Last July, the British Society for Rheumatology produced a guideline for the management of rheumatoid arthritis in the first two years of the disease.
The second part of the guideline is due to be released later this year. It concentrates on management of rheumatoid arthritis after the first two years.
There are a number of ways in which GPs can contribute to the care of patients with rheumatoid arthritis. Management does not stop when referral to secondary care is made.
GPs need to be aware of several important points. From the first guideline, early referral of patients is stressed.
Disease-modifying anti-rheumatic drugs (DMARDs) should be started, ideally within 12 weeks of disease onset and early treatment has been shown to slow disease progression.
GPs are familiar with the textbook presentation of rheumatoid arthritis, with descriptions of symmetrical arthropathy involving the metacarpophalangeal joints, and morning stiffness. However, what should the GP do when the presentation is less obvious?
Sometimes it is difficult to decide whether the patient has inflammatory arthritis. The message from rheumatologists, however, is clear: refer any patient in whom the diagnosis is suspected. Inflammatory arthritis can be present with a normal ESR and CRP.
Patients with osteoarthritis suffer from stiffness and it can be difficult to decide if they have true morning stiffness. A general rule is that patients with osteoarthritis stiffen up after exercise, whereas patients with inflammatory arthritis are stiff after resting.
In the second guideline, the role of the GP as part of the wider multidisciplinary team is stressed. Annual review of the patient is proposed and will probably take place in secondary care.
GPs are already familiar with screening for cardiovascular risk in patients with diabetes and hypertension. It is proposed that GPs extend their screening to involve patients with rheumatoid arthritis.
The reasons for this are clear: cardiovascular disease (CVD) claims more lives in patients with rheumatoid arthritis than the disease itself.
Premature CVD causes a great deal of the morbidity associated with the disease. Most studies report a 1.5- to 2-fold risk of CVD with rheumatoid arthritis, compared with the general population.
GPs should monitor weight, BMI, waist measurement, BP, lipids and fasting glucose and smoking status.
Advice should be offered to reduce weight and increase exercise. Smoking cessation should be encouraged. Statins should be commenced in line with cardiovascular risk tables produced by the British Heart Foundation.
At the moment, this work is not part of the quality framework of the new GMS contract. However, it is hoped that musculoskeletal problems will be included in the quality framework in the near future.
Rheumatoid arthritis is a separate risk factor for osteoporosis. Steroid treatment and inability to take part in weight-bearing exercise are other risk factors. Although many patients will be screened in secondary care, GPs need to be aware of the risk of developing osteoporosis and refer for DXA scanning. Guidelines from the Royal College of Physicians are useful resources.
Patients with rheumatoid arthritis have a higher incidence of depression than the general population. In a rheumatology outpatient department, 40 per cent of those questioned had severe depression.
They are less likely to respond to antidepressants compared with patients who do not have rheumatoid arthritis.
Depression can be very disabling and difficult to spot. GPs can become exasperated with trying to manage some patients with rheumatoid arthritis who become ‘heartsinks’.
It is definitely worth pausing and taking a step back from these patients and considering whether or not they may be depressed.
In my own experience, such patients are difficult to manage. Often they will not accept that they may be depressed and blame their morbidity on the rheumatoid arthritis.
It is sometimes useful to use a depression screening questionnaire. The GP can then prescribe antidepressant medication or a talking therapy such as cognitive behavioural therapy.
Patients taking DMARDs such as methotrexate, steroids and anti-TNF drugs are immunosuppressed and should be offered annual influenza vaccination, pneumovax and antiviral drugs or immunoglobulin if they develop varicella or measles and are not immune.
Although not routinely accepted for patients starting DMARD therapy, a varicella titre would be useful as a baseline measurement.
Patients with rheumatoid arthritis are at risk of infection. Several treatments commonly used in rheumatoid arthritis including biologic therapy, glucocorticoids and methotrexate, can exacerbate and also mask signs of infection.
Infection should be identified by screening, for example, MSU, chest X-ray and blood count to look for raised white cell count.
Infection should be treated early in such patients, and temporarily withdrawing immunosuppressive therapy during infection should be considered on the advice of a consultant rheumatologist.
Anti-TNF therapy can reactivate latent TB. Patients should have been screened for TB before they are commenced on such therapies. This is usually done in secondary care.
Patients with rheumatoid arthritis are often in pain. This contributes to the debilitating nature of the disease and as GPs we will be the first line of approach when patients seek help to ease this pain.
GPs are used to managing pain, but often it is not done well. Use NSAIDs with gastro-protection if necessary for short- or medium-term control of symptoms.
Cox-2 inhibitors are effective in pain management in rheumatoid arthritis. They are safer in terms of gastric side-effects than NSAIDs.
Both Cox-2 inhibitors and NSAIDs produce a small increase in thrombotic events and hence an increase in cardiovascular risk and should be used in the short or medium term only and after counselling the patient about the possible side-effects.
Evidence about this can be found in MHRA guidance and EMEA guidelines.
Patients who have had rheumatoid arthritis for a number of years will undoubtedly have neck problems.
Sometimes this is just in the form of pain, but atlanto-axial subluxation can occur, due to bony erosions of the atlas and axis, and this can cause a progressive myelopathy.
If patients present with long tract signs, then urgent referral to an orthopaedic surgeon should be made. Otherwise, permanent disability and paralysis can occur.
Dr Warburton is a GP in Ironbridge, Shropshire
- O’Dell J R. Therapeutic strategies for rheumatoid arthritis. N Engl J Med 2004; 350: 2,591–602.
- Solomon D H, Goodson N J. The cardiovascular system in rheumatic disease. J Rheumatol 2005; 32: 1,415–17.
- Hill J, Bird H A, Hopkins R, Lawton C, Wright V. Survey of satisfaction with care in a rheumatology outpatient clinic. Ann Rheum Dis 1992; 51: 195–7.
- MHRA. Press release: Updated safety information for non-steroidal anti-inflammatory drugs (NSAIDs). www.mhra.gov.uk/home
- EMEA. Press release: European Medicines Agency review. www.emea.europa.eu/pdfs/human/press/pr/41313606.pdf