Lumpy Rheumatoid

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By Dr Irwin Lim, Rheumatologist

photo 1

It’s been a while since I’ve seen these many lumps on a rheumatoid arthritis (RA) patient.

He’s had not-so-well controlled RA for decades and just presented from St Elsewhere.

These lumps are rheumatoid nodules. There are firm and felt under the skin, usually close to joints, and often close to areas which get exposed to trauma for example the hands, knuckles, and elbows.

Often you can move the nodules but sometimes, the nodules are firmly connected to the tissues under the skin.

photo 4

Rheumatoid nodules can also be found in areas distant from joints – the lungs, heart and other internal organs.

They can range in size, think a pea to a walnut. They can be painless but some people find them uncomfortable and irritating, particularly if they get bumped a lot.

photo 3

Rheumatoid nodules are thought to be present in up to 20%-30% of RA patients, and are thought to be associated with more severe disease. Most patient with rheumatoid nodules have a positive rheumatoid factor (RF).

Smoking is thought to increase nodules. Methotrexate use has uncommonly been linked to increased development of rheumatoid nodules.

I don’t get to see these very often nowadays, certainly not in 20-30% of my RA patients. Maybe it’s because I get to see patients relatively early in their disease course or our treatments are more effective. I don’t know.

Happy to hear what you guys think.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
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How does Ankylosing Spondylitis affect your sleep?

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Image courtesy of graur codrin/ FreeDigitalPhotos.net

Image courtesy of graur codrin/ FreeDigitalPhotos.net

 

By Dr Irwin Lim, Rheumatologist

This post is a special request from Barry, a regular contributor.

Barry is happy for me to share with you that he has spondyloarthritis (SpA), with both Ankylosing Spondylitis (AS) and Crohn’s disease.

He’s on TNF-inhibitor therapy (Cimzia) as well as an anti-inflammatory medication to help his problems, including a number of other medications.

Barry’s major issue is sleep disturbance and he’s allowed me to quote him:

“The night sweats occur for a few day period once every month or so. I wake up in constant thirst from sweating, and with chills. It occurs during about half of my flare ups. None of my doctors have a good explanation as to the cause, or advice about dealing with night sweats.

The topic I wanted to address is more broad than night sweats. During “good periods” (a very relative term), I wake up 3 or 4 times a night, due to stiffness. During severe flares, I wake maybe 10 – 15 times a night. (I bet many of your patients experience this to some degree. It SHOULD be addressed on your patient survey.)

This level of sleep interruption greatly effects my physical and mental health. It’s depressing. It aggravates all of my conditions, more than any other single factor.

Apart from the flare ups, there are other night time issues. How do you get yourself comfortable to sleep? As mentioned before, I cannot sleep on my front or back due to my spine. I position pillows in front and behind me to keep on my side. But sometimes I have significant hip pain. This is a dilemma.”

I imagine some portion of your patients experience this to some degree. I’m curious what nighttime issues they face and how they deal with them. Do they have advice for my issues? This has potential to be a very beneficial topic for your followers. And you might learn a bit about what difficulties your patients face. I can’t be the only one with these issues, right?”

As a rheumatologist, I know that my SpA patients can be sleep-disturbed, and I do ask some rudimentary questions about this. If patients have night sweats, I would typically worry about:

a) Infection
b) Blood disorders/malignancy
c) Very active, poorly controlled inflammatory/autoimmune disease

I don’t know Barry’s history in any significant detail. I of course don’t want to be providing personalised advice on social media as it would not be appropriate. Barry understands this. But he would like general help from readers of this blog.

He tells me he has great doctors who he has faith in, and I am sure they’ve already excluded any nasties. He’s from the USA, so it’s likely that he has been thoroughly investigated rather than under-investigated.

In addition, the recurrent and long term nature of these nocturnal symptoms would suggest that they are part of his “regular” medical issues.

AS/SpA can of course cause significant stiffness and discomfort at night. My experience is that this improves a lot once the disease is controlled with NSAIDs and/or TNF inhibitor therapy (when effective).

But do these problems continue even when your rheumatologist tells you the disease is under control? And, what about the night sweats?

Barry, and I, would love to hear your experiences.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
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Improving how I introduce myself as a rheumatologist

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By Dr Irwin Lim, Rheumatologist

33 members of our BJC Health team just completed a tiring weekend learning about HealthChange Methodology.

Our physiotherapists, exercise therapists, massage therapists, dieticians, rheumatology care coordinator, admin & reception staff, and our rheumatologists all together. Confronted by information and tools to help us improve our ability to help our clients/patients change behaviour.

The truth is compliance in healthcare is poor. I’m not sure what the best available stats are but I have an inkling that compliance with taking medication is probably around the 50% mark. I’d imagine compliance with exercise prescription and dietary changes are likely to be lower. Follow through with smoking cessation advice is likely to be abysmal.

