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Recent papers on rheumatology

Dr Louise Warburton looks at recent papers that have caught her eye

Dr Louise Warburton looks at recent papers that have caught her eye

How can I prescribe allopurinol more safely?

Paper: Suboptimal physician adherence to quality indicators for the management of gout and asymptomatic hyperuricaemia; results from the UK General Practice Research Database (GPRD). TT Mikuls et al.

Method: Despite its frequent use, it appears that allopurinol is often prescribed inappropriately. The following quality indicators of allopurinol prescribing were developed and used to measure the quality of prescribing in the UK GPRD:1 If a gout patient is receiving an initial prescription for allopurinol and has renal impairment (serum creatinine greater than or equal to 2mg/dl, or creatinine clearance of less than 50ml/min), then the initial daily dose of allopurinol should be less than 300mg.2 If there is concominant prescribing of allo-purinol with azathioprine or 6 mercaptopurine, the dose of azathioprine or 6-MP should be reduced by 50 per cent, to avoid toxicity.3 If a patient has asymptomatic hyperuricaemia (no previous history of gout or tophi and no renal disease, no ongoing malignancy), urate lowering therapies are not indicated.

Results: A total of 63,105 patients were studied and 185 fell under quality indicator 1, 52 were under indicator 2 and 471 were eligible for indicator 3.Using these indicators, 25-57 per cent of practices showed allopurinol prescribing errors.

Conclusion: One-quarter to one-half of all patients at risk of possible prescribing errors for allopurinol showed prescribing errors in their medication.

What I am going to do: Audit my practice's prescribing of allopurinol and check that I have no patients who are asymptomatic and never had acute gout who are taking allopurinol.

What is the best management of frozen shoulder?

Paper: Richard Dias et al. Clinical review: frozen shoulder. BMJ. 2005. Vol 331. 1453-1456 Method: This was an article written de novo and researched using references.

Results: Frozen shoulder is a true clinical entity and very different from other shoulder problems such as impingement. It tends to be self-limiting and is rare under the age of 40. It lasts about 30 months but recovery can be accelerated by simple measures. Physiotherapy alone is of little benefit. Steroid injection is beneficial and best combined with physiotherapy. Resistant cases can be referred for manipulation under anaesthetic and rarely arthroscopic release.Nearly all patients recover, but the normal range of movement may never return.

Conclusion: Injection plus physiotherapy has the best outcome.

What I am going to do: I will definitely inject every patient who has a painful shoulder and clinical signs of a frozen shoulder, and then refer on for physiotherapy, rather than do just one of the above.

Should I re-refer patients with chronic ankylosing spondylitis back to the rheumatology clinic?

Paper: N. Barkham et al. The unmet need for anti tumour necrosis factor therapy for ankylosing spondylitis (AS). Rheumatology 2005; 44: 1277-1281.

Method: Patients with AS in a Leeds outpatient department were identified over a four-year period.Their degree of disability was assessed using several scales such as the Bath Ankylosing Spondylitis disease Activity Index (BASDAI), by postal questionnaire. A total of 246 questionnaires were returned.

Results: Almost two-thirds of the patients would meet the criteria for anti-TNF therapy under recommended guidelines, but had not been prescribed them. Some 27 per cent of the group were on standard DMARDS.

Conclusion: There is a large unmet need for effective therapy in AS, with almost two-thirds of patients meeting the proposed criteria for biological therapy.

What I am going to do: I know of at least one patient in my practice with severe AS who was discharged from the local clinic a few years ago, because the feeling was little could be done for him. I will reassess and refer him back to the clinic for consideration of anti-TNF or at the very least, DMARDs.

Who is at risk of septic arthritis?

Paper: Septic arthritis as a late complication of carcinoma of the breast. Rheumatology 2005: 44: 1157-1160. V. Chanet et al.

Method: This paper looked to see if a past history of radiation therapy for carcinoma of the breast is a risk factor for septic arthritis. Records of 282 patients were retrospectively searched.

Results: Some 10 cases of septic arthritis had had previous radiotherapy, nine for carcinoma of the breast and six of these patients had septic arthritis of the shoulder, three had septic arthritis of the sternoclavicular joint. One case had had radiotherapy for carcinoma of the cervix, and presented with septic arthritis of the hip.These cases were compared to septic arthritis in patients who had not had radiotherapy.Those who had radiotherapy tended to have less fever and took longer to diagnose, sometimes despite X-ray changes.

Conclusion: Prior radiotherapy seems to be a risk factor for septic arthritis, and the presentation may be more subtle than normal.

What I am going to do: Be aware of this as a problem in women who have had radio-therapy for breast carcinoma (several in my practice).Be more cautious in the diagnosis of shoulder pain in these patients and about injecting steroids into the joint

.Louise Warburton is a GPSI in rheumatology and a GP in Coalbrookdale, Telford

Competing interests none declared

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