Little Rheumatology gems for GP Trainees

HDR 7/12/10Hayley Faries, ST1 Rheumatology

Overview

• Case• Pathophysiology + Management• Some nuggets…– MTX monitoring– Important complication

Case• 54yo male, BMI 30• Alcohol 30 units/wk• c/o pain in left great toe– Acute onset over few hrs,

very severe pain– Unable to tolerate bed covers

touching foot

Gout• Epidemiology

– M>F 9:1, middle age, females more post menopausal

• Pathophysiology– Uric acid under secretion (diuretics, salicylates)

• Diagnosis– Mono-arthritis with High urate (usually)– Great toe/ metatarsal (50%), can affect wrists, elbows, ankles– Asymmetrical– Severity of pain– Prev attack

Gout (2) - assessment• Confirm and exclude alternate diagnosis

– Septic arthritis• Assess severity (joints and function)• Prev attacks and Rx tried• Assess risk factors

– Medication (diuretics, aspirin), Alcohol, BMI, High purine diet (liver, kidneys, seafood, yeast extract)

– FHx (20% positive FHx)

• Identify assoc conditions:– Type II DM, Hypertension, cardiovascular disease

• Check urate levels– Often normal, may be high in 42%; still treat

Gout (3) – Acute Management• NSAID (Diclofenac,Indomethacin, Naproxen)

– Continue until 48hr after attack has resolved (7-10d)

OR…

• If C/Is to NSAIDs– Colchicine 500 microg BD for 5-10days, then reduce to OD for 4-6 weeks.– If both C/I consider Prednisolone– If all of the above C/I… Paracetamol and Codeine– Do not stop Allopurniol in acute attack

• At DAY 10 or when acute attack GONE… consider ALLOPURINOL 100mg OD– Lowers level of Uric acid in blood

Management (4)- Allopurinol

• Indications: – 2 or more attacks in a yr or after 1st attack in high risk people

• Tophi, xray changes, renal impairment– Long term duretic

• Risks:– Need to monitor U+Es every 3/12 in 1st yr – Titrate (by 50-100mg) every few weeks to Uric Acid levels <300

• Average dose 100 – 300mg OD– Check bloods 4 weeks after starting Rx– Co-prescribe NSAID low dose or Colchicine for 6 wks to prevent attack

when starting Allpurinol– Consider need for GI cover

Gout (5) - Management• Self help

– Rest, Elevate limb, avoid any trauma, Ice pack

• No improvement/ Resistant Gout (i.e. received 4-5 days 1st line Rx)– Review diagnosis, check compliance, encourage self care– Increase dose of medication or add Paracetamol– Other therapies to consider

• IM Depomedrone…Must be SURE it is gout! (not septic arthritis), benefit is that it lasts 2-3 months

• Prednisolone 20mg PO• If very resistant, can do reducing course of Pred by 2.5mg/wk• Intra-articular injection for flare if known gout

Follow Up and Referral

• RV pt at 4-6wks– Recheck Urate levels– Consider BP check/BM/lipid profile– Risk factor advice

• Diet, exercise, avoid dehydration, stop smoking, alcohol, weight

– Consider advance prescription for future attacks

• Refer– Septic arthritis suspected– Diagnostic uncertainty, or systemically unwell– Allopurniol at max but still recurrent attacks– Complications (kidney stones) present

Methotrexate monitoring• Indications to STOP:– Course of Abx/ any infection (restart when Abx

finished)– ALT >3x normal – Low WCC, Low Neut.

• Safe to continue:– Lymphopaenia– ALP rise – Hb drop 9-10 not likely 2ary to MTX

• Though, may need to investigate cause for drop in Hb

Digital Ulcers

In-patient cases – Digital Ulcers• 48yo Scleroderma +Raynauds - Infected digital ulcers

– Think osteomyelitis• 42yo Sjogren’s syndrome - Wet gangrene toe

– IV Iloprost (vasodilatory) and IV Abx

• Digital Ulcers for GPs– Complication of CTD– Fingers/Toes/ any pressure area– Think infection with redness/pain/discharge -> ABX!– Take swab– Conservative advice

Thank you, any questions?