7 responses to “Five clinical points on Rheumatoid Arthritis in Family Practice”

  1. This is very helpful! I am hoping you can clarify 3 points:
    1) The BC Clinical Guideline of 2012 says that family physicians cannot order anti-CCP (if MSP is to cover it). Has that changed since 2012?
    2) If we suspect RA and are going to start a pt on medication prior to their seeing a rheumatologist, is it better to start with methotrexate (barring contraindications) or hydroxychloroquine? From what you’re saying, methotrexate is the initial agent of choice, but the BCCG suggests that until the dx has been confirmed (or you’re “confident”), you should start the pt on hydroxychloroquine.
    3) Although long-term prednisone has deleterious effects, does it have any beneficial long-term effects to use prednisone in the initial tx if sx are severe, perhaps by knocking the disease into remission more effectively?
    Thank you!!

  2. EXCELLENT summary!!

  3. Thanks for your questions. Below are the answers:

    1) I don’t know if it has changed – I suspect not. It is not a very expensive test – I think it is $26.00. Given the importance of not missing early RA, it is a good test to get in patients who have swollen joints – particularly wrists, MCPs, elbows, MTPs. I think it should be covered in areas that do not have access to rheumatology.

    2) BCCG guidelines are reasonable. Simply starting the pt on HCQ is a good idea and something that most primary care docs would be comfortable doing. Of course getting an urgent rheum consult within four weeks is reasonable. If the GP is comfortable starting MTX, then it is the preferred treatment. It really depends how comfortable the GP is making the diagnosis of RA and how familiar he/she is in MTX initial evaluation, patient counselling and monitoring. Most GPs that I know would prefer not to start MTX on their own.

    3) We are all pretty much in agreement that long term prednisone has no good effects.
    However, a short course of prednisone in the 1st six weeks is something that about half of us will do in addition to MTX or combination DMARD therapy. However this should never be done BEFORE making a diagnosis or BEFORE starting DMARD therapy such as MTX. My worry is that the patient will feel better and not be started on MTX and thus may miss the window of opportunity of early DMARD therapy.

  4. Is there any benefit to doing anti-CCP if the RF is positive in someone with early suggestive symptoms?

  5. Another reason to discourage smoking. In the past I have started hydroxychloroquine pending the specialist assessment. Methotrexate sounds like the way to go moving forward.

  6. Dear Dr Shojania,

    Would the same points also apply to ankylosing spondylitis patients?

    In particular:
    -should all AS patients should be on biologics (DMARDS)?
    -NSAIDS do not change outcomes?

    Thank you.

  7. No, this is different in patient with AS. NSAIDS play a more integral role in management of patients with AS, especially in terms of symptom control.
    There is evidence that daily NSAIDS in Ankylosing Spondylitis might reduce syndesmophyte progression in patients with elevated CRP. Therefore, use of daily NSAIDs and their pros and cons should be discussed with the patients.
    Biologic use in AS is mainly targeted at treatment of symptoms. Currently, there is little evidence that it may reduce progression of ankylosing.

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