By Kristi V. Mizelle, MD
Primary care physicians encounter rheumatic disease in their day-to-day practice. There is an increasing prevalence of rheumatic disorders, including osteoarthritis, gout, rheumatoid arthritis, and more. Prevention, detection, diagnosis, and treatment of these conditions begin with primary care physicians.
1) Test for ANA sub-serologies ONLY after a positive ANA and clinical suspicion of immune-mediated disease.
According to the American College of Rheumatology (ACR), antinuclear antibody (ANA) sub-serologies often test negative if the initial ANA test is negative. Some laboratories offer “arthritis panels,” which complete multiple tests, including ANA and ANA sub-serologies. These panels can result in extraneous testing and false-positive results. Avoid broad panel testing and consider specific diseases to guide testing.
2) Only test for Lyme Disease as a cause for musculoskeletal symptoms if there’s an exposure history and appropriate exam findings.
Avoid testing in patients with a low pre-test probability of Lyme disease, as this could result in more false-positive tests. For example, don’t perform serologic testing for Lyme disease to screen asymptomatic patients who live in endemic areas or evaluate patients who present only with nonspecific symptoms. Do not consider diffuse arthralgias, myalgias, or fibromyalgia alone as criteria for musculoskeletal Lyme disease.
3) Manage osteoarthritis using both medicinal and non-medicinal therapies.
Exercise is recommended for hand, knee, and hip osteoarthritis management. Examples include aerobic movement like walking and biking, isokinetic weight lifting/resistance exercises, and aquatic exercise. Lifestyle changes like exercise can be some of the hardest to make but can be very rewarding through increased strength, balance, weight loss, and more. The ACR also recommends non-steroidal anti-inflammatory drugs (NSAIDs) across all three types of osteoarthritis. NSAIDs can be helpful, but use caution to monitor for potential side effects like gastritis or kidney injury.
4) Use urate-lowering medications to treat gout.
The updated ACR guidelines for the treatment of gout in 2020 included several recommendations. Initiate treatment for gout in several populations, including patients with at least one pouty tophus (collection of gout crystals), patients with frequent gout flares at least twice annually, or patients who have damage from gout on x-rays. Allopurinol is the first-line treatment for gout over all other therapies. Use a treat-to-target strategy to achieve a serum urate target of less than six mg/dl. These three strategies ensure patients aren’t under-treated for gout.
5) Taking a good history helps determine if a patient has mechanical or inflammatory back pain.
Communicating with your patient to collect a thorough history can be crucial in distinguishing mechanical versus inflammatory back pain. Causes of mechanical back pain include degenerative disc/joint disease and causes of inflammatory back pain include psoriatic arthritis and other types of axial spondyloarthritis. The mnemonic IPAINcan help to recall key components of inflammatory back pain.
• Insidious onset
• Pain at night (with improvement upon getting up)
• Age at onset (< 40 years)
• Improvement with exercise
• No improvement with rest
Refer patients with these inflammatory symptoms to a rheumatologist for further diagnosis and care. Currently, on average, it takes eight to ten years for patients in this disease category to receive a diagnosis. Recognizing Inflammatory back pain could shorten the time between symptom onset and diagnosis.
Primary care physicians will undoubtedly encounter those with rheumatic disorders during their day-to-day practice. Keep these strategies in mind to better serve patients.
Sources
1. https://www.choosingwisely.org/societies/american-college-of-radiology/
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4740967/
3. https://www.jrheum.org/content/37/9/1978
4. https://www.aafp.org/afp/2012/0601/p1086.html
5. https://www.rheumatology.org/Portals/0/Files/Gout-Guideline-Early-View-2020.pdf
6. https://pubmed.ncbi.nlm.nih.gov/31908149/
Kristi V. Mizelle, MD, MPH, FACR is a TPMG Board certified rheumatologist and internal medicine physician who is currently accepting new patients by physician referral. mytpmg.com
