Rheumatology for Registrars Pam Brown May 2007 [email protected] Pam Brown May 2007...

Rheumatology for Registrars

Pam Brown

May 2007

[email protected]

Workshop contentWorkshop content

What do you want from this workshop

Common conditionsOsteoporosisOA, PMR, RA, Back pain - Group work and

presentations

Websites and other resources

Qs and As


Common conditionsOsteoporosisOA, PMR, RA, Back pain - Group work and

presentations

Websites and other resources

Qs and As

My credentials!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

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

E-learning and signpostingE-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

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

Why learn about rheumatology?Why learn about rheumatology?

PCR Society Survey 1986 – 25% of consultations were for musculoskeletal conditions

2004 survey 100 consecutive patients24% musculoskeletal20% paediatrics10% psychiatry, CHD/stroke, respiratory

Musculoskeletal4 back pain, 1 gout, 1 RA, 3 PMR, 2 osteoporosis4 OA, 4 injuries, 5 aches and pains

PCR Society Survey 1986 – 25% of consultations were for musculoskeletal conditions

2004 survey 100 consecutive patients24% musculoskeletal20% paediatrics10% psychiatry, CHD/stroke, respiratory

Musculoskeletal4 back pain, 1 gout, 1 RA, 3 PMR, 2 osteoporosis4 OA, 4 injuries, 5 aches and pains

GP consultations 3rd RCGP Morbidity StudyGP consultations 3rd RCGP Morbidity Study

45-64 65-74 >75

Men Respiratory Circulatory Circulatory

M/S Respiratory Respiratory

Circulatory M/S M/S

Women M/S Circulatory Circulatory

Respiratory M/S M/S

Mental Respiratory Respiratory

QuizQuiz

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?

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?

Rheumatology basicsRheumatology basics

We learn about ‘diseases’OAOsteoporosisGout

Patients present with ‘symptom complexes’Groin painStiff jointsCan’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

We learn about ‘diseases’OAOsteoporosisGout

Patients present with ‘symptom complexes’Groin painStiff jointsCan’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

Rheumatology basicsRheumatology basics

Need to identify ‘red flags’Malignancy

Wt loss, systemic symptoms, unremitting pain, night pain

Bone or joint sepsisHot, swollen joint, systemic upset, single joint involvement

Nerve or vessel problemsNerve root distribution pain, weakness, sensory lossCold extremity, pulseless

Remember referred pain!

Remember most have multiple pathology

Need to identify ‘red flags’Malignancy

Wt loss, systemic symptoms, unremitting pain, night pain

Bone or joint sepsisHot, swollen joint, systemic upset, single joint involvement

Nerve or vessel problemsNerve root distribution pain, weakness, sensory lossCold extremity, pulseless

Remember referred pain!

Remember most have multiple pathology

History and examinationHistory 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

Resources

Clinical assessment of the musculoskeletal system ARC handbook/DVD

Crash course Rheumatology and orthopaedics - Coote and Haslam

Rheumatology Guidebook - Ferrari, Cash and Maddison

ExaminationExamination

Multiple joints involved – screen all joints eg GALS; localise and examine specific joints

Single joint/area – examine this and joint above and below

Examination systemInspectionPalpationMovements – Active, passive, resistedSpecial tests

Multiple joints involved – screen all joints eg GALS; localise and examine specific joints

Single joint/area – examine this and joint above and below

Examination systemInspectionPalpationMovements – Active, passive, resistedSpecial tests

Common diseases/conditionsCommon diseases/conditions

Osteoporosis

OA

Back pain

Polymyalgia rheumatica/Giant cell arthritis

Rheumatoid arthritis

Osteoporosis

OA

Back pain

Polymyalgia rheumatica/Giant cell arthritis

Rheumatoid arthritis

Group work 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

Spend 10 minutes preparing a 5 minute summary presentation using your own knowledge and the resources provided.




