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Rheumatology for Registrars

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1 Rheumatology for Registrars
Pam Brown May 2007

2 Workshop content What do you want from this workshop Common conditions
Osteoporosis OA, PMR, RA, Back pain - Group work and presentations Websites and other resources Qs and As

3 My credentials! GP 20+ years
Previously Clinical assistant in rheumatology Currently Clinical assistant osteoporosis Trustee, National Osteoporosis Society Steering committee Primary Care Rheumatology Society Lecturer, University of Bath MSc in Primary Care Rheumatology Team doctor, Team Wales Commonwealth Games, 2002 and 2006

4 E-learning and signposting
Individual musculoskeletal learning needs assessment Prioritise information gaps and cover sequentially or agree to fill opportunistically as PUNs and DENs arise Use web-based resources/signposted websites to fill gaps Review musculoskeletal learning needs assessment at end of registrar year continue to update with PUNs and DENs

5 What do you want from this workshop

6 Why learn about rheumatology?
PCR Society Survey 1986 – 25% of consultations were for musculoskeletal conditions 2004 survey 100 consecutive patients 24% musculoskeletal 20% paediatrics 10% psychiatry, CHD/stroke, respiratory Musculoskeletal 4 back pain, 1 gout, 1 RA, 3 PMR, 2 osteoporosis 4 OA, 4 injuries, 5 aches and pains

7 GP consultations 3rd RCGP Morbidity Study
45-64 65-74 >75 Men Respiratory Circulatory M/S Women Mental

8 Quiz Which joints most commonly involved in OA?
What are the underlying causes for gout? 3 red/3 yellow flags in back pain? Survival rate 1 year after hip fracture? What test should we carry out on all fallers? How can we differentiate OA and RA? Starting doses of steroids in PMR and GCA?

9 Rheumatology basics We learn about ‘diseases’
OA Osteoporosis Gout Patients present with ‘symptom complexes’ Groin pain Stiff joints Can’t walk upstairs We use history, examination and investigation to sort out the differential diagnosis, then formulate a management plan for the individual patient sitting in front of us

10 Remember most have multiple pathology
Rheumatology basics Need to identify ‘red flags’ Malignancy Wt loss, systemic symptoms, unremitting pain, night pain Bone or joint sepsis Hot, swollen joint, systemic upset, single joint involvement Nerve or vessel problems Nerve root distribution pain, weakness, sensory loss Cold extremity, pulseless Remember referred pain! Remember most have multiple pathology

11 History and examination
Resources Clinical assessment of the musculoskeletal system ARC handbook/DVD Crash course Rheumatology and orthopaedics - Coote and Haslam Rheumatology Guidebook - Ferrari, Cash and Maddison

12 Examination Multiple joints involved – screen all joints eg GALS; localise and examine specific joints Single joint/area – examine this and joint above and below Examination system Inspection Palpation Movements – Active, passive, resisted Special tests

13 Common diseases/conditions
Osteoporosis OA Back pain Polymyalgia rheumatica/Giant cell arthritis Rheumatoid arthritis

14 Group work Spend 10 minutes preparing a 5 minute summary presentation using your own knowledge and the resources provided. Pathological process Management options/plan Guidelines/evidence based info available to guide decision-making eg SIGN, NICE, Prodigy Who needs referral Areas of uncertainty and challenges

15 Osteoporosis Osteoclasts resorbing more bone than osteoblasts laying down – gradual loss of bone; increased fracture risk Fracture as acute exacerbation of osteoporosis, the chronic disease Target high risk groups Previous fracture patients – new, old Oral steroids 3 months or more Frail elderly housebound/care homes Multiple risk factors primary prevention

16 Mx options Lifestyle – exercise, ca/vitamin D, stop smoking, moderate alcohol intake – throughout life Ca 1-1.2g/vitamin D 800iu/day in frail elderly/those at risk to prevent hip #/adjuvant Rx Bisphosphonates, raloxifene, strontium ranelate Teriparatide for severe osteoporosis # patients – pain relief, prompt surgery, good quality rehab


18 NICE Technology Appraisal 87 January 2005
Secondary prevention in post-menopausal women with clinically diagnosed fracture only All patients should have adjuvant Ca/vit D Over 75 treat; others by DXA and age Bisphosphonates, raloxifene, teriparatide NICE primary prevention, secondary prevention update (strontium), guideline 2007?

