Note to referrer. 

The Rheumatology department offers management for osteoporosis associated with inflammatory rheumatic diseases. For patients with osteoporosis not linked to inflammatory rheumatic disease, please refer to the endocrinology or orthogeriatrics departments.

Criteria for referral to rheumatology for osteoporosis: 

  • Patients with inflammatory rheumatic disease 
  • Failure/ contraindication for oral bisphosphonates 

In case of intolerance alendronate, please try risedronate (which causes slightly less in the way of GI side effects than alendronate) before considering parenteral options if there is no contraindication. 

Glucocorticoid induced osteoporosis

Bone protections should be started without waiting for DXA in patients who has been started on glucocorticoids with following criteria:

  • Anyone with prior fragility fracture 
  • Women ≥ 70years 
  • Postmenopausal women, and men age ≥50 years, prescribed high doses of glucocorticoids, i.e., ≥7.5 mg/day of prednisolone or equivalent over 3 months (N.B., this is equivalent to ≥30mg/day of prednisone for 4 weeks over 3 months) 
  • Postmenopausal women, and men age ≥50 years, with a FRAX probability of major osteoporotic fracture or of hip fracture exceeding the intervention threshold
Measurement of BMD to assess treatment response
  • Please measure the FRAX score with BMD after 5 years of treatment with bisphosphonates
  • If the FRAX score is above the NOGG intervention threshold or the T score is < -2.5, please continue treatment for an additional 5 years
  • It is important to note that there might be some decline in the T score with age, and treatment results in a less rapid decline in BMD

Gout is a condition that can be managed in primary care.
Treatment of gout flare

Use either of colchicine, NSAIDs or short course steroid for the treatment of acute attack of gout. 

  • Any NSAIDs can be used. Please be aware of contraindications and drug interaction. 
  • In case of colchicine suggested dose is 0.5mg twice daily. Only use colchicine in case of  if within 1 to 3 days of onset of gout – I find it doesn’t work so well if gout attack started a week ago – then steroids more helpful. 
  • Short course of steroid
Offer urate lowering therapy for 
  • multiple or troublesome flares
  • CKD stages 3 to 5 (glomerular filtration rate [GFR] categories G3 to G5)
  • diuretic therapy
  • tophi
  • chronic gouty arthritis

 

  • Wait for 2 -4 weeks before starting the allopurinol/ febuxostat. In case of recurrent gout flares, allopurinol can be started along with colchicine prophylaxis 0.5mg to 1mg daily
  • Please assess the risk of skin reaction
  • Allopurinol can be increased up to 900mg as per S. uric acid 
  • Check urate every 4 weeks and titrate dose of allopurinol aiming for urate <360 
  • Continue colchicine until target urate is reached 

Check whether on any diuretics (eg thiazide or furosemide) if possible, stop, thiazide switch to alternative anti-hypertensive. 

IF on anti-hypertensive medication consider switching to losartan which has some urate lowering properties AND of course advise about lifestyle factors (diet and alcohol)

Key messages to patients
  • it takes time to suppress the urate and patients need to work in partnership with their GP to check the bloods and titrate the dose 
  • patients can continue to have attacks for 12 months after adequate suppression of the urate  
  • allopurinol can trigger an acute attack, which is why we give the colchicine cover
USE OF FEBUXOSTAT IN GOUT

New evidence suggests both allopurinol and febuxostat can be used as main agents for lowering urate. Concerns about febuxostat's cardiovascular risk from the CARES trial have been addressed by the recent FAST trial, showing febuxostat is non inferior to allopurinol. The latest update from the Medicines and Healthcare products Regulatory Agency update (May 2023) is, in patients with pre-existing major cardiovascular diseases, febuxostat therapy should be used cautiously, particularly in those with evidence of high urate crystal and tophi burden or those initiating urate-lowering therapy. 

Therefore, in the patient as allopurinol is not suitable, febuxostat may be used cautiously. 

Most cases of gout can be safely treated in primary care.

Suspect gout Consider gout
Rapid onset (often overnight) of severe pain together with redness and swelling in first MTP joint Rapid onset (often overnight) of severe pain together with redness and swelling in joints other than MTP joints
Tophi  
If septic athritis suspected Immediate referral
Asses for inflammatory arthritis Evalution and referral to rheumatology if required

Diagnosis

Measure serum urate

  • Diagnosis of gout confirmed if the serum urate more that 360 micromol/ L

  • In case of urate level less than 360 micromol/ L repeat urate levels at least 2 weeks after flare has settled 

Rheumatology referral needed only if:

  • Diagnosis of gout is uncertain
  • Treatment is contraindicated / ineffective / not tolerated
  • CKD stage 3b – 5 ( GFR categories G3b- G5)
  • They have had an organ transplant

Management of gout

General
  • Patient education
  • Assess risk factors
    • Obesity
    • Medicines - diuretics
    • Systemic hypertension
    • CKD
  • Stress on diet and alcohol
Treatment of gout flares
  • Rest
  • Elevation
  • Icing
  • Use one of three options of drugs:
    • NSAIDS (add PPI if appropriate)
    • Colchicine (0.5mg twice daily)
    • Steroid (oral short course/intraarticular steroid if available for monoarthritis)
Offer Urate lowering therapy if:
  • Multiple/troublesome flares
  • CKD stage 3-5
  • Diuretic therapy
  • Tophi
  • Chronic gouty arthritis
Urate lowering therapy
  • Start after 2 weeks of last flare of gout 
  • Start either Allopurinol or febuxostat 
  • Use allopurinol as first line in case of major cardiovascular risk
Prevention of flares
  • Discuss the benefit and risk of treatment to prevent flares 
  • In patients who chose to take medicine for gout – initiate colchicine 0.5mg – 1mg at least for 3 months. 
  • If colchicine is contraindicated use low dose NSAIDs or low dose steroid 
Treat to target
  • Monthly uric acid and optimisation of therapy to a uric acid level of <360micromol/ L 
  • Lower urate level target of <300 micromol/ L in case of 
    • Tophi / chronic gouty arthritis 
    • Ongoing frequent flares despite of urate value <360 micromol /L 
  • Once target achieved – annual urate measurement 
     

PMR is a condition that can be managed in primary care.

