Zero to GP - GP Revision Podcast

Rheumatoid Arthritis - Essential GP Revision

• Thomas Watchman • Season 1 • Episode 9

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0:00 | 17:47
SPEAKER_00

Hi, this is Tom, and welcome back to the Zero to GP podcast. In this episode, I'm going to be going through rheumatoid arthritis, covering the information you need to know for your AKT exam. The format, as always, is I'm going to ask you questions. I want you to ideally write down your answer, or at least say it out loud, and then I'm going to go through the answers and an explanation. If you like this episode and this podcast, consider um heading over to zero to finalshop.com to have a look at the AKT revision book. This is one book that covers all the key content you need for your AKT exam, and also just for general knowledge when you're going to be practicing as a GP. There's also zero2gp.com where you can find short answer questions and a fact trainer tool, which acts a bit like Anki, where you can do space repetitions of the key facts you need to know for your AKT exam. There's also a traditional multiple choice question, question bank, and flashcards, as well as all the notes covering the whole RCGP curriculum. But enough about that, let's get straight into this episode and start with the first case. So the first case is a 28-year-old woman, and she presents with a rapid onset, but now persistent joint pain. And she shows you her hands, and they look like this, with swelling of the um of the knuckles and the first joint in the fingers and the wrists. So the first question is what how would you describe when you're writing referral this pattern of joint symptoms? So the key description here, which will help when you're writing your referral to sound clever, is that this is a symmetrical distal polyarthritis. Symmetrical meaning that it affects more or less the same joints on both sides of the body. It's distal because it's affecting the joints distally in the hands, so the small joints of the fingers and hands and the wrist, rather than the proximal joints like the shoulders and hips, and it's a polyarthritis, poly meaning multiple arthritis being joint pathology, so um it's affecting multiple joints distally and symmetrically. This is a typical pattern for rheumatoid arthritis. The next question is what three key symptoms would suggest inflammatory joint pathology as opposed as opposed to mechanical joint pathology. The three key symptoms of inflammatory joint pathology are pain, swelling, and stiffness. And these symptoms tend to be worse at the start of the day, first thing in the morning, lasting for an hour or two, and worse with rest, and they tend to improve a bit with activity, so they get better as the day goes on, and they get better with activity and worse with rest. Okay, so we got this 28-year-old woman, she's got a rapid onset of persistent pain, swelling, and stiffness in her joints. The next question is which joints are typically affected in the hands? The typically affected joints are the proximal interphalangeal joints or PIP joints, so the first joint on the fingers, the MCP or the metacarpal phalangio joints, which are the kind of knuckle joints, and the wrist. These are typical joints affected in rheumatoid arthritis. The distal interphalangeal joints or DIP joints are not typically affected in rheumatoid arthritis. DIP joint pain is more of a feature of osteoarthritis. The next question is what's the clinical finding when you examine the hands and you examine the joints? The finding is synovitis, which is inflammation and swelling of the synovial membrane of the joints. And this causes a boggy kind of feeling around the joints. It's not actually bone swelling, it's the synovial lining that's swollen and boggy and squidgy. The next question is which antibodies are relevant in this case when you're suspecting rheumatoid arthritis? The usual first antibody to check is rheumatoid factor. And rheumatoid factor is the typical go-to sort of first line antibody to check, but it's only positive in about 60 to 70% of patients with rheumatoid arthritis. It's also not very specific, meaning it can go in it can go up in other conditions like infections, systemic illness, and so on. The other antibodies relevant to rheumatoid arthritis are anti-CCP antibodies, which is anti-cyclic citrullinated peptide antibodies. These anti-CCP antibodies are more specific. They're very specific to rheumatoid arthritis, meaning if they're positive, they are suggestive of rheumatoid arthritis. They're also a bit more sensitive than rheumatoid factor. Although both of these, rheumatoid factor and anti-CCP antibodies, could be negative and the person could still have rheumatoid arthritis. The next question is what other bloods are relevant? So you're seeing this patient for the first time and you want to check bloods to exclude other conditions and to see whether it's rheumatoid arthritis. What other bloods are relevant? The other bloods to consider checking at the initial presentation are FBC, Usenes, and LFTs to look for other differential diagnoses and other illnesses and comorbidities. The other thing to check is the inflammatory markers, so CRP or ESR. And inflammatory markers are often raised in rheumatoid arthritis, but they can be normal in some patients with rheumatoid arthritis. So you can't exclude it just based on the inflammatory markers. Okay, so we've got this 28-year-old woman. She's got a symmetrical distal polyarthritis, and she's got synovitis on examination. The next question is: what's the primary care management? This patient's presenting you for the first time.

SPEAKER_01

What are you going to do?