Who needs referral


OsteoporosisOsteoporosis

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 groupsPrevious fracture patients – new, oldOral steroids 3 months or moreFrail elderly housebound/care homesMultiple risk factors primary prevention

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 groupsPrevious fracture patients – new, oldOral steroids 3 months or moreFrail elderly housebound/care homesMultiple risk factors primary prevention

Mx optionsMx 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 ranelateTeriparatide for severe osteoporosis# patients – pain relief, prompt surgery, good

quality rehab

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 ranelateTeriparatide for severe osteoporosis# patients – pain relief, prompt surgery, good

quality rehab

NICE Technology Appraisal 87January 2005

NICE Technology Appraisal 87January 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?

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?

OsteoporosisOsteoporosisSteroid-induced osteoporosis

>65, previous fracture or other risk factors – Rx bisphosphonate + Ca/vit D

<65 DXA – Rx if T score –1.5

GuidelinesRCP/BATS/NOS Osteoporosis guidelines and Rx updateRCP/BATS/NOS Glucocorticoid-induced OP guidance 2002SIGN guidelinesBlue book for orthopaedic surgeonsNICE guidance for secondary preventionNICE Falls guideline

Steroid-induced osteoporosis>65, previous fracture or other risk factors – Rx

bisphosphonate + Ca/vit D<65 DXA – Rx if T score –1.5

GuidelinesRCP/BATS/NOS Osteoporosis guidelines and Rx updateRCP/BATS/NOS Glucocorticoid-induced OP guidance 2002SIGN guidelinesBlue book for orthopaedic surgeonsNICE guidance for secondary preventionNICE Falls guideline

OsteoporosisOsteoporosisReferral

Diagnostic uncertaintySpecialist investigations – men, pre-menopausal, DXA if no

open accessRx failures/specialist Rx – intolerance, IV bisphosphonate,

teriparatide (PTH)

UncertaintiesNICE primary prevention TA 2007nGMS contract 2007/8?10 year fracture risk assessment tool 2007

ChallengesOnly 10% high-risk patients treated at presentMotivating primary care to take action

ReferralDiagnostic uncertaintySpecialist investigations – men, pre-menopausal, DXA if no

open accessRx failures/specialist Rx – intolerance, IV bisphosphonate,

teriparatide (PTH)

UncertaintiesNICE primary prevention TA 2007nGMS contract 2007/8?10 year fracture risk assessment tool 2007

ChallengesOnly 10% high-risk patients treated at presentMotivating primary care to take action

Group work Group work Spend 10 minutes preparing a 5 minute summary

presentation using your own knowledge and the resources provided.




Who needs referral


Spend 10 minutes preparing a 5 minute summary presentation using your own knowledge and the resources provided.




Who needs referral


OA key factsOA key facts

Common >1.5 million people in E and W10-20% of these symptomaticOnly small percentage present for help

Failure hyaline cartilage – no DMARDs yet

Joints affectedHands – DIP, PIP, CMC thumbHips, knees, ankles, great toesCervical and lumbar spine

Xray appearances correlate poorly with symptoms

Common >1.5 million people in E and W10-20% of these symptomaticOnly small percentage present for help

Failure hyaline cartilage – no DMARDs yet

Joints affectedHands – DIP, PIP, CMC thumbHips, knees, ankles, great toesCervical and lumbar spine

Xray appearances correlate poorly with symptoms

Management planManagement 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

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

OA managementOA management

Pain reliefSimple/compound analgesics, exercisesGlucosamine sulphate, patellar taping, TENSTopical capsaicin/NSAID; acupunctureOral NSAIDs – COX2s, gastro-protectionInjections – peri-articular, intra-articularJoint replacement

Unload the jointLose weightWalking stickShock-absorbing shoes

Pain reliefSimple/compound analgesics, exercisesGlucosamine sulphate, patellar taping, TENSTopical capsaicin/NSAID; acupunctureOral NSAIDs – COX2s, gastro-protectionInjections – peri-articular, intra-articularJoint replacement

Unload the jointLose weightWalking stickShock-absorbing shoes

Joint replacementJoint replacementNICE referral guidance hip/knee OA

? Infection – same dayRapid deterioration/severe disability (2/52 hip,

soon – ‘locally agreed’ knee)Symptoms impair QOL – routineGiving way despite Rx– soon (knee only)Acute inflammation (gout, haemarthrosis,

pseudogout) – 2/52 (knee only)

