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Recent papers on rhuematology

GP Dr Louise Warburton reviews interesting papers on rheumatology with clinical implications for primary care

GP Dr Louise Warburton reviews interesting papers on rheumatology with clinical implications for primary care

Have treatments for patients with rheumatoid arthritis really improved in recent years?

The paper Treatment of rheumatoid arthritis. BMJ 2006; 332:152-5

Review In this interesting article, Paul Emery reviews the current treatments for rheumatoid arthritis (RA) and comments on how management has changed in the 10 years. He uses a review of the literature, Medline and personal archives.

Discussion He comments that treatments have improved hugely with the introduction of anti-TNF drugs. For a group of patients not responding to methotrexate, the addition of infliximab virtually halted progression of the disease.

The most exciting part of the discussion is about early diagnosis. A new marker for RA has been discovered and is being used in many rheumatology departments. It is called anticyclic citrullinated peptide (anti-CCP). Levels of anti-CCP are raised as much as 10 years before symptoms of arthritis develop. Anti-CCP is a strong predictor of persistence in inflammatory arthritis. Also, such patients can have minor levels of joint inflammation for up to 10 years before their disease begins.

Conclusion It should be possible to screen for a disease that is becoming virtually treatable. The future outlook for patients with RA should be vastly different from what it was a few years ago. For patients presenting with newly diagnosed arthritis, there is now the potential for virtual cure.

GPs need to appreciate the unique opportunity of making a long-term difference to patients presenting with inflammatory arthritis and hence the need for timely referral.

What I will do now I now appreciate the importance of early referral for patients in whom there is a suspicion of inflammatory arthritis. My local rheumatology unit does not yet have access to anti-CCP, so I will lobby my consultant and biochemistry laboratory to provide this important service.

Is joint injection more effective than physiotherapy or a wait-and-see approach in managing patients with tennis elbow?

The papers Mobilisation with movement and exercise, corticosteroid injection or wait and see for tennis elbow. BMJ 2006 Nov 4;333(7,575):939-44. Editorial Tennis elbow in primary care. BMJ 2006: Nov 4;333(7,575):927-8

Method A randomised controlled trial involving 198 participants aged 18 to 65 with a clinical diagnosis of tennis elbow of a minimum six weeks' duration, who had not received any other active treatment by a health practitioner in the previous six months. Interventions included eight sessions of physiotherapy, steroid injections or wait and see.

Results This study confirms the short-term benefit of steroid injections at six weeks, as opposed to a wait-and-see approach. However, physiotherapy treatment is superior to injection at 12 weeks and continuing on to a year after diagnosis. In fact, injections fared worse than a wait-and-see approach at 12 weeks and one year.

Conclusion Tennis elbow is very common, occurring in four to seven per 1,000 patients per year. Recurrence is common. It seems injections are not the way forward for long-term relief.What I will do now Some GPs are trigger happy with the use of joint and soft tissue injections. We are all keen to use a new skill once it has been acquired and patients are impressed by the quick, short and sharp treatment option of an injection. However, this paper demonstrates that it may not be the best management in the long term for tennis elbow.

Those of us who work as GPSIs in musculoskeletal clinics will have realised this. For conditions such as tennis elbow and plantar fasciitis, there is usually an associated biomechanical problem underlying the condition. Until this is addressed, for example with insoles for plantar fasciitis, the condition will recur. The difficulty with tennis elbow is knowing what this intervention is. Physiotherapists obviously have the expertise. Physiotherapy appears to be superior to injection.If resources allow, I will refer my patients with tennis elbow for physiotherapy. If they don't allow, then I will wait and see.

Do patients respond better to face-to-face interventions than being given literature alone?

The paper Self-management of arthritis in primary care: randomised controlled trial. BMJ. 2006 Oct 28:333(7574):879-83

Method In this randomised controlled trial in general practice, 812 patients were recruited from 74 practices in the UK. Patients were randomised to a six-session course of education in the self-management of osteo-arthritis of the hips and knees. An educational booklet was provided, with information from the Arthritis Research Campaign. The control group received the booklet alone.

Results No significant improvement in the pain or functional capacity was found between the groups. However, improved self-efficacy and reduced anxiety scores were demonstrated in the group given the educational course.

Follow-up consultations with GPs were not reduced, although this may be because the intervention encouraged patients to seek advice from their GP.

Conclusion This paper reinforces what we all probably knew; that patients respond better to face-to-face interventions than to being given literature alone.What I will do now In future I will spend more time explaining the nature of osteoarthritis to patients and, where resources allow, refer them to physiotherapy or occupational therapy where they will get both treatment and education.

Are rheumatologists' treatment decisions influenced by the patient's age?

The paper Are rheumatologists' treatment decisions influenced by patients' age? Rheumatology 2006;45:1555-7

Method A random sample of rheumatologists working in the US were sent a questionnaire describing a hypothetical patient with rheumatoid arthritis.

Two cases were used, which differed only in the age of the patient. The consultants were offered the choice of adding a new disease-modifying agent (DMARD) to the current regimen, switching DMARD or increasing the dose of prednisolone.

Results The results showed that rheumatologists preferred using the aggressive DMARD regimens in younger patients and in the older patient were most likely to choose an increase in the dose of prednisolone. The age bias was stronger in male physicians.

Conclusions Age bias is a well-known problem in medicine in fields such as cardiology and oncology. It has not been demonstrated in rheumatology until now.What I will do now As GPs, we do see older people presenting with a new-onset inflammatory arthritis. Obviously, as the disease is more common in patients in their 30s and 40s, this is not a usual scenario.

I know that I am guilty of not referring these patients to a rheumatologist as quickly as a younger patient. I may try to manage them longer in primary care with NSAIDs or COX-2 inhibitors. It seems that rheumatologists are guilty of the same bias.People's life expectancies are increasing, as are their number of co-morbidities. We should try to manage all new-onset diseases actively and this will improve people's quality of life as they get older.

Dr Louise Warburton is a GP in Shropshire and a GPSI in musculoskeletal medicine

Competing interests None declared

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