- Written By: Sarah Vincent FM PGY2, and Kelly Mitchelmore FM PGY2 out of Memorial University in Newfoundland
- Expert Review By: Dr Sean Hamilton, Divisional Chief of Rheumatology for Eastern Health, Newfoundland, as well as Dr Ian Parsons, FM and Sports Medicine physician, Newfoundland.
In patients presenting with musculoskeletal pain, include referred and visceral sources of pain in the differential diagnosis. (e.g., angina, slipped capital epiphysis presenting as knee pain, neuropathic pain).
The main take away point here is that joint pain can be the presenting symptom for conditions that have nothing to do with the joints! Your history, physical exam and application of clinical context will guide you towards potential referred sources of pain.
Some examples are:
- Children who present with non-traumatic hip, groin, thigh or knee pain should have an x-ray to rule out slipped capital epiphysis
- A burning sensation over the extremity is suspicious for neuropathic pain
- Elderly individuals, diabetics, and women can present with atypical symptoms of angina, such as back pain or arm pain
Objective Seven ‘a’
In patients with a diagnosed rheumatologic condition, actively inquire about pre-existing co-morbid conditions that may modify the treatment plan.
What are some components of the past medical history that are important to consider in patients with a diagnosed rheumatologic condition?
Many rheumatologic medications have contraindications or serious side effects. A thorough history before initiating treatment can help you make the best choice for your patient. Specifically ask about:
- Liver disease
- Gastrointestinal disorders, such as peptic ulcer disease, dyspepsia and gastrointestinal bleeds
- Kidney problems, such as chronic renal impairment and history of acute kidney injury
- Cardiovascular disease, such as heart attack, stroke, hypertension and heart failure
- Ask about risk factors for infectious diseases, such as hepatitis B & C, TB and HIV
Are there any social history questions that would be pertinent for these patients?
Asking about alcohol use is important, as many medications have a risk of hepatotoxicity.
Discussing family planning early on enables the adjustment of medications before pregnancy, and provides the opportunity to counsel on the appropriate dose of folic acid supplementation in this patient population. This is especially true in young women with RA or SLE.
I’ve heard that once a disease modifying antirheumatic drug has been started patients can’t get immunizations! Is this true?
While most immunizations are safe, live immunizations should be avoided once disease modifying antirheumatic drugs have been started. Ideally, patients will have their immunizations up to date before starting therapy. Refer to the Canadian Immunization Guide for the most up to date recommendations on the immunization of special patient populations.
In patients with rheumatoid arthritis, start treatment with disease-modifying agents within an appropriate time interval.
When should I start thinking about starting patients on disease-modifying anti-rheumatic drugs?
The short answer is as soon as possible! It’s been demonstrated that earlier diagnosis and drugs prevents joint damage, makes remission easier to achieve and prevents loss of function. Ideally, treatment should start within three months of symptom onset.
Is this something that falls within the scope of family practice?
That’s a great question! It will depend on the location of the prescriber and access to a rheumatologist in that area.
Family physicians will often start patients on methotrexate if specialist consultation is not readily available. Biologics or Synthetic Specific DMARD’s such as Janus Kinase Inhibitors should normally be started by Rheumatologists or Internists with a special interest in rheumatology rather than family doctors.
Additionally, some insurance companies will only cover the cost of biologic medications if a specialist prescribes them.
What should I do as part of pre-treatment work up for my patients?
Pre-treatment evaluation before starting pharmacologic therapy includes baseline CBC, aminotransferases, CRP, and, in the setting of immunomodulators, screening for latent TB and hepatitis B and C.
Once treatment has started, what should I be monitoring to assess the effectiveness of the treatment?
Generally, the target is low disease activity or remission. Five main treatment goals can guide your monitoring for treatment effectiveness. These are:
- Minimization of joint pain and swelling
- Prevention of radiographic damage
- Prevention of visible deformities
- Maintaining quality of life
- Controlling extra-articular manifestations.