19 Osteoporosis Steroid-induced osteoporosis Guidelines
>65, previous fracture or other risk factors – Rx bisphosphonate + Ca/vit D <65 DXA – Rx if T score –1.5 Guidelines RCP/BATS/NOS Osteoporosis guidelines and Rx update RCP/BATS/NOS Glucocorticoid-induced OP guidance 2002 SIGN guidelines Blue book for orthopaedic surgeons NICE guidance for secondary prevention NICE Falls guideline

20 Osteoporosis Referral Uncertainties Challenges Diagnostic uncertainty
Specialist investigations – men, pre-menopausal, DXA if no open access Rx failures/specialist Rx – intolerance, IV bisphosphonate, teriparatide (PTH) Uncertainties NICE primary prevention TA 2007 nGMS contract 2007/8? 10 year fracture risk assessment tool 2007 Challenges Only 10% high-risk patients treated at present Motivating primary care to take action


22 Group work Spend 10 minutes preparing a 5 minute summary presentation using your own knowledge and the resources provided. Pathological process Management options/plan Guidelines/evidence based info available to guide decision-making eg SIGN, NICE, Prodigy Who needs referral Areas of uncertainty and challenges

23 OA


25 OA key facts Common Failure hyaline cartilage – no DMARDs yet
>1.5 million people in E and W 10-20% of these symptomatic Only small percentage present for help Failure hyaline cartilage – no DMARDs yet Joints affected Hands – DIP, PIP, CMC thumb Hips, knees, ankles, great toes Cervical and lumbar spine Xray appearances correlate poorly with symptoms

26 Management plan Identify those with inflammatory arthropathy or other disease Patient education and self-management Achieve symptom relief and improve quality of life Maintain mobility and function Refer appropriate patients for surgery or other management Remember hip fracture in patients with hip pain

27 OA management Pain relief Unload the joint
Simple/compound analgesics, exercises Glucosamine sulphate, patellar taping, TENS Topical capsaicin/NSAID; acupuncture Oral NSAIDs – COX2s, gastro-protection Injections – peri-articular, intra-articular Joint replacement Unload the joint Lose weight Walking stick Shock-absorbing shoes


29 Joint replacement NICE referral guidance hip/knee OA
? Infection – same day Rapid deterioration/severe disability (2/52 hip, soon – ‘locally agreed’ knee) Symptoms impair QOL – routine Giving way despite Rx– soon (knee only) Acute inflammation (gout, haemarthrosis, pseudogout) – 2/52 (knee only)



32 Polymyalgia rheumatica and Giant cell arteritis
50% of those with GCA have PMR symptoms 15-50% PMR patients have symptoms GCA Muscle pain/stiffness hip and shoulder girdle Flu-like symptoms, fever, weakness, wt loss GCA – headaches, blurred or double vision, jaw/tongue pain, pain on chewing ESR/CRP +/- temporal a biopsy; use Ix to exclude other diagnoses eg myeloma

33 PMR/GCA Management Plan
PMR steroid regime 10-20mg/day 2-4/52 2-4 weekly reduce by 2.5mg to 10mg 4-6 weekly reduce by 1mg to 5mg Continue 5mg for 12/12 Final reduction - reduce by 1mg/day every 6-8/52 to 3mg then every 12/52 until stopped GCA steroid regime Visual disturbance admit urgently Otherwise 40mg/day 2-4/52 2-4 weekly reduce by 5mg to 10mg then as for PMR Remember prophylaxis with bisphosphonates

34 RA


36 Remember increased CHD risk!
RA key facts Incidence 5/10,000 per year; peak 50-60yrs 0.5-1% of population, 3 females:1male 50% disabled/unable to work by 10 years Different presentations Symmetrical inflamed small joints Fatigue and EMS but little to see initially Episodic polyarthritis/palindromic symptoms Systemic disease - extra-articular conditions Nodules, vasculitis, scleritis, pericarditis Remember increased CHD risk!

