birmingham gp’s rheumatology update
TRANSCRIPT
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Birmingham GP’s Rheumatology update
Dr Subhra Raghuvanshi,
Speciality Registrar Rheumatology
12/10/2015
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Summary
• Clinical images / Case studies
• RA update
• Gout
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Rheumatoid Arthritis • 2010 ACR/EULAR criteria
• Number and site of involved joints
a. 2 to 10 large joints = 1 point
b. 1 to 3 small joints = 2 points
c. 4 to 10 small joints = 3 points
d. Greater than 10 joints = 5 points
• Serological abnormality
• Low positive (above the upper limit of normal [ULN]) = 2 points
• High positive (greater than three times the ULN) = 3 points
• Elevated acute phase response = 1 point
• Symptom duration at least six weeks = 1 point
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BSR – HQIP Audit
• Early assessment and seconday care management of EIA (Early inflammatory arthritis)
• NICE Guidelines and management for RA
• Best practice tariff
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https://www.nice.org.uk/guidance/cg79/chapter/1-recommendations#referral-diagnosis-and-investigations
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Case Study
• 19 year old, Warwick university student
• Referred urgently by GP –
- marked widespread arthritis 1/52
- Temperature
- Cervical lymphadenopathy
- URTI 10/7
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Temperature 39.5HR 130 BP 110/70Sats 97%
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• Diagnosis :
Parvovirus B19 PCR + 3/7
• Treatment - IV abx- NSAIDS / Paracetamol- IV Fluids - PO Prednisolone 20mgs po od. - Discharged 5/7- OPD f/u 4-6 weeks
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Differential diagnosis • Viral arthritis – parvovirus B19, rubella, HCV, HBV, alpha
viruses (chikungunya), HTLV
• Systemic rheumatic diseases – RA, PSA, palindromic RA, reactive arthritis, PMR, crystal arthritidis, Enteropathic
• Sarcoid arthropathy (ankles, EN)
• Paraneoplastic – myelodyaplasia, lymphoma, lung cancers (HPOA)
• OA
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Case Study
• 75 year old male
• Background
- Smoker
- RA for 8 years
- Hypertension
- Diabetic
- Gout
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• Drug history : Methotrexate
Folic acid
Amlodipine
Metformin
Allopurinol
• Presents to GP : 2/52 Lethargy, generally unwell, loss of appetite
• O/EUnwellHR 95BP 115/80Temp 37.4Sats 93%Chest : Bibasal crackles
• Investigations :
Urgent Bloods Chest Xray
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• Blood tests:
Hb 112WCC 4.5Neut 3.1Plt 220ALT 66ALP 170Ur 8.1Crt 110CRP < 5
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• What would you do next ??
• Old records / discharge letters : on Tocilizumab infusion !
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Treatments
Non Biologic
DMARDS
Methotrexate SulphasalzineHydroxychloroq
uine
Steroids Biologics
Anti-TNF
Adalimumab, Etanercept, Infliximab,
Cimzia
Anti-CD20
Rituximab
IL6 blocker
Tocilizumab
Biosimilars
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• www.rheumatology. oxfordjournals.org
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Management of acute gout
• Rest, analgesic, antiinflammatory 1-2 weeks
• NSAIDS + gastroprotection
• Colchicine (500ugm bd-qds)
• Allopurinol not be commenced , but continued if on it
• Opiate analgesics
• Intra-articular corticosteroids, i.m, p.o
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Chronic, recurrent gout • Plasma urate levels < 300umol/l • ULT- 2nd attack, or continuing attacks within 1 year- renal insufficiency- uric acid stones- tophi- continued treatment with diuretics
• Allopurinol commenced 50-100mgs/day po od• Uptitrated monthly by 50-100mgs/day • Monthly U+E’s • Maximum dose 900mg• Prophylaxis : Colchicine 500umcgs od-bd (6months), NSAIDS / Coxib’s
(6weeks)• Second line agents – uricosuric acid, xanthine oxidase inhibitors
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Questions ?