galway.

The views expressed above are those solely of the author(s)and in no way may be deemed to reflect the views or policy of either MSD Science Centre or Merck Sharp & Dohme Ireland (Human Health) Limited.

Posted in Musculoskeletal on 17 September 2009
Tags: rheumatoid arthritis

Tagcloud

abortion, accupuncture, ACE inhibitors, acne, ADHD, alcohol, allergies, Alzheimer's, anaemia, anaethesia, anorexia, antibiotics, antidepressants, antihistamine, anxiety, appetite control, arthritis, ASCOT, aspirin, asthma, atherosclerosis, autism, autoantibodies, back pain, beta carotene, beta-blockers, bipolar disorder, birth, bleeding, blindness, blood pressure, body dysmorphic disorder, body mass, breast cancer, breast feeding, bronchitis, Caesarean section, calcium, cancer, carcinogens, carcinoma, cardiac syncope, cardiolgy, cataracts, cervical cancer, chemotherapy, child psychiatry, children, cholesterol, clinical trial, clopidogrel, Clostridium difficile, cognitive behavioural therapy, colectomy, colic, colorectal cancer, complementary and alternative therapies, contraception, COPD, coronary care, coronary stents, Crohn's, cystic fibrosis, defibrillator, dementia, depression, dermatology, diabetes management, diet, disability, DNA, Down's syndrome, eating disorders, echinacea, ECT, eczema, elderly people, endoscopy, epilepsy, erectile dysfunction, euthanasia, exercise, fat, fertility, fitness, flu pandemic, fluoxetine, folic acid, food labelling, fracture, fragile X syndrome, general surgery, genetics, gerontology, GIK infusion therapy, GORD, gout, haemodialysis, hearing, heart attack, heart disease, heart failure, heart health, hepatitis, HIV, hospital care, HPV, HRT, hyperglycaemia, hypertension, hypoglycaemia, IBD, ICU, incontinence, infant, infant mortality, infection, inflammatory bowel disease, influenza, invasive candidiasis, IQ, Irish Heart Foundation, irritable bowel syndrome, keyhole surgery, kidney disease, laser, learning difficulties, leukaemia, liver disease, lumbar disk herniation, lung cancer, lung disease, lymph nodes, macular degeneration, macular oedema, magnetic resonance imaging (MRI), malaria, malnutrition, Marfan syndrome, media, medical ethics, medical research, medication, meningitis, mental illness, metabolic syndrome, migraine, miscarriage, mortality rate, MRSA, multiple sclerosis (MS), NCHDs, nephrology, neurology, OAB, obesity, obstetrics, occupational health, ocular medicine, omega-3, opthalmology, oral cancer, organ transplantation, orthopaedics, osteoporosis, otolaryngology, ovarian cancer, paediatrics, pain management, pancreatic cancer, panic, Parkinson’s disease, patient safety, patient-physician communication, personality disorders, physiotherapy, plastic surgery, polio, practice, pre-eclampsia, pregnancy, preventative health care, probiotics, prostate cancer, psoriasis, psychiatric admission, psychiatry, psychotherapy, PTSD, public health, quality of life, radiology, radiotherapy, rectal cancer, reproductive health, research, resuscitation, rheumatoid arthritis, rheumatology, rhinitis, salt, SARS, schizophrenia, screening, seizures, self harm, sexual abuse, sexual health, sexually transmitted infections, SGA, sinusitis, skin cancer, sleep disorders, smoking, smoking ban, spinal injury, sports medicine, statins, stress, stroke, substance abuse, suicide, supplement, surgery, syncope, technology, teenagers, testosterone, thoracic surgery, thrombosis, thyroid cancer, tonsillectomy, tonsillitis, Tourette's syndrome, toxicology, travel medicine, tuberculosis, tumour angiogenesis, type 1 diabetes, type 2 diabetes, ulcer, ulcerative colitis, urinary incontinence, vaccine, vitamins, weight, WHO, women's health, World Health Assembly

«Previous article | Next article»

Top tips in rheumatology

Dr Bobby Coughlan offers readers his top tips on the management of rheumatology patients in the first article in a new, six-part series

In a new six-part series, specialists offer top tips on the diagnosis, assessment and management of stroke, dyslipidaemia and heart failure, as well as bone, rheumatology and respiratory/sleep disorders. In the first instalment, Dr Bobby Coughlan, Consultant Rheumatologist at University College Hospital, Galway, sets out his top ten tips on managing patients who present to primary care with rheumatological symptoms.