So, we wanted to learn how we could improve patient/client compliance and adherence. We wanted to learn how to better engage patients in their own care. Basically, to be more effective in delivering good outcomes.

A core component of what we learned was the need to be much more Client Centred. Clients/patients need to be given choice and control. The way we conduct consultations need to become much more Client Centred.

I still have to process the stuff we learned over the coming weeks and months.

But I thought I’d share one simple change I’m going to make.

Seeing patients day-in day-out, I’m guilty of forgetting that for patients coming to see a rheumatologist for the 1st time, there may be quite a degree of anxiety and uncertainty.

Is this the right doctor for me? Why do I have to see another health professional when I’ve seen so many already? What is he going to do different? What is a rheumatologist?

We actually sat down to try and work out how best to address this at the start of the consultation, quickly and efficiently. How should I introduce myself? How should I allay these fears?

I’ve been a doctor for 18 years. This shouldn’t have been as hard as it seemed. Good thing my colleagues were there to help & we had good facilitators.

Anyway, this is the workflow/spiel we came up with:

(I walk to the waiting room & call out the patient’s name)

Mr David Smith…

Hello, my name is Irwin (handshake)

Please come this way. Please have a seat.

Can I start by finding out what you would like to be called/addressed?

I am a rheumatologist. Have you seen one before? 
(usually not)

Well, let me explain my role. I’m a specialist in arthritis; in problems affecting bones, joints, muscles & tendons; and in immune diseases.

(helps reinforce that the patient is seeing the correct doctor)

David, could I please ask what’s your understanding of why you are here?

Good. Well, by the end of this consultation, what I hope you’ll take away is a better understanding of the problem and a plan to help you manage that problem. I’m here to work together with you to develop this plan.

Is that what you are expecting?

(Benefit statement -> patients should know what’s in it for them. The patient should also feel involved & respected)

What do you think of getting this style of introduction? Does it help you as a patient to have the specialist you are seeing describe what they do up front? Is it obvious they are there to help you or does it actually help if the health professional actually articulates how they plan to help?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
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Does the prospective father need to stop Methotrexate?

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MethotrexateDr Irwin Lim, Rheumatologist

Received an email from Kay, which I’m sharing with her permission:

“My partner has been taking Methotrexate (Methoblastin) for Psoriasis for an extended period of time.  I believe that the dose is 20mg per week.

Are you aware of any referenced evidence or trials relating to birth defects where the male partner has been taking Methotrexate at the point of conception?  

I am having a lot of trouble finding any detailed information about this topic though I did find one forum where there was a broad indication that there is no real evidence in this situation and claims by some women that they have given birth to babies with no defects despite their partners treatment.  

I really can’t see my partner being able to come off the drug for the three months that the pharmaceutical manufacturers recommend as he suffers a lot of pain within about two weeks of stopping.

We have been very conscious about the potential side effects and so have been very careful to not get pregnant – unfortunately, not careful enough.”

She’s obviously quite concerned by the situation, which is fair enough, given the general recommendation is to cease Methotrexate in both females, and males, prior to trying to conceive.

I think it’s clearly accepted that the prospective mother should cease Methotrexate, usually for a period of 3 months, prior to falling pregnant. The situation with males should be different, given their obviously different role in pregnancy.

My response to Kay was:

“I am not aware of any known case where a male patient continued on Methotrexate and then this led to a birth detect. Please do understand that birth defects do occur at a background rate in people not on medications as well.

I do know that the recommendation is for the male to cease Methotrexate prior to attempting conception but I do not think this is based on any scientific evidence. Rather it is based on avoiding litigation from distraught parents.

I have not insisted that my male patients stop their Methotrexate and have been privy to patients conceiving healthy babies while the male patient continued on Methotrexate.

Hopefully, this helps you. You and your husband should discuss this in much more detail with the treating rheumatologist.”

Kay also highlighted 2 very useful fact sheets from OTIS (Organization of Teratology Information Specialists):

https://www.mothertobaby.org/files/methotrexate.pdf
http://www.mothertobaby.org/files/paternal.pdf

I thought it worth opening up this topic for discussion here.

What are your experiences with this issue, either as a patient, a partner, or a health care professional?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
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Can TNFi for Psoriatic Arthritis worsen Psoriasis?

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Psoriasis

By Dr Irwin Lim, Rheumatologist

Tumor Necrosis Factor inhibitors (TNFi) have been used for more than a decade as effective treatment for a variety of inflammatory diseases such as rheumatoid arthritis, ankylosing spondylitis, juvenile idiopathic arthritis, inflammatory bowel disease and psoriasis/