SPEAKER_00

The important thing here is she needs an urgent rheumatology referral. The key thing, the key management step in primary care is to refer her to rheumatology. They might want some blood tests done beforehand, but that shouldn't delay the referral. The next question is what interim symptomatic treatment can you give her? So she's got all this pain and stiffness and swelling. What could you give her while she's awaiting assessment by rheumatology to help with her symptoms? The most helpful thing here is NSAIDs, for example, neproxin, and you could consider giving something like omephrazole to prevent gastritis and stomach issues while taking the neproxin. Importantly, the guidelines say avoid giving steroids at this point. If you give her something like prednisolone, it will very quickly dampen down her symptoms and improve the symptoms, but it will then mask the symptoms. So by the time she sees rheumatology, they're going to find it much more difficult to make a diagnosis if the symptoms have been resolved because you've given her some steroids. The next question is what secondary care imaging could be performed? So she turns up in the rheumatology clinic, they're wondering about the diagnosis of rheumatoid arthritis, what imaging will they do? So if there's any doubt about whether there's cinnovitis, they can do an ultrasound scan or an MRI scan to look for cynovitis and determine whether cynovitis is present. The other thing they'll do is a hand X-ray to look for any bone or joint changes relating to the rheumatoid arthritis. Let's look a slightly different case for a moment. Let's say there's a 35-year-old woman and she presents to you as a GP with recurrent episodes of joint pain and swelling. And when this when an episode happens, one or two distal joints tends to swell up and become stiff and painful. These episodes have a rapid onset, so they come on over hours, and then they resolve within 48 hours. And between episodes, her joints are absolutely normal.

SPEAKER_01

What's your suspected diagnosis here?

SPEAKER_00

In this case, you might suspect palindromic rheumatism. And this is just like the case that we've presented, recurrent episodes of short duration inflammatory joint symptoms that look like rheumatoid arthritis, but they resolve within 48 hours. These patients may have recurrent episodes that carry on, or they might settle down, or they may go on to develop rheumatoid arthritis. So back to our original case, we've got a 28-year-old woman, symmetrical distal polyarthritis, she's assessed by rheumatology, and rheumatoid arthritis is diagnosed. So the next question is what are the first line conventional DMARD options? So what options might rheumatology prescribe first line for her? Typical first line options are methotrexate, which is the usual go-to, lefunamide, and sulfur salazine. The next question is: what about if she's got mild symptoms of rheumatoid arthritis or palindromic disease? What's the usual go-to DMID in that situation? The usual choice for mild disease or palindromic disease is hydroxychloroquine. Next question is what short-term treatment might rheumatology prescribe as she's starting, say, methotrexate, to help uh settle the symptoms quickly. So usually when you start methotrexate or DMARD, it takes a couple of months maybe to uh for it to start kicking in and really helping with the symptoms. In the interim, they may use systemic uh glucocorticoids or steroids to dampen down the inflammation and help with the symptoms. And this could be oral or it could be an intramuscular injection that lasts several months and uh kind of wears off as the DMARDs start kicking in. Or if it's just one joint, they might use intra-articular steroids. The next question is what about if there's an inadequate response to DMARDs? So she tries a few high-intensity DMARDs and she's not getting a good enough response. What's the next step that rheumatology will look at? At this point, they'll consider biologic drugs. So these are kind of heavy-duty targeted immunosuppressant drugs. For example, adolimumab. Okay, so we got a 28-year-old woman, she's got rheumatoid arthritis diagnosed, and let's say methotrexate is started. So the question is, next question is, how is methotrexate prescribed? So methotrexate initially will be prescribed by rheumatology, but then once she's stable on it, it's going to be handed over on a shared care agreement for the GP to carry on prescribing. And it's usually prescribed or it's it's prescribed once weekly. And it's quite important that it's not taken every day, it's just once a week. And it's prescribed either orally as orally as tablets. So the patient takes tablets once a week, or it can be intramuscular or subcutaneous in severe disease. Again, still taken weekly. The next question is what's also prescribed along with methotrexate? Patients will also be prescribed folic acid, five milligrams, which will be taken once weekly on a different day to the methotrexate. The other question is in this case of this twenty-eight-year-old woman with rheumatoid arthritis starting methotrexate, what other consideration do we need in this situation? This patient's gonna need highly effective contraception because methotrexate is highly teratogenic, meaning harmful to pregnancy, can cause all sorts of problems in pregnancy, miscarriage, uh, all sorts of things, but also congenital abnormalities. So she's gonna need highly effective contraception, and if she was planning a pregnancy, methotrexate would be an inappropriate choice. She would need to stop methotrexate at least three months before considering pregnancy. The next question is what are the safer options? Which DMARDs are consider safer in pregnancy. The two DMARDs that are considered generally safer in pregnancy are hydroxychloroquine and sulfur salazine. And the next question is, or the final question actually, is if this patient was to come to you and she's she's on methotrexate, but now she's got a systemic infection, let's say a bad chest infection or some some other kind of systemic infection, how are you gonna manage her methotrexate while she has this systemic infection. And then once she's feeling better, she's afebrile, she's kind of back to normal, finished her antibiotics, you can then restart the methotrexate. So thanks for listening to this episode on methotrexate. Hopefully you found it helpful. Do leave a comment below if you have any specific requests for which topics you want me to cover in these videos. And I hope to see you in the next video, which will be in about a week's time.