Top Tip 1:
Inflammatory arthritis
To establish a diagnosis of inflammatory arthritis, one needs to enquire from the patient about the presence of pain, swelling and inactivity stiffness. The presence and degree of inactivity stiffness are strong indicators of the degree of underlying inflammation.

The distribution of the joint involvement is an indicator of the type of arthritis e.g. lower limb or upper and lower limb, symmetrical or asymmetrical, small joint or intermediate joint. It is also important to enquire about associated conditions such as psoriasis, inflammatory bowel disease, current or previous eye inflammation.

Top Tip 2: Hand pain
In a patient who complains of hand pain, it is important to establish from where exactly the pain is originating. Identify the origin by assessing each joint individually. Note the location of the pain and the distribution of the painful joints.

Involvement of the distal interphalangeal (DIP) joints is a strong indicator of nodal osteoarthritis. Involvement of the base of the thumb is an indicator of osteoarthritis at that site. Involvement of the proximal phalangeal (PIP) joints and/or the metacarpo-phalangeal (MCP) joints should bring to mind the possibility of rheumatoid arthritis (RA) or inflammatory osteoarthritis (OA).

In the case of rheumatoid arthritis, it is important to examine the feet. Tenderness or swelling at the metatarso-phalangeal (MTP) joints in both feet, together with symptoms and signs at the MCP and PIP joints, are strong indicators of rheumatoid arthritis.

Elevated C-reactive protein and/or erythrocyte sedimentation rate can help to establish the presence of inflammation. In the presence of symmetrical, peripheral inflammatory arthritis in the hands and feet, elevated rheumatoid factor and anti-CCP antibody levels are strong indicators of the presence of RA.

Treating RA aggressively and early has radically altered the outlook for patients with this disease and it is imperative that RA patients are seen and treated at an early stage in the disease process to reduce the chance of long-term damage, deformity and disability.

Top Tip 3: RA and coronary artery disease
Rheumatoid arthritis is a significant independent risk factor for the development of ischaemic heart disease. Attention should therefore be paid to other risk factors for coronary artery disease in RA patients.

In those with RA and ischaemic heart disease, the presentation can be somewhat unusual and angina may not be the presenting symptom. This may be because of the nature of the coronary artery involvement or because of the associated impairment in mobility that also reduces the patient’s ability to exert him/herself.

Top Tip 4: Gout
Patients with gout have an arthritis that is entirely treatable. Allopurinol is the drug of first choice in treating these patients and, in the majority of cases, it is the only drug needed long term. With allopurinol, it would be expected that the serum uric acid level would be reduced to the mid-normal range.

To avoid provoking attacks of gout while establishing the patient on allopurinol, it is best to increase the dose by 100mg increments every three to four weeks until the target uric acid level is reached. The target level may require the patient to be on 600mg or 700mg of allopurinol daily.

While escalating the dose, and for two or three months afterwards, one can use prophylactic colchicine (500mcg daily) or a non-steroidal anti-inflammatory agent. It is important to maintain the uric acid level within the target range for several months, or even a year or two, before attempting to reduce the dose of allopurinol.

Again, the dose should be reduced very slowly, with careful monitoring of serum uric acid level.

When reducing to maintenance dose, reductions of 100mg increments should also be used but, on this occasion, dose adjustments should be made at intervals of at least three to six months. Gout is a very gratifying condition to treat because it does respond very well to this sort of therapy. In patients with abnormal or impaired renal function, dose escalation, peak dose and rate of escalation must be greatly modified.

The use of anti-inflammatory agents requires similar modification in this patient group. Sometimes this treatment is best done in conjunction with a nephrologist or rheumatologist.

Top Tip 5: Shoulder pain
Patients with shoulder disease frequently complain of pain anterior to the shoulder or in the upper arm. In our clinic, the commonest problem is rotator cuff tendonitis, specifically shoulder tendonitis of the supraspinatus tendon.

This occurs in middle-aged and elderly individuals and is very amenable to treatment. The classical symptoms are that of pain on abduction of the shoulder, pain when lying on the shoulder and pain on elevating the arm. The pain radiates into the upper arm.

On clinical examination, passive shoulder movements are usually near normal and the pain is reproduced by resisted shoulder abduction. Most patients respond very well to treatment with corticosteroid injected into the subacromial space. This is one of the most common intra-articular procedures undertaken in rheumatology and can be done in primary care.

Persisting or recurring episodes of tendonitis warrant further investigation with either a plain film x-ray or MRI scan of the shoulder, with a view to possible surgical intervention.