37 RA management Aim for early diagnosis – refer if suspicious
Reduce symptoms – NSAIDs, analgesics, DMARDs Minimise disease progression, maintain function/QOL Education DMARDs Multidisciplinary support – physio, OT Surgery Minimise adverse drug effects Shared care for DMARD monitoring, clear guidelines on testing/responsibility TNF antagonists (etanercept, infliximab) Steroids – I/A or low dose oral - specialist use only Manage co-morbidities eg lung disease, CHD


39 Back pain


41 Back pain key facts 16.5M people have back pain each year
3-7 M consult; 1.6M attend OPD; 100,000 admitted; 24,000 have surgery per year 7% adults present to GP each year 90% recover within 6/52; 2-7% chronic pain Once off for 6/12, only 50% return to work 100M days lost from work

42 Back pain key facts Types Xray LS only if Xray and FBC, ESR
Simple mechanical back pain – 90% recover 6/52 Nerve root pain – sciatica – 50% recover 6/52 Inflammatory back pain – AS, Psoriasis, Colitis Others – trauma, OP, tumours Xray LS only if Red flag or Fracture risk (trauma, steroids, osteoporosis, >70) Xray and FBC, ESR Cancer, recent infection, fever >38, IV Drug abuse, pain worse at rest, wt loss, prolonged steroids Royal College of Radiologists 1998 Making the best use of a department of clinical radiology

43 CERTIFICATE Areas to explore with the back pain patient
What do you think is the Cause of your pain Ever had prolonged back pain previously? Ever had other long term pain problems? Other people’s Response to the back pain Time off for the problem If off work – do you think you will return? Financial – benefits or compensation? What Investigations already? What are you doing to Cope? Affect – have you felt down, depressed or hopeless? What have you been Told by physios, doctors etc? Expectations – what do you hope we can do to help?


45 Red flags Significant injury PMH cancer
First presentation <20 or >55 Systemic upset – fever, wt loss Steroid Rx or abusing drugs Thoracic pain Multilevel neurological signs or symptoms Structural deformity Pain constant, progressive and unrelenting Difficulty urinating

46 Psychosocial Yellow flags in back pain
Belief that back pain is harmful/disabling Avoiding movement because of fear of triggering pain Reduced activity levels Low mood Withdrawal from social interaction Opting for passive Rx rather than actively participating Litigation or benefit from back pain

47 Back pain management plan
Symptomatic Rx Analgesics, NSAIDs, muscle relaxants Mobilise, exercise, ice, heat, electrical therapies (U/S, diathermy, interferential, TENS) Complementary therapies Acupuncture, manipulation – chronic only Rehabilitation to improve mobility and flexibility Education and exercise to prevent recurrence Surgery where appropriate Avoid diazepam, bed rest, plaster jackets, time off work Waddell G et al Low back pain evidence review 1999 RCGP London

48 Back pain referral Immediately for cauda equina syndrome – incontinence, urinary retention, loss of sensation and muscle tone around anus Urgently for possible serious spinal pathology/red flags Consider routine referral for nerve root pain not resolving within 4-6 weeks – orthopaedic or neurosurgical

49 Secondary care referral – why?
Diagnostic difficulties OA/RA; unusual conditions Investigative help Special imaging – MRI, CT, bone scan Nerve conduction studies Specialist conditions RA, AS, SLE, Pagets Specialist treatments DMARDs, surgery, joint/soft tissue injections, multidisciplinary team access


51 Other topics to consider adding to your learning plan
Arthritis self-management Buszewicz et al BMJ 2006 Use of biologicals in RA Ledingham et al 2005 BSR website Gout Underwood BMJ 2006;332:1315-9; Zhang et al Ann Rheum Dis 2006;65: and Chronic widespread pain (fibromyalgia) Papageorgiou et al Annals Rheum Dis 2002;61: SLE D’Cruz BMJ 2006;332:890-1 Ankylosing Spondylitis McVeigh and Cairns BMJ 2006;333:581-5 Septic arthritis DTB 2003; BMJ 2006;333:1107-8

52 Case study 1 Mrs Jones is 70 and has noticed progressive weakness and tiredness over recent weeks. Now difficulty getting in and out of the car and climbing stairs. Smokes 15/day, obese, looks pale. PMH COPD, MI aged 62 yrs, lives with husband.