NICE referral guidance hip/knee OA? Infection – same dayRapid deterioration/severe disability (2/52 hip,

soon – ‘locally agreed’ knee)Symptoms impair QOL – routineGiving way despite Rx– soon (knee only)Acute inflammation (gout, haemarthrosis,

pseudogout) – 2/52 (knee only)

PMR/GCA

Polymyalgia rheumatica and Giant cell arteritis

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

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

PMR/GCA Management PlanPMR/GCA Management PlanPMR steroid regime

10-20mg/day 2-4/522-4 weekly reduce by 2.5mg to 10mg4-6 weekly reduce by 1mg to 5mgContinue 5mg for 12/12Final reduction - reduce by 1mg/day every 6-8/52 to

3mg then every 12/52 until stopped

GCA steroid regimeVisual disturbance admit urgentlyOtherwise 40mg/day 2-4/522-4 weekly reduce by 5mg to 10mg then as for PMR

Remember prophylaxis with bisphosphonates

PMR steroid regime10-20mg/day 2-4/522-4 weekly reduce by 2.5mg to 10mg4-6 weekly reduce by 1mg to 5mgContinue 5mg for 12/12Final reduction - reduce by 1mg/day every 6-8/52 to

3mg then every 12/52 until stopped

GCA steroid regimeVisual disturbance admit urgentlyOtherwise 40mg/day 2-4/522-4 weekly reduce by 5mg to 10mg then as for PMR

Remember prophylaxis with bisphosphonates

RA key factsRA 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 presentationsSymmetrical inflamed small jointsFatigue and EMS but little to see initiallyEpisodic polyarthritis/palindromic symptoms

Systemic disease - extra-articular conditionsNodules, vasculitis, scleritis, pericarditis

Remember increased CHD risk!

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 presentationsSymmetrical inflamed small jointsFatigue and EMS but little to see initiallyEpisodic polyarthritis/palindromic symptoms

Systemic disease - extra-articular conditionsNodules, vasculitis, scleritis, pericarditis

Remember increased CHD risk!

RA managementRA managementAim for early diagnosis – refer if suspicious

Reduce symptoms – NSAIDs, analgesics, DMARDs

Minimise disease progression, maintain function/QOLEducationDMARDsMultidisciplinary support – physio, OTSurgery

Minimise adverse drug effectsShared care for DMARD monitoring, clear guidelines on

testing/responsibilityTNF antagonists (etanercept, infliximab)Steroids – I/A or low dose oral - specialist use only

Manage co-morbidities eg lung disease, CHD

Aim for early diagnosis – refer if suspicious

Reduce symptoms – NSAIDs, analgesics, DMARDs

Minimise disease progression, maintain function/QOLEducationDMARDsMultidisciplinary support – physio, OTSurgery

Minimise adverse drug effectsShared care for DMARD monitoring, clear guidelines on

testing/responsibilityTNF antagonists (etanercept, infliximab)Steroids – I/A or low dose oral - specialist use only

Manage co-morbidities eg lung disease, CHD

Back pain

Back pain key factsBack 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

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

Back pain key factsBack pain key facts

TypesSimple mechanical back pain – 90% recover 6/52Nerve root pain – sciatica – 50% recover 6/52Inflammatory back pain – AS, Psoriasis, ColitisOthers – trauma, OP, tumours

Xray LS only ifRed flag orFracture risk (trauma, steroids, osteoporosis, >70)

Xray and FBC, ESRCancer, 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

TypesSimple mechanical back pain – 90% recover 6/52Nerve root pain – sciatica – 50% recover 6/52Inflammatory back pain – AS, Psoriasis, ColitisOthers – trauma, OP, tumours

Xray LS only ifRed flag orFracture risk (trauma, steroids, osteoporosis, >70)

Xray and FBC, ESRCancer, 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

CERTIFICATECERTIFICATEAreas 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?

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?

Red flagsRed 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

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

Psychosocial Yellow flagsin back pain

Psychosocial Yellow flagsin 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

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

Back pain management planBack pain management planSymptomatic Rx

Analgesics, NSAIDs, muscle relaxantsMobilise, exercise, ice, heat, electrical therapies (U/S,

diathermy, interferential, TENS)

Complementary therapiesAcupuncture, 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

Symptomatic RxAnalgesics, NSAIDs, muscle relaxantsMobilise, exercise, ice, heat, electrical therapies (U/S,

diathermy, interferential, TENS)

Complementary therapiesAcupuncture, 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

Back pain referralBack 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

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

Secondary care referral – why?Secondary care referral – why?