Top Tip 6: Spondylitis
Patients with back pain who have early-morning wakening and prominent inactivity stiffness should always be considered for the possibility of anklosing spondylitis. The diagnosis is usually confirmed with an x-ray of the sacroiliac joints. On rare occasions, there is no sacroiliac involvement and/or sacroiliac joint is normal on x-ray.

In such cases, a rheumatology assessment is important. The outlook for patients with spondylitis has radically altered with the advent of biological treatments and again, early intervention will frequently maintain normal function.

Top Tip 7:
Raynaud’s phenomenon
In patients with Raynaud’s symptoms, it is important to establish if the disease is primary or secondary in nature. It goes without saying that these patients should avoid cigarette smoking. The presence of antinuclear antibodies or anticentromere antibodies should heighten the suspicion of an underlying connective tissue disease. The absence of these antibodies is reassuring. The presence of normal capillaroscopy is a strong indicator of primary (benign) Raynaud’s disease.

Top Tip 8: Fibromyalgia
Fibromyalgia is a common cause of widespread musculoskeletal pain. It is usually associated with poor sleep pattern, daytime fatigue and other conditions such as irritable bowel syndrome. There is no serological or imaging technique that can provide a definitive diagnosis.

Fibromyalgia is essentially a clinical diagnosis and a diagnosis of exclusion. In patients with fibromyalgia, it is important to encourage conditioning exercises in spite of fatigue and this usually takes the form of a structured exercise programme.

The patient should exercise vigorously once or twice daily and this will often improve the quality of sleep, reduce daytime fatigue and reduce pain. Some agents, such as anticonvulsants or tricyclic antidepressants, will help matters but are not curative.

Top Tip 9: Osteoporosis
There are few indications for doing bone-density scans in patients who are premenopausal or under the age of 55. The focus in the assessment, management and treatment of osteoporosis is on fracture prevention. Patients with low bone mineral density (BMD) who are under 50 have a very low incidence of fracture and so the issue of treatment does not arise.

Most of the evidence is based on the treatment of patients in the postmenopausal years. All patients over the age of 50, with a low trauma fracture, need to be assessed for future risk of fractures.

Measuring BMD is a key component of this assessment. Where BMD is in the osteoporotic range, there is no doubt that treatment is indicated. In younger patients and premenopausal women, there is little or no indication for doing bone-density scans. The risk of fracture in this age group is very small and is not greatly increased by low BMD.

Standard bisphosphonate therapy is used and tolerated by the vast majority of patients with osteoporosis. Poor compliance can be addressed by using either parental annual (zolendronate) or three monthly (ibandronate) preparations.
Increasingly, we are finding that patients on multiple medications find an annual zolendronate infusion to be useful from the point of view of reducing oral medications and reducing any risks from oesophagitis.

Paradoxically, some compliance issues can be addressed by giving the patient daily treatment (strontium or a bisphosphonate). Strontium is also suitable for patients who are intolerant of bisphosphonates or who have oesophageal disease.

In patients who are elderly and have sustained a fragility fracture, treatment can be initiated even in the absence of a DEXA scan. It might be useful in these patients to obtain a serum vitamin D level, as many will have vitamin D deficiency, which also increases the risks of falls and complicates the underlying bone disease. Confounding vitamin D deficiency can be treated with simple dietary supplementation.

Top Tip 10: Falls
Osteoporosis is responsible for an increased risk of fracture in certain patients. These ‘low trauma fractures’ usually involve a fall. So, in addition to addressing the patient’s bone density with pharmaceuticals, it is important to address the patient’s risk of falls.

This includes simple strategies like ensuring the patient does not have postural hypotension related to antihypertensive, cardiac or psychotropic medicines.

Exercise can prevent further decline in patients with impaired mobility. It is important therefore that these patients are encouraged to partake in regular simple exercises such as supervised walking, so that the remaining neuromuscular function is exercised and ‘trained’ as best as possible to reduce the risk of falls.

Falls prevention should include assessment of the patient’s environment for contributory factors such as loose carpets and obstructions on the floor as well as lighting and steps.

Dr Bobby Coughlan, Consultant Rheumatologist at University College Hospital, Galway.

The views expressed above are those solely of the author(s)and in no way may be deemed to reflect the views or policy of either MSD Science Centre or Merck Sharp & Dohme Ireland (Human Health) Limited.

Posted in Musculoskeletal on 17 September 2009
Tags: rheumatoid arthritis