What are the appropriate management strategies for patients presenting with rheumatological conditions?

Management of Rheumatological Conditions

Initial Assessment and Diagnosis

For suspected rheumatoid arthritis, refer urgently to a rheumatologist if small joints of hands/feet are affected, more than one joint is involved, or there has been a delay of three months or longer between symptom onset and seeking medical advice, even with normal acute-phase response or negative rheumatoid factor. 1

Essential Baseline Evaluation

Before initiating therapy, obtain the following:

• Laboratory workup: Rheumatoid factor and/or anti-cyclic citrullinated peptide antibodies (ACPA), C-reactive protein and/or ESR, complete blood count, glucose, creatinine, liver function tests, bone profile (calcium, alkaline phosphatase), and urinalysis 1
• Additional testing when indicated: Protein electrophoresis, TSH, creatine kinase, vitamin D, ANA, ANCA, or tuberculosis screening based on clinical presentation 1
• Comorbidity assessment: Document hypertension, diabetes, cardiovascular disease, chronic kidney disease, obesity, peptic ulcer disease, osteoporosis, cataracts/glaucoma risk, and chronic infections 1, 2

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Disease-Specific Pharmacological Management

Rheumatoid Arthritis

Start methotrexate as first-line disease-modifying antirheumatic drug (DMARD) therapy for patients with active rheumatoid arthritis who have had insufficient response to or are intolerant of NSAIDs. 1, 2

Treatment Algorithm:

1. Initial therapy: Methotrexate monotherapy with NSAIDs and/or low-dose glucocorticoids (≤10 mg/day prednisone equivalent) as needed for symptom control 1
2. Monitor disease activity: Use SDAI (Simplified Disease Activity Index) for patients with elevated acute-phase reactants or CDAI (Clinical Disease Activity Index) for others, assessed at 1-3 month intervals 1, 3
3. Escalation criteria: If inadequate response after 3-6 months of methotrexate optimization, add biologic DMARD (TNF inhibitor, abatacept, tocilizumab, or sarilumab) or JAK inhibitor (tofacitinib, baricitinib) 1

Methotrexate Monitoring:

• Liver function tests: Perform at baseline and every 4-8 weeks during therapy 2
• Hematologic monitoring: Check CBC regularly; discontinue immediately if significant drop in blood counts (WBC <3000/mm³, platelets <100,000/mm³) 2
• Renal function: Monitor creatinine clearance, especially in elderly patients where serum creatinine may overestimate renal function 2

Ankylosing Spondylitis and Axial Spondyloarthritis

NSAIDs are first-line drug treatment for patients with pain and stiffness; continuous treatment is preferred for persistently active symptomatic disease. 1

Treatment Progression:

1. First-line: NSAIDs (including COX-2 inhibitors) with consideration of cardiovascular, gastrointestinal, and renal risks 1
2. Physical therapy: Non-pharmacologic interventions including dynamic exercises should be continued alongside drug therapy 1, 3
3. Anti-TNF therapy: Initiate in patients with persistently high disease activity despite conventional treatments according to ASAS recommendations 1
4. Important caveat: DMARDs including sulfasalazine and methotrexate have NO evidence for efficacy in axial disease, though sulfasalazine may be considered for peripheral arthritis 1

Psoriatic Arthritis

Begin with NSAIDs and local glucocorticoid injections for oligoarthritis, then escalate to conventional DMARDs if ineffective, followed by biologic DMARDs (TNF inhibitors, IL-12/23 inhibitors like ustekinumab, or IL-17 inhibitors like secukinumab/ixekizumab) or targeted synthetic DMARDs for active disease with unfavorable prognostic factors. 1

Polymyalgia Rheumatica

Initiate glucocorticoids at 12.5-25 mg/day prednisone equivalent, then taper rapidly after initial response, with systemic glucocorticoids limited to ≤10 mg/day for no more than 6 months to avoid cumulative side effects. 1, 3

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Non-Pharmacological Management (All Rheumatological Conditions)

Implement a multidisciplinary approach including patient education, occupational therapy for joint protection techniques and assistive devices, and dynamic exercise programs incorporating both aerobic and progressive resistance training. 1, 3

Specific Interventions:

• Thermal modalities: Heat or cold application for pain relief 4, 5
• Assistive devices: Evaluate ability to perform ADLs and provide appropriate mobility aids 4
• Exercise programs: Regular low-to-moderate intensity exercise improves mobility and strength 4, 5
• Splinting/orthoses: Use for affected joints to maintain alignment and reduce strain 4, 5
• Cognitive behavioral therapy: For fatigue management and reducing sense of helplessness 1

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Monitoring and Follow-Up

Monitor disease activity using validated composite measures (DAS28, SDAI, or CDAI) at 1-3 month intervals during active disease, incorporating patient history, clinical parameters, laboratory tests, and imaging as indicated. 1, 3, 6

Imaging Considerations:

• Spinal radiographs: Should not be repeated more frequently than every 2 years unless clearly indicated in individual cases 1
• MRI and ultrasound: Play valid roles in early diagnosis and monitoring of structural damage 7

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Critical Pitfalls to Avoid

Drug-Related Cautions:

• Methotrexate contraindications: Avoid in pregnancy (Category X), nursing mothers, alcoholism, chronic liver disease, immunodeficiency syndromes, and blood dyscrasias 2
• NSAID risks: Carefully assess cardiovascular, gastrointestinal, and renal risks before prescribing; avoid in elderly patients with multiple comorbidities when possible 1, 4
• Prolonged glucocorticoid use: Do not exceed 6 months of systemic therapy due to cumulative side effects including osteoporosis, infection risk, and metabolic complications 1, 3
• Drug interactions: Monitor closely when combining methotrexate with NSAIDs, trimethoprim/sulfamethoxazole, or other hepatotoxic agents 2

Disease-Specific Warnings:

• Avoid electrotherapy (TENS) and chiropractic therapy in RA: Conditionally recommended against due to lack of efficacy evidence and potential cervical spine complications, respectively 5
• Biologic switching: In ankylosing spondylitis, switching to a second TNF blocker may be beneficial in patients with loss of response 1
• Surgical consultation: For acute vertebral fracture in ankylosing spondylitis, consult spinal surgeon immediately 1

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Special Populations

Elderly Patients:

Use caution with dose selection reflecting greater frequency of decreased hepatic/renal function and decreased folate stores; monitor closely for early signs of hepatic, bone marrow, and renal toxicity as bone marrow suppression, thrombocytopenia, and pneumonitis may increase with age. 2

COVID-19 Considerations:

Continue rheumatologic medications in most cases, but consider temporarily holding methotrexate or leflunomide in patients with active COVID-19 infection; maintain ACE inhibitors and ARBs as there is insufficient evidence of harm. 1