A treat to target approach is recommended, which involves dose optimization of methotrexate and subsequent addition of DMARDs as needed. Regular, systematic monitoring and treatment adjustment minimizes inflammation, preventing joint damage.
Objective Seven ‘b’
In patients with a diagnosed rheumatologic condition: choose the appropriate treatment plan
Objective Nine ‘b’
In patients experiencing musculoskeletal pain, treat with appropriate doses of analgesics.
The treatment of rheumatologic conditions is an extensive topic, in the interest of time we will not be going into the fine details. We will review key management points from the perspective of family medicine, so buckle up for the ride!
First, we will go through nonpharmacologic strategies, as these are crucial in managing any progressive joint disorder.
- Physical activity
· Cardiorespiratory, strength training, joint rom activities are beneficial for all
· Tai chi can be beneficial for knee and hip osteoarthritis
· Every Arthritis Patient should have their own Joint Exercise Program tailored to their joint needs, and developed for them by a Physiotherapist
2. Psychosocial interventions
· Self-efficacy and self-management programs, which can be found on patient support websites
· Counseling – emotional / psychological support for chronic disease
· Cognitive Behavioural Therapy (CBT)
3. Joint protection, such as splints and braces
4. Ambulation aids can improve function and ambulation. They also increase patients involvement in activities of daily living
5. Heat and cold for osteoarthritis
· Heat can relax muscles, lubricate joints, and relieve stiffness. It may be beneficial in the morning and before physical activity to loosen up the joint
· Cold reduces swelling, blood flow and blocks nerve impulses. It improves range of motion, function and strength
6. Weight loss was traditionally recommended for osteoarthritis based on the idea of decreasing the load on weight bearing joints. There is more evidence that exercise decreases pain and improves function.
While maintaining a healthy weight should be a goal for all patients, as we all know it is often very difficult for patients to lose and maintain weight and can be discouraging when they don’t see results. Focusing on the benefits of exercise for improving joint symptoms may have the secondary benefit of weight loss without the psychological impacts.
7. Gout is the only joint disorder when dietary measures can improve symptoms. Purine intake should be limited, which includes liver, kidney, beef, lamb, pork, sardines and shellfish. High-fructose corn syrup and alcohol should also be limited.
Next, we will move on to the key management points for osteoarthritis
- Acetaminophen is often used initially but the evidence for efficacy is weak in OA. One of the reasons it’s used as the initial choice relates to its farther greater safety compared to NSAID’s, especially in older patients. Typically, an initial trial may be 1 g po BID for about two weeks. If not effective we may gradually increase to as high as 1 gm QID if there are no contraindications. If acetaminophen lacks efficacy, there is no point continuing with it.
- Topical agents available include capsaicin and diclofenac
· Capsaicin is applied 3-4x / day, and it can take up to 4 weeks for maximum effect. Treatment is often limited by tingling, burning and pain. It can be considered for knee osteoarthritis. It is not recommended for hand osteoarthritis due to a lack of evidence and increased risk of eye contamination.
· Diclofenac is applied 3-4x / day, and it can take up to 2 weeks for maximum effect
· Topical NSAIDs should be used before oral NSAIDs in patients greater than 75 yrs old and in renal impairment
3. Oral NSAIDs can be divided into two categories, non-selective and selective. There are numerous NSAIDs available in Canada. The most common nonselective NSAIDs used in joint disorders are ibuprofen and naproxen, and celecoxib is the most common selective NSAID used.
· NSAIDs can cause hypertension, edema, MI, stroke, renal impairment, GI tract ulcer, perforation, and bleeding. Before initiating treatment, it is essential to assess your patients risk of CV, GI and renal complications. Key factors to consider include:
o Alcoholic liver disease
o Pelvic ulcer disease/GI bleed
o Oral steroids
o ACEI, ARB, DRI, diuretics
o Renal disease
· See figure in show notes – the general concept is that more risk factors should make you think about choosing a selective vs non-selective NSAID, the addition of GI protection or an alternate therapy
· H2 antagonists and antacids will relieve symptoms of dyspepsia but will not help prevent GI complications
· Celecoxib is as effective as non-selective NSAID for hip/knee osteoarthritis, with the benefit of less gastroduodenal ulcers. It still can impact renal function.
