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The waiting game

Non-Covid clinical crises: New inflammatory arthritis or flare up of existing

Pulse’s series on how to manage non-Covid subacute problems when you’re out of your comfort zone and there’s minimal help available

Autoimmune rheumatic diseases include rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), connective tissue diseases (CTDs) and Vasculitis.

For any patients with a known inflammatory arthritis (RA, PsA, CTD) established on a DMARD (and not on steroids) who are suffering with a flare up of their disease, a short course of low dose steroids is advisable such as prednisolone 15mg for 1 week, reducing by 5mg every week with aim of cessation. Flare-ups in patients already on prednisolone should increase to the previous lowest tolerated effective dose and then reduce as per previously agreed regime. A flare up typically constitutes an increased level of inflammatory-type joint pain, with increased early morning stiffness and joint swelling.

New cases of suspected inflammatory arthritides, fulfilling the criteria for local early inflammatory arthritis referral pathways, are best dealt with on a case-by-case discussion with the on-call Rheumatologist as services vary nationally. Some centres have advocated the use of video platforms for these new virtual clinics.

Consider giant cell arteritis (GCA) where a patient presents with insidious onset of temporal headache, is over the age of 50 and has raised inflammatory markers. (See dedicated article for more on this).

DMARDs to stop/avoid during active infection include Methotrexate, Leflunomide, Mycophenolate mofetil/Myfortic, Azathioprine and biologic agents. They can be restarted once the symptoms/signs of an infection have resolved. Medications to continue are prednisolone, Hydroxychloroquine and Sulphasalazine.

Patients on DMARDs with shared care agreements in place can have some flexibility around the frequency of blood monitoring at this time. An example would be having up to six monthly bloods for those with stable results who have been on Methotrexate, Mycophenolate mofetil, Leflunomide or Azathioprine for over 6 months. Those patients who are on Hydroxychloroquine do not need regular blood tests nor do those who have been on Sulphasalazine for 2 years or more.

New cases of suspected CTDs and/or vasculitis should be discussed with the on call Rheumatologist as well as cases of flare-ups.

Further advice is available on https://www.rheumatology.org.uk/News-Policy/Details/Covid19-Coronavirus-update-members.

Dr Shireen Shaffu is a consultant rheumatologist at the University Hospitals of Leicester NHS trust and has a special interest in connective tissue diseases and vasculitis. Dr Rebecca Neame is a consultant rheumatologist at University Hospitals Leicester NHS Trust

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