Rheumatology

Question 1

What is the approach to management in rheumatological conditions?

Answer 1

1. Individual treatment plan.
2. No tolerance for inflammation.
3. Shared care with National Rheumatology team.
4. MDT approach.

• Switch off inflammation.
• Provide analgesia.
• Maintain joint function.
• Prevent joint deformities.
• Treat complications, extra-articular manifestations.
• Ensure optimal nutrition.
• Rehabilitation.
• Maintain psychological health.
• Educate.

Question 2

What are the principles for switching of inflammation in rheumatological disease?

Answer 2

• NSAIDs
  
  • 1st line.
  • 1/3 have control with NSAIDs
  • Peak action 4-6 weeks.
  • Decrease pain and stiffness.
  • Monitor FBC, UEC, LFTs and urine.
  • Do not alter natural course of disease.
• Corticosteroids
  
  • Useful in short courses.
  • Long-term reserved for severe systemic disease or incapacitating polyarthritis.
  • Consider malignancy before starting.
  • Intra-articular injection can be useful.
  • Does not alter natural course of disease.
• DMARDs
  
  • Methotrexate
    
    • Oldest and lease toxic.
    • May take 6-12 weeks to see effects.
    • Weekly PO or SC
    • Effective in uveitis not responsive to steroids.
    • Relapse commonly occurs after stopping.
    • Give rescue folate.
    • Shouldn’t drink alcohol.
    • Teratogenic.
    • Monitor FBC and LFT’s
  • Hydroxychoroquine
    
    • Good safety profile.
    • Useful in mild JIA
  • Sulfasalazine
    
    • Good safety profile
    • Useful in mild JIA
  • Leflunamide
• Biologics
  
  • Etanercept
    
    • Weak anti-TNF
    • Weekly SC injection (doesn’t sting)
  • Adalimumab
    
    • Anti-TNF
    • Fortnightly SC injection (stings)
    • Better for uveitis
  • Infliximab
    
    • Anti-TNF
    • IV
  • Tocilizumab
    
    • Anti-IL-6
    • Risk of infusion reaction and mast cell activation