Diagnostic difficultiesOA/RA; unusual conditions

Investigative helpSpecial imaging – MRI, CT, bone scanNerve conduction studies

Specialist conditionsRA, AS, SLE, Pagets

Specialist treatmentsDMARDs, surgery, joint/soft tissue injections,

multidisciplinary team access

Diagnostic difficultiesOA/RA; unusual conditions

Investigative helpSpecial imaging – MRI, CT, bone scanNerve conduction studies

Specialist conditionsRA, AS, SLE, Pagets

Specialist treatmentsDMARDs, surgery, joint/soft tissue injections,

multidisciplinary team access

Other topics to consideradding to your learning plan

Other topics to consideradding 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;65:1301-1311 and 1312-1324

Chronic widespread pain (fibromyalgia) Papageorgiou et al Annals Rheum Dis 2002;61:1071-74

SLE D’Cruz BMJ 2006;332:890-1

Ankylosing Spondylitis McVeigh and Cairns BMJ 2006;333:581-5

Septic arthritis DTB 2003;41 65-68 BMJ 2006;333:1107-8

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;65:1301-1311 and 1312-1324

Chronic widespread pain (fibromyalgia) Papageorgiou et al Annals Rheum Dis 2002;61:1071-74

SLE D’Cruz BMJ 2006;332:890-1

Ankylosing Spondylitis McVeigh and Cairns BMJ 2006;333:581-5

Septic arthritis DTB 2003;41 65-68 BMJ 2006;333:1107-8

Case study 1Case 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.

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.


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

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


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

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


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

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


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

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


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

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


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

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


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;139:476-482

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;139:476-482

Further readingFurther reading

ARC website www.arc.org.uk

Prodigy www.prodigy.nhs.uk

NICE www.nice.org.uk

Clinical Evidence www.clinicalevidence.com

National Library for Health www.library.nhs.uk, specialist libraries -musculoskeletal

And see website list/resources handout

ARC website www.arc.org.uk

Prodigy www.prodigy.nhs.uk

NICE www.nice.org.uk

Clinical Evidence www.clinicalevidence.com

National Library for Health www.library.nhs.uk, specialist libraries -musculoskeletal

And see website list/resources handout

http://www.arc.org.uk/

http://www.prodigy.nhs.uk/

http://www.nice.org.uk/


http://www.library.nhs.uk/


http://www.arc.org.uk/

http://www.prodigy.nhs.uk/





Questions?

NICE Secondary PreventionBisphosphonates

NICE Secondary PreventionBisphosphonates

Age 75 and over – Rx without DXA

65-75 – Rx if DXA confirms T-2.5SDDon’t wait for scan; Rx and stop if not confirmed

<65 – Rx if:Approximately T-3SD or below orT-2.5 +1 or more age-independent risk factors

BMI<19FH maternal hip #<75 yrsuntreated premature menopausemedical disorders assoc with bone loss or

immobility

Age 75 and over – Rx without DXA

65-75 – Rx if DXA confirms T-2.5SDDon’t wait for scan; Rx and stop if not confirmed

<65 – Rx if:Approximately T-3SD or below orT-2.5 +1 or more age-independent risk factors

BMI<19FH maternal hip #<75 yrsuntreated premature menopausemedical disorders assoc with bone loss or

immobility

NICE Secondary Prevention Raloxifene

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

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

NICE Secondary Prevention Teriparatide

NICE Secondary Prevention Teriparatide

Women aged 65 or older with

Unsatisfactory response (further # after 1 yr Rx, BMD below pre-Rx level) or intolerant

ANDExtremely 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)

Women aged 65 or older with

Unsatisfactory response (further # after 1 yr Rx, BMD below pre-Rx level) or intolerant

ANDExtremely 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)

Rheumatology for Registrars Pam Brown May 2007 [email protected] Pam Brown May 2007...

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