Therapeutic Guidelines - Rheumatology

Analgesics
- Paracetamol
- Nonsteroidal anti-inflammatory drugs
- Opioid analgesics
- Skeletal muscle relaxants
Corticosteroids
Disease-modifying and immune-modulating antirheumatic drugs
- Disease-modifying antirheumatic drugs (DMARDs)
  - Azathioprine
  - Cyclophosphamide
  - Cyclosporin
  - Gold (sodium aurothiomalate)
  - Hydroxychloroquine
  - Leflunomide
  - Methotrexate
  - Mycophenolate mofetil
  - Sulfasalazine
  - Other drugs
- Biological disease-modifying antirheumatic drugs (bDMARDs)
  - Tumour necrosis factor (TNF) inhibitors (adalimumab, etanercept and infliximab)
  - Anakinra
- Drugs in development
Drugs used for the treatment of gout
- Allopurinol
- Colchicine
- Uricosurics (probenecid and sulfinpyrazone)
- Newer drugs
  - Rasburicase (recombinant urate oxidase)
  - Febuxostat
Fish oil (omega-3 long chain polyunsaturated fatty acids)
Glucosamine and chondroitin in osteoarthritis
Vasoactive drugs
- Angiotensin converting enzyme inhibitors (ACEIs)
- Vasodilators
- Prostanoids
- Bosentan
Complementary and alternative medicine
- CAM use in osteoarthritis
- CAM use in rheumatoid arthritis
- Safety of CAM
- Sources of information

Management of chronic rheumatological diseases

Overview
- Aims of clinical management
- Factors influencing clinical care
- Multidisciplinary health care team
Chronic pain
- Principles of adjunctive treatment
- Nonpharmacological management
- Pharmacological management

Joint aspiration—key features

Synovial fluid examination and interpretation
- Macroscopic examination
- Microscopic examination
- Further aspects of interpretation of synovial fluid analysis
Contraindications

Recent-onset arthritis

Monoarthritis
Oligoarthritis
Polyarthritis

Rheumatoid arthritis

Background
Diagnosis
Prognosis
General approaches to management
Nonpharmacological management
Pharmacological management

Crystal deposition disease

Gout
Calcium pyrophosphate deposition disease (pseudogout)

Spondyloarthropathies, including psoriatic arthritis

Ankylosing spondylitis
Reactive arthritis
Enteropathic spondyloarthropathies
- Peripheral arthritis
- Sacroiliitis and spondylitis
Psoriatic arthritis

Osteoarthritis (degenerative joint disease)

Osteoarthritis of the knee
Osteoarthritis of the hip
Osteoarthritis of the hand

Assessment of spinal pain

‘Mechanical’ syndromes
Nonmechanical or ‘red flag’ entities
Are there associated neurological features?
Are there other contributors to distress?
Are investigations required?

Low back pain

Nonspecific low back pain
Symptomatic lumbar disc herniation
Symptomatic spinal canal stenosis
Exercises

Upper limb conditions

Shoulder region
- Rotator cuff disease
- Adhesive capsulitis (frozen shoulder)
Elbow region
- Lateral and medial epicondylitis (‘tennis elbow’ and ‘golfer’s elbow’)
Wrist and hand region
- De Quervain’s tenosynovitis
- Chronic wrist pain
  - Ligament injuries
  - Ganglia
  - Ischaemic necrosis
- Nerve entrapment syndromes
  - Carpal tunnel syndrome
- Trigger finger (flexor tenosynovitis)

Lower limb conditions

Hip and groin region
- Infants, children and adolescents
  - Perthes’ disease
  - Slipped capital femoral epiphysis
  - Irritable hip
  - Avulsion of anterior superior or inferior iliac spines and the ischial tuberosity
- Adults
  - Conditions causing hip or groin pain
  - Groin pain
  - Lateral hip pain
  - Exercises for increasing flexibility and strength of muscles in the hip region
Knee region
- Acute knee pain
  - Atraumatic cases
  - Cases associated with trauma
    - Acute ligament sprains, meniscal tears, collateral and cruciate ligament injuries
- Subacute and chronic knee pain
  - Problems associated with the extensor mechanism
    - Patellar tendonopathy
    - Patellofemoral pain syndrome and chondromalacia patellae
  - Fat pad syndrome
  - Osgood-Schlatter’s disease
  - Lateral knee pain
  - Iliotibial band syndrome
  - Conditions presenting with knee pain and localised swelling
    - Baker’s cyst
    - Semimembranosus bursitis
    - Pre-patellar bursitis
    - Meniscal cysts
Lower leg region
- Deep vein thrombosis
- Ruptured popliteal (Baker’s) cyst
- Musculotendinous injuries
  - Calf strain
  - Pes anserinus bursitis/tendonopathy
- Acute compartment syndrome
- Chronic exertional compartment syndrome
- Stress fracture
- Medial tibial stress syndrome
Ankle region
- Tibiofibular syndesmosis injury
- Achilles tendonitis
- Rupture of the Achilles tendon
- Tibialis posterior tendon dysfunction
Hindfoot region
- Plantar fasciitis
- Fat pad syndrome
- Sever’s disease
Forefoot region
- Stress fractures
- Chronic metatarsophalangeal pain (metatarsalgia)
- Morton’s neuroma
- Freiberg’s osteochondrosis
Footwear

Fibromyalgia

What is fibromyalgia?
History taking
Physical examination
Management
When to refer to a specialist

Approach to musculoskeletal disease in children and adolescents

History
Examination
Investigation

Children and adolescents

Juvenile idiopathic arthritis
- Pauciarticular-onset arthritis
- Seronegative polyarticular arthritis
- Seropositive polyarticular arthritis
- Systemic-onset arthritis
- Enthesitis-related arthritis (ERA)
- Psoriatic juvenile arthritis
Connective tissue diseases
- Vasculitis
  - Henoch-Schönlein purpura
  - Kawasaki disease
- Other connective tissue disorders
  - Juvenile dermatomyositis
  - Systemic lupus erythematosus (SLE)
  - Scleroderma
Periodic fever syndromes
- Familial Mediterranean fever
- Hyperimmunoglobulin D syndrome
- Tumour necrosis factor receptor–associated periodic syndrome
Rheumatic fever

Musculoskeletal conditions in pregnancy

Lumbar back pain
Pelvic pain
Transient osteoporosis of pregnancy
De Quervain’s tenosynovitis
Carpal tunnel syndrome
Leg cramps
Use of antirheumatic drugs in pregnancy
Use of antirheumatic drugs in breastfeeding

Connective tissue disease

Clinical and laboratory features relevant to all connective tissue disease
Sjögren’s syndrome
Systemic lupus erythematosus
Scleroderma
- Skin fibrosis
- Raynaud’s phenomenon
- Digital calcinosis
- Digital ulceration
- Oesophageal dysmotility
- Small bowel involvement
- Large bowel involvement
- Pulmonary fibrosis
- Pulmonary arterial hypertension
- Hypertension and scleroderma renal crisis
Mixed connective tissue disease and overlap syndromes