Rheumatoid Arthritis. GP workshop 15 January 2011

Transcription

1 Rheumatoid Arthritis GP workshop 15 January 2011

2 Case 1 A 72 year old Malay woman with RA comes for routine follow up. She feels generally unwell in the last 5 days. Appetite is fair. Her joints are fine. Her daughter accompanies her. Medications include: methotrexate 20 mg weekly hydroxychloroquine 200 mg od, prednisolone 5 mg od, enalapril 5 mg od, metformin 500 mg simvastatin 10 mg on risedronate 35 mg weekly Vit D 1000 IU od

3 Clinical examination Comfortable, in wheelchair. Afebrile, haemodynamically stable, no oral ulcers, scattered bilateral wheeze both lungs, JVP normal, no pedal oedema. Joints non tender, not swollen.

4 Thoughts Impression? Comorbidities Acute problems Chronic problems

5 Laboratory investigations Hb 9.5, WBC 2.82, Plt 326 ALT 29, AST 40, Creatinine 97,CRP 65 HbA1C 6.5% Previous visit Hb 9.0, WBC 7.69, Plt 357 ESR 96

6 Thoughts Leucopenia : possible causes Viral infection Methotrexate toxicity Pulmonary pathology LRTI

7 What next? Antibiotic- Azithromycin Beta 2 agonist inhaler Stop methotrexate Daily folic acid 5 mg See in 1 week with repeat FBC, CRP.

8 Methotrexate A typical dose regimen may be:- 7.5mg weekly increasing by 2.5mg every 6 weeks to a maximum of 25mg. Lower doses should be used in the frail elderly or if there is significant renal impairment. Regular ( weekly) folic acid supplements are thought to reduce toxicity. Cotrimoxazole or trimethoprim must be avoided in patients taking methotrexate. Excess alcohol should be avoided. Avoid Live vaccines. NSAIDs in addition to the above doses of methotrexate are not contraindicated. Annual flu vaccine should be given.

9 Withhold MTX if. and discuss with rheumatologist WBC <4.0x10^9/l Neutrophils<2.0x10^9 Platelets<150x10^9 /l >2-fold rise in AST, ALT Unexplained fall in albumin Rash or oral ulceration New or increasing dyspnoea or cough MCV>105fl investigate; if B12 or folate low start appropriate supplementation Significant deterioration in renal function reduce dose Abnormal bruising or sore throat withhold until FBC result available NB: in addition to absolute values for haematological indices a rapid fall or a consistent downward trend in any value should prompt caution and extra vigilance.

10 Case 2 A 56 year old bus driver with erosive RA comes for routine review. He tells you that he has recently had more pain in his shoulders and right elbow but is otherwise well. His medications include methotrexate 15 mg weekly, folic acid 5 mg weekly and prednisolone 5 mg daily. Routine lab monitoring: normal FBC, ALT, AST and ESR is 10.

11 Clinical examination Tenderness on palpation of shoulders and right elbow, no swelling detected. Other joints are fine, old deformities of fingers noted. Unremarkable CVS, Respiratory examination.

12 Activity of disease? Thoughts

13 Pharmacovigilance

14 Review of medications reveals that he has stopped methotrexate as his son bought medicine from Korea ginseng

15 Reassurance and the role of education Chronic disease Flares and quiescent periods- tight control Self empowerment: exercise, diet, emotional health, medications, supplements, pacing of activities Occupation Engaging family members STOP smoking

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17 Clinical Course of RA Severity of Arthritis Years Type 1 Type 2 Type 3 Type 1 = Self-limited 5% to 20% Type 2 = Minimally progressive 5% to 20% Type 3 = Progressive 60% to 90% Pincus. Rheum Dis Clin North Am. 1995;21:619.

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19 Uncontrolled RA is Expensive A serious, progressive condition Tremendous morbidity and functional disability Accelerated mortality Substantial work disability Costs vary directly with the severity and activity of disease

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21 Tips in Rheumatoid Arthritis Increased risk of infection Steroids -use as bridging therapy, low dose, once daily Beware monoarticular flare think infection! Stop DMARD in the setting of infection Atypical presentation if on biologic Stress doses of steroid in infection if on long term steroid Cardiovascular burden Lymphoma risk

22 Extra-articular manifestations of RA

23 A 48 year Chinese woman presents with persistent joint pains for 3 months with fatigue. Labs show ESR 60 mm/hr, mild anaemia. What is the most important next step? A)Check rheumatoid factor to confirm diagnosis B)Prescribe a selective COX-2 inhibitor C)Give a course of high dose oral prednisolone D)Consider starting a disease-modifying anti-rheumatic agent E)Inform patient of poor prognosis due to crippling arthritis

24 Approach to polyarthritis History and Physical examination Is joint inflammation present? Will it remit or persist? Two features in history taking of diagnostic and prognostic value: morning stiffness > 60 min symptom duration > 6 wk predicts persistence > 12 wk higher spec RA diagnosis

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