4. Intra articular steroids can be used 3-4 times per year in weight bearing joints. Risks include joint space narrowing, joint deterioration, worsening pain, worsening function and a charcot type neuropathy.
5. Duloxetine, a serotonin and norepinephrine reuptake inhibitior, can be considered if concomitant depression, neuropathic pain or widespread pain.
6. There is conflicting evidence for the benefit of glucosamine and chondroitin. It is not recommended in guidelines, but given its good safety profile, a trial for patients with mild to moderate OA, is reasonable as evidence, both Positive and Negative, vary from study to study.
7. Opioids should be considered as a last resort, if patients have failed all other options or are unable to take NSAIDs. Main risks include dependence, dizziness, falls and constipation.
Key treatment points for rheumatoid arthritis include:
- All patients with RA should be on a DMARD
· DMARDs have a delayed onset of action of 8-12 weeks
· Methotrexate is the preferred first choice DMARD
· Side effects: GI upset, transaminitis, myelosuppression, stomatitis
· Rarely, patients may develop liver toxicity or pneumonitis
· Alternative traditional DMARDs include hydroxychloroquin, sulfasalazine and leflunomide
· Newer DMARDs include the biologics agents, such as anti-TNF agents, abatacept, tocilizumab and rituximab
2. NSAIDS decrease inflammation but do NOT change outcomes. They can be used as ‘bridging’ therapy while waiting for DMARDs to take effect.
3. Smoking cessation should be recommended for all patients with rheumatoid arthritis. Smoking causes more severe disease, and disease onset occurs earlier. There is greater radiologic progression compared to non-smokers.
Next we will move on to ankylosing spondylitis. Key points are:
- NSAIDs are first line
- Glucocorticoids and conventional DMARDs are NOT recommended for predominant axial involvement
- Biological DMARDs (TNFi and IL-17 inhibitors) can be used in patients with high disease activity or failure/contraindication to NSAIDs
The main treatment points for systemic lupus erythematosus are:
- Hydroxychloroquine is recommended for all patients, if tolerated
· It controls symptoms long term and prevents disease flares
· Long term use is associated with retinal toxicity. Patients should see an ophthalmologist regularly as per published guidelines
2. Steroids can provide rapid symptom relief. Doses should be limited to <7.5mg/day and long-term use should be avoided
3. Immunosuppressants and biologics: choice depends on primary disease manifestation(s), patient age, childbearing potential, safety concerns, cost and prior treatment failures
4. In acute organ failure, including lupus nephritis or cerebritis, IV cyclophosphamide and mycophenolate mofietil are first line, often preceded by high dose IV glucocorticoids
For the treatment of PMR:
- Prednisone is the mainstay of therapy.
· Response is achieved relatively quickly at the appropriate dose
· Prednisone 10 mg per day would be a good starting dose with the option of going as high as 20 mg per day. If the patient requires more than 20 mg per day of Prednisone per day, than you should question your diagnosis of PMR
· Taper prednisone slowly over the course of a year
2. Relapses are common! Up to 50% of individuals will have them. Treat relapses with prednisone as well
3. Ongoing monitoring of patients for development of symptoms of GCA is essential
And last, but not least, the management of gout!
- NSAIDs, colchicine and oral steroids are all reasonable first line options
- Treatment should start within 24 hours of attack
- Combination therapy is an appropriate when symptoms are severe, the attack is polyarticular or large joints are involved
- Do NOT stop or change the dose of urate-lowering drugs during an acute attack, because symptoms may be exacerbated or prolonged
- Urate lowering therapy CAN be started during an attack IF effective anti-inflammatory treatment has been started
In assessing patients with a diagnosed rheumatologic condition, search for disease-related complications.
Extra-articular manifestations of rheumatologic conditions are quite broad. A full review of systems is essential when monitoring for complications.
