As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure. Some of this morsel is straight advice from a local rheumatologist rather than strict EBM.
- commonest presentation
- middle aged female with multiple small joints
- remember that if symptoms less than 6 weeks then it’s usually one of many viruses
- there are formal diagnostic criteria
- heavily weighted on number of joints involved and some of the tests
- >6 weeks duration is on the criteria
- 10% of healthy population has pos rheumatoid factor.
- Swollen joint much more diagnostically useful than simple painful joint
- anti CCP the big new test. Very specific test but not sensitive
- Rheumatoid in general carries increased CV risk never mind the NSAID use
Treatment pearls
- flare of known RA
- steroids depomedrone 80mg IM or 40mg oral for a week
- NSAIDs – remember naproxen is the only one with low CV risk
- mouth ulcers on methotrexate?
- change to nightly dose
- double up on folic acid dose
- abnormal LFT on methotrexate?
- ALT is usually first to rise, if continuing to rise at 2 weeks consider stopping
- abnormal FBC on methotrexate?
- neuts <1.5 then stop drug.
- it was suggested that MTX be held in all infections needing antibiotics even when WCC is normal
- Long term steroids are rarely appropriate any more – if you find someone floating around on long term steroids from 15 yrs ago the they’ve probably been lost to follow up and it’s worth referring them again.
References:
- Excellent rheumatology lecture somewhere in the midlands of Ireland Spring 2015
- Rosen’s 8th Chap 116
Featured Image: James Heliman MD, CC License, Wikipedia