53 Case study 1 Differential – PMR, osteomalacia, neurological problem, anaemia, cardiac failure History – headaches etc for GCA, back pain, blood loss, dyspnoea, other systemic symptoms Examination - muscle weakness, wasting, ‘get up and go’ test Bloods including ESR, CRP, FBC, vitamin D

54 Case study 2 Mr Thomas is a 68 year old diabetic who presents with pain and swelling of his R knee. He also describes some pain in his hands. PMH – Type 2 DM 10 years; Peptic ulcer 1985, MI 1999 with mild LVF; hypertension since 1995

55 Case study 2 Differential – gout/OA/pseudogout
Hands same pathology as knee? – Clinical examination Single jt problem – rule out infection Is he hyperuricaemic? (Diuretics?) Bloods/aspirate knee if effusion/x-ray NSAID use – prev peptic ulcer, LVF, BP Gout – alternatives to NSAIDs

56 Case study 3 55 year old lady presents with low back pain radiating to her R leg. Already visited 2 of your partners. Declaring ‘something has to be done, these painkillers just don’t work’. She has been resting in bed for most of last 2 weeks, and off work for 4 weeks. PMH No previous back pain; breast cancer 2 years ago; RTA 6 weeks ago

57 Case study 3 Red flags – first back pain, prev Ca breast, ? Intractable pain Yellow flags – RTA compensation?, bed rest, different partners for opinion, emotional approach Check carefully for local tenderness and neurology Bloods and x-ray NSAID or compound analgesics

58 Case study 4 Mrs Williams is a 66 year old lady. Recent MI, noted to be hypertensive and hyperlipidaemic during admission. Attends for analgesics after breaking her wrist slipping on ice as she was discharged from hospital 2/52 ago. PMH PMR since 2004 Medication statin, calcium channel blocker, prednisolone 5mg od

59 Case study 4 Fracture – high risk for further fractures
PMR - CSIO; legal issues; reduce steroids Mx – DXA or just Rx? HT Mx – thiazide diuretics retain Ca, decr # risk; statins decr # risk Mx osteoporosis – , analgesia, physio when POP removed, bisphosphonate, Ca/Vit D RCP/BATS/NOS Corticosteroid osteoporosis 2002 Schoofs et al Thiazide diuretics and risk for hip # Ann Int Med 2003;139:

60 And see website list/resources handout
Further reading ARC website Prodigy NICE Clinical Evidence National Library for Health specialist libraries -musculoskeletal And see website list/resources handout

61 Questions?


63 NICE Secondary Prevention Bisphosphonates
Age 75 and over – Rx without DXA 65-75 – Rx if DXA confirms T-2.5SD Don’t wait for scan; Rx and stop if not confirmed <65 – Rx if: Approximately T-3SD or below or T or more age-independent risk factors BMI<19 FH maternal hip #<75 yrs untreated premature menopause medical disorders assoc with bone loss or immobility

64 NICE Secondary Prevention Raloxifene
Alternative to bisphosphonates (as previous) If bisphosphonates contraindicated (SPC) If women physically unable to comply with special recommendations for use If unsatisfactory response Further fragility # despite adhering fully to Rx for 1 year, AND decline in BMD below pre-Rx baseline If intolerant Oesophageal ulceration, erosion or stricture or lower GI symptoms, requiring discontinuation Rx

65 NICE Secondary Prevention Teriparatide
Women aged 65 or older with Unsatisfactory response (further # after 1 yr Rx, BMD below pre-Rx level) or intolerant AND Extremely low BMD (T–4SD or below) OR Low BMD (T–3SD or below) AND >2 # AND 1 or more additional age-independent risk factor (BMI<19, maternal hip # <75 yrs, untreated premature menopause, prolonged immobility)

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