1.Understanding antibodies: Rheumatoid factor & CCP
Rheumatoid arthritis is a clinical diagnosis.
Rheumatoid factor and CCP/ACPA are important, but should be avoided as screening tests.
A negative result does not exclude rheumatoid arthritis, nor does a positive result equate to a diagnosis of rheumatoid arthritis.
Patients with suspected inflammatory arthritis should be referred to Rheumatology without delay.
2.Understanding antibodies: ANA and ENAs
Testing ANA and ENAs should be reserved for patients suspected to have a diagnosis of a connective tissue disease, e.g. lupus.
Testing ANA and ENAs should be avoided in the investigation of widespread pain or fatigue alone.
The immunology lab at LTHTR now undertake a CTD screen, if this is positive then they will do more specific antibody testing. This does mean that you can get more antibody results than you’d bargained for which can then be difficult to interpret. If you’re not sure you can interpret the results then avoid ticking the box. These tests can be costly.
Antibodies are not always of clinical significance and there can be cross-reactivity between antibodies, consider if patients have another autoimmune disease.
We are always happy to discuss results and provide advice and guidance.
3.Vitamin D Testing
Everyone should consider Vitamin D supplementation during winter.
People who have restricted access to sunlight (e.g. those living in institutions or who cover their skin), or have dark skin, should consider supplementation all year round.
Vitamin D testing should be reserved for people at high risk from deficiency and avoided as part of routine investigation.
Repeat testing is not normally indicated in those taking supplements.
Vitamin D testing can be costly (£24 per test).
In most cases patients should be advised to take “over the counter” supplements.
Reconsider the diagnosis if patient <50 yrs.
Typically, the onset is abrupt and the classical presentation is proximal muscle pain and stiffness affecting the shoulder girdle muscles.
Always check both ESR and CRP before starting steroids and observe the trend.
If PMR is suspected and a trial of steroids is being considered, a dose of 15-20mg should be sufficient.
Steroids then need to be gradually tapered, e.g. 15mg daily for 3 weeks, 12.5mg daily for 3 weeks, 10mg daily for 4-6 weeks and then reduce by 1mg increments each 4-8 weeks. Patients will be on treatment for 1-2 yrs.
If patient flares on reducing steroids always check ESR/CRP to help confirm if it is a flare. Increase back to the last dose of steroid which controlled symptoms.
PMR can be managed in primary care but we are always happy to provide advice.
Patients to refer to rheumatology:
- Atypical presentation
- Systemic symptoms
- Very high inflammatory markers
- Normal inflammatory markers
- Difficulty reducing steroids
Consider prophylactic treatment if >2 attacks in 12 month period.
If starting prophylactic treatment with allopurinol or febuxostat advise pre-medicating with colchicine 500 microgram BD or NSAID for 2 weeks.
Repeat urate after 2-4 weeks after starting allopurinol or febuxostat and increase dose until urate <300.
Colchicine is continued for 6 months alongside allopurinol or febuxostat
Manage expectations as patients can still experience attacks of gout for up to a year after adequately suppressing urate.
Don’t forget lifestyle advice: foods to avoid, keeping hydrated, reducing alcohol intake.
Consider investigations for secondary causes of osteoporosis eg bone profile, TFTs, coeliac screen, immunoglobulins
Consider repeating DXA and a bisphosphonate treatment holiday after 5 years of adherent oral bisphosphonate treatment, unless the patient remains at high risk of fracture, for example:
- post treatment T-score ≤ -2.5 with history of fragility fractures.
- history of hip, vertebral or multiple fragility fractures.
- continuing oral glucocorticoid therapy of ≥7.5mg/day prednisolone or equivalent
- frailty, frequent falls and/or age ≥75.
- If at continued high risk of fracture, consider and a bisphosphonate treatment holiday after a total of 10 years of adherent oral bisphosphonate treatment.
During a treatment holiday ensure calcium and vitamin D intake is sufficient and reassess future fracture risk/need for treatment if there is a new fracture or after 2-3 years (e.g. repeat DXA) if there is no new fracture.
Patients to consider referring to rheumatology:
- Diagnostic difficulty.
- Have a contraindication or are intolerant to oral bisphosphonates (consider the option of effervescent alendronic acid).
- Further fracture while on therapy (a single fragility fracture within the first 2 years of bisphosphonate treatment does not constitute treatment failure).
- Severe osteoporosis which may require specialist osteoporosis treatments e.g. teriparatide.
- Other metabolic bone diseases such as osteomalacia or Paget's disease.
- Confirmed osteoporosis or low trauma fractures in men.
Advice & Guidance (this section is work in progress)
Information about how to access Advice & Guidance service
What is appropriate for Advice & Guidance
- Advice about initial management of common conditions which can be managed in primary care eg PMR, gout, osteoporosis
- Advice about interpretation of antibody results