Approach to Rheumatology

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Thank you.

The rheumatologists tend to think that we're the we're sort of pure

Okay, that's excellent. Look let's start off by saying look how would you go about classifying rheumatological conditions? Uh how do you think about your classification system for when you think about rheumatological or inflammatory conditions?

I'm sorry to are really trying to do that.

Really?

And that can usually be done on on history um and examination, but particularly on history. So really any Worse we have. So then once we've decided that something Then there's really rheumatoid arthritis, spondyl arthritis, the inflammatory connective tissue diseases like lupus, crystal arthritis, and viral arthritis. The medical students. So again, I think that's a good thing.

Yeah. So the the term seronegative can be a bit ambiguous

And then into the spondyl arthritis category. And spondylloarthritis is a really good umbrella term and that encompasses several Mechanistically and clinically they're probably pretty simple. So th th

So if we use that

So it's just those three main categories then really. So the rheumatoid arthritis is the main group just pu purely with a rheumatoid condition. Then you're a spondyl arthritis and you got your your gout your gut crystal ones which include gout and uh pseudo.

Yep. And then you've got your connective tissue diseases and that o that of course incorporates lots of different diseases, lupus, split.

And they and while they often present with with arthritis, they the the clue to diet.

And what's the overall incidence of uh with these sort of conditions? I mean, obviously the rheumatoid one's the most common one, is it, or is it a connected tissue one more common? And overall, what's the incidence?

So rheumatoid. a relatively common uh disease. Uh this if you lump all common. Reactive arthritis less so and enteropathic arthritis less so. So on

Particularly in this country with uh with our ethnic mix are much less common. Um, Probably about

So wh which group is lupus more common in then? Is it more the Europeans, is it or?

It's most common really in all of the

of year um on average in in people who are non Caucasian. So Here we go. But it it's the autoimmune connected tissue diseases are fascinating.

What other associations are there? I mean obviously female is more common in rheumatoid, I believe itself, isn't it?

Yeah, in general. And we're not entirely sure why that's the case. There's lots of uh lots of

But certainly women seem to be more frequently affected than men for most of these diseases.

It's worth remembering that both genders can be affected with any of these diseases. So we we never rule out a diagram.

And the uh it's also a poor prognostic factor for many of our diseases. So we we know, for example, in rheumatoid arthritis and also in ankylosing spondylitis that if you stop smoking

Um, whereas persistent smoking is associated with a poorer uh treatment outcome overall. And is the is the pathology different between the different conditions? I mean the actual joint destruction and an antenosinovitis that occurs, or is it actually similar pathology that develops?

No, I think we're still. the inflammation.

multiple joints associated with um and persistent uncontrolled.

clinical features so there are there are entheses all around the joints so inflammation in the entheses will often spread into the joints so that gives you your your arthritis but we also

They're all common features of spondyl arthritis. Um structure inside the anterior chamber of the eye and that gets inflamed as well.

in the office.

same drugs in the hope that they would work. And often they did. But what we're seeing now that we've got more targeted therapies is that the effectiveness

Excellent. Uh that probably segues into how a patient may present. Yeah. introduces the idea of how a student might see a patient if they're seeing s someone in exam, how would they actually s how would they present for say a rheumatoid one conversus nakolosing spondylitis versus gap What sort of different presentations do you think Exhibit.

Clues on his own. through these diverse presentations. And so it will often be someone who presents with some So the algorithm Where peripheries. Symmetrical or asymmetrical? Immediately. Clearly.

It's worth thinking about the pattern of onset of the symptoms, so acute versus subacute versus chronic, and then whether or not it's uh the pattern.

So for uh for rheumatoid arthritis.

But in the very early stages it can it can look very similar to viral arthritis. So we often ask w we often expect the students to have thought about risk factors for viral disease like parvovirus, which we tend to catch from kids. Our pulses, uh, rain oats phenomena, uh, and the like. Um, and then for crystalline.

Um uh and so on. So um having

And if you can sort of h stick to that algorithm then then usually what you end up doing is narrowing down in the end to really

So basically if you can predict that it's an inflammatory arthropathy, you've got those three main rheumatological spondyl arthro spondyl artropathies and also the Um otherwise the non inflammatory ones include osteoarthritis or a something like fibromyalgia type condition or a viral dynamic. Is that the main main overall headings and things?

So the viral arthritis will often present in an inflammatory way that's really indistinguishable from rheumatoid.

Um but yeah you're right.

So the the main w c concern I would have if I if I was a medical student coming up with the exam would be seeing a patient with monoarticular inflammatory arthropathy and trying to work out whether that's what the diagnosis is or whether it's actually

a a a monoarthritis it would be the duration of symptoms. So And so this is where we really teach the students that uh any anyway. practice but also for uh for exam uh situations. So uh you know a mo a monoarthritis you have to be thinking about infection uh until proven otherwise an important

So the the uh rheumatological monoarticular inflammatory arthropathy is is not quite as common as a uh crystal deposition or a uh infection or We'll be right back. I'd like to let you know that Aussie MedEd is sponsored by Heidi Health, who provide Heidi AI transcription platform. The team at Heidi have told me that Heidi is the AI scribe built in Australia and trusted in nearly two million consults every week.