PMR can be easily diagnosed with history of core symptoms, high inflammatory markers and a good response to steroid.

Please find the core inclusion and exclusion criteria:

Core inclusion criteria Core exclusion criteria
  • Age >50 years, duration >2 weeks
  • Recent acute onset bilateral shoulder or pelvic girdle aching, or both
  • Morning stiffness duration of >45 min
  • Evidence of an acute-phase response
  • Active infection
  • Active cancer
  • Active GCA (see part iii)
 

The presence of the following conditions decreases the probability of PMR, and they should also be excluded:

  • Other inflammatory rheumatic diseases
  • Drug-induced myalgia
  • Chronic pain syndromes
  • Endocrine disease
  • Neurological conditions, e.g. Parkinsons disease

I assume that the patient has been examined and this is essential. 

Investigation suggested are:  FBC, ESR, CRP, Renal and liver function test, protein electrophoresis, bone profile, TSH, CK, RF (ANA and anti CCP if inflammatory arthritis is suspected) and chest Xray may be required. 

PMR can be diagnosed with normal inflammatory markers if there is a classic clinical picture and response to steroids.

In patients with suspected PMR please consider a trial of prednisolone 15mg daily, review after 2 weeks to check response (also repeat ESR and CRP) would expect a dramatic improvement within 2-3 days. Continue same dose of steroid until symptoms are well controlled, usually 3 weeks. Please follow the flow chart for further tapering of steroid. 

Start prednislone 15mg OD with PPI and bone protection
Continue same until symptoms are well controlled usually 3 weeks
↓
Once the symptoms are under contol
Prednisolone 12.5mg OD for 3 weeks
↓
If assymptomatic
Prednisolone 10mg OD for 4-6 weeks
↓
Further dose reduction 1mg every 4-8 weeks until the treatment is stopped

Please add PPI and Ca/VitD and would refer for DXA to determine if additional bone protection needed.

Manage patient expectations:

  • will be on steroids 1-2 yrs
  • 1/3 of patients will flare, 1/3 will need a steroid sparing agent

Consider referral to rheumatology in case of:

  • Atypical features like normal inflammatory markers 
  • Lack of shoulder involvement 
  • Poor response to steroids 
  • Not possible to reduce corticosteroids at reasonable intervals without causing relapse
  • Corticosteroids are required for more than 2 years
  • anti-CCP / high positive RF or swollen peripheral joints

Please correspond via A&G in these situations to prioritise the patient being seen in the department.

Most of the Polymyalgia rheumatica can be treated in primary care.

Suspect PMR if: a person more than 50 years old with core symptoms for at least 2 weeks  Rule out

Recent acute onset Bilateral shoulder and/or pelvic girdle aching lasting more than 2 weeks.

 GCA
Morning stiffness (for more than 45 minutes) Active cancer

Evidence of an acute phase response – new acute phase response  (ESR and or CRP)

 Infection

Other more general symptoms, such as low-grade fever, fatigue, anorexia, weight loss, or depression

 Inflammatory arthritis
  Drug induced myopathy - statin
  Fibormylagia
Look for GCA Direct referral to the SDEC
Asses for inflammatory arthritis Evaluation and referral to rheumatology if required
Diagnosis

Confirm the diagnosis by: 

  • Core features of PMR 

  • Exclusion of differential diagnosis like RA and fibromyalgia 

  • Good response to oral steroid within a week 

  • Normalisation of inflammatory markers within 4 weeks

When to refer PMR to rheumatology
  • Atypical features like normal inflammatory markers
  • Lack of shoulder involvement 
  • Poor response to steroids 
  • Not possible to reduce corticosteroids at reasonable intervals without causing relapse.
  • Corticosteroids are required for more than 2 years
  • Positive ACCP/ high positive rheumatoid factor / peripheral joint swelling

Management of PMR

Start prednislone 15mg OD with PPI and bone protection
Continue same until symptoms are well controlled usually 3 weeks
↓
Once the symptoms are under control
Prednisolone 12.5mg OD for 3 weeks
↓
If assymptomatic
Prednisolone 10mg OD for 4-6 weeks
↓
Further dose reduction 1mg every 4-8 weeks until the treatment is stopped

Add bone protection along with steroids without waiting for BMD in case of:

  • Prior fragility fracture 
  • Women aged ≥ 70 years 
  • Postmenopausal women, and men age ≥50 years, prescribed high doses of glucocorticoids, i.e., ≥7.5 mg/day of prednisolone or equivalent over 3 months (N.B., this is equivalent to ≥30mg/day of prednisone for 4 weeks over 3 months) 

Start Calcium vitamin D for all and measure DEXA – to start bisphosphonates Postmenopausal women, and men age ≥50 years, with a FRAX probability of major osteoporotic fracture or of hip fracture exceeding the intervention threshold.