A full table outlining common extra-articular manifestations can be found in our show notes. Some common ones to keep in mind are:
- Dactylitis and nail involvement with psoriatic arthritis
- Scleritis, episcleritis, mononeuritis multiplex, and carpal tunnel with rheumatoid arthritis
- Pericarditis, pleuritis, psychosis, oral ulcers, discoid, and malar rash with SLE
- Aortic regurgitation, uveitis, and enthesitis with ankylosing spondylitis
- Urethritis and cervicitis with gonococcal infections suspicious for septic joint or reactive arthritis
Objective Nine ‘a’
In patients experiencing musculoskeletal pain, actively inquire about the impact of the pain on daily life.
We all know the classic FIFE acronym used to explore illness from the patient perspective. Is there anything specific to ask patients presenting with MSK pain?
It’s important to spend time exploring the disease’s impact on the patient’s function, as you can then tailor your management plan to target the patient’s specific complaints. Joint disorders such as OA and RA are progressive and
creating realistic and achievable goals will strengthen the therapeutic relationship.
Be sure to ask about their ability to work, participate in social activities, and the effect on relationships/caregivers. Review the impact on performing activities of daily living, such as bathing, toileting, dressing, and cooking. Ask the patient about their current mobility, both in and outside the home.
Objective Nine ‘c’
In patients experiencing musculoskeletal pain, arrange for community resources and aids, if necessary.
What other resources are available for patients with joint disorders?
Consider referral to OT – they can help with joint protection techniques, return to work/work accommodations, assistive devices, bracing, and suggesting appropriate footwear.
Consider referral to PT – they can help with strength, flexibility, range of motion, exercise tolerance, assistive devices, and using a cane.
The Arthritis Society Canada webpage is an excellent patient resource and can connect patients to local resources in their province.
There is also a Canadian program, GLA:D, which is an education and exercise program for knee and hip osteoarthritis. Please refer to their website for details.
We will end this episode with everyone’s favorite, some clinical pearls!
- Abrupt onset of joint pain, complete inability to bear weight, and history of immunosuppression, IVDU, or prosthetic joint are highly suspicious for septic arthritis which is considered an emergency.
- When comparing physical exam findings for RA and OA, key differences are:
· OA is asymmetric, RA is symmetric
· In the hand: OA affects 1st CMC, RA affects the MCP’s (the knuckle joints)
· In the back: OA affects cervical, thoracic and lumbar spine, RA affects cervical spine
· In the feet: OA affects 1st MTP, RA affects all MTP
3. Although inflammatory arthropathies are usually oligo or polyarticular, they can present early on as mono arthropathies.
4. DMARDs should be started as soon as possible once rheumatoid arthritis is diagnosed. NSAIDs will NOT alter outcomes but are helpful as bridging for symptom relief until DMARDs begin to work.
5. A full review of systems is essential when monitoring patients with rheumatologic conditions for disease related complications.
6. Treatment for gout should start within 24 hours of an attack. NSAIDs, colchicine and oral steroids are all reasonable first line options. Do not stop urate lowering therapy during an attack.
7. Acetaminophen and non-pharmacologic measures should be used as initial treatment of osteoarthritis. Topical NSAID, oral NSAID and intra-articular steroids can be tried in sequence if symptoms persist.
8. Polymyalgia rheumatica is a non-articular rheumatic disease, seen in patients over the age of 50, which causes pain and stiffness in proximal muscle groups, including the shoulders, neck, hips, and thighs. Patients will have an elevated CRP, with negative RF and anti-CCP.
9. Always consider the clinical context! Joint and MSK pain are not always caused by joint pathology.
10. Diagnostic Criteria for most rheumatic conditions can be found on the American College of Rheumatology website. Avail of this resource as it can help guide you on what investigations should be done based on your differential.
11. There are several tests which can be ordered on blood work for evaluation of a rheumatic diseases with varying sensitivities and specificities. Don’t be afraid to consult a resource or our rheumatology colleagues to help order and potentially interpret these tests! They are a lot to memorize!
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