The more the more

I think you've answered the questions you'd ask on the history and you've basically gone through the examination. Are there anything important uh other things we have missed out on the examination you might look? before we move on to investment.

The examination's really important um and I I I mean I don't there's probably no Certainly a lot of people. Of uh

The much more important thing is that people just remember to examine the joints. And this is really important in in sort of general in the emergency department that when people present with any The way that it's done um you know similar but also slightly

That's all really valuable to give people confidence to actually look at the joints. Um and you know, in the inpatient setting in hospital, in the general medical ward rounds, to actually pull

What about what about investigations in my order then? What are the ones you take?

So the the best way to use There's often a temptation just to do every to do this sort of mythical thing called the rheumatic screen and that usually just involves people writing down every antibody uh They're most useful when you've when you've developed a coherent

If you think someone's got uh a high likelihood of having rheumatoid arthritis, then really you Helpful particularly. Either rule in nor rule out any of these diagnoses. We really advocate for people to use the other antibodies, particularly.

a little bit more sparingly. So if you really antibody and use that alone because it's a very sensitive test. And then to use other

And that uh and that kind of rule.

which are important diseases but super rare diseases. And so there's there's always

I suppose you use ultrasound and x-ray a fair bit uh to help you diagnose uh joint distraction or cyanovitis as well, do you? Or is that less commonly

So we uh I I personally I probably use investigat image

They really only show um disease damage and that takes quite a lot of time to accrue. So in someone who's only had symptoms for a few weeks or months, um you can understand the popularity of it. It's it's accessible

for the most part. Um and it can

So it's really a trick. Unfortunately though it doesn't matter. Yeah. Probably the image. We used to really be constrained just to use plain x rays and and um it takes many years Really clear.

Thank you.

Excellent. And now we've probably progressed to the treatment. Uh what uh what are the main uh category of drugs you'd use? Well how do you divide the other ones into different?

So we've got um so this is where the we've seen

Similarly, we've had we've had uh cortisone since uh the late nineteen forties and that uh we um it's hard to imagine And we've had disease modifying drugs. But it was really

And that was how things stayed for about twenty years, but now we've really got three classes of uh disease modifying drugs. So we've got

uh IL six, I L seventeen, I L twenty three, um and various other molecular targets. These are interleukins, they c interleukans and ILs. Yep. Yep. We'll be right back.

Um and then even more than that.

We've suddenly got all these different classes of medications, so the conventional synthetic demands, targeted synthetic demodes, and the biological demodes. Rumors were that's right.

And what what ones of those would do you think the G the sorry, the G P and the medical student would need to know? I mean which ones uh They obviously would need to know all these biologics and there's probably special indications for them. It's probably gonna get special approval. What would be the main ones to know? They're obviously the anti info the non steroidals, the steroids, and then the more basic

I think for a medical student

Methotrexate in particular. Um that that's so we referred in rheumatism So um having a it's probably

used and what its potential um toxicities are.

important thing to that everyone who

it can be a very toxic drug. So everyone needs to to know that. And the other tip for students

I think knowing

Thank you.

sufficient although it's important to to know a little bit about them.

that they are fairly potent uh immune modulators and so the um infection is all

And any of those need to be stopped during s or prior to surgery? Obviously they increase the risk of infection. Are there any others that have any other side effects from whilst undergoing an anaesthetic or general anas general procedure? Yeah, that's a really good question.

It's pretty stripe. So the conventional V Mark. It looks like if uh patients who continue their methotrexate or sulfur salazine oramamide in the all the way

Actually have I

We now advocate that they just continue through uh with with no change. Well probably probably reduces the inflammation around the joint when they're having surgery, or something.

uh for the most part. So so that's a really useful thing to know.

we would minimize.

Seems to be the best way to go. But the situation's different for the biologic and targeted synthetic DMARS. So we essentially we

So the biologics are for the most part given by subcutaneous injection. Some of them are intravenous. And they're given at different doses. a drugs. So for example Golimimab is a TNF inhibitor that's given once a month.

do without having that injection and that's that appears to reduce the risk of infection and then you can restart the the the biologic. Um usually a couple

Excellent. Well I think look, I think we've covered a lot today and uh there's also so many other questions I would normally would like to go through, but um maybe I might better convince you another time to come back on. But this has been brilliant. Excellent, excellent. Certainly I was hoping to discuss fibromyalgia but I think there's another topic on its own, so

The information provided to you today is designed to complement the information provided to you in your local region and should supplement your readings and teachings in that area. Please don't take it as the only way of treating this condition or assessing a condition, but really as one of various ways of assessing.

Well thanks once again for listening to our podcast, Ozzy Medet with the Australian Medical Education. Really enjoy hosting this podcast. I hope you find it useful to give a pragmatic approach to everyday conditions. If you have any questions or information you want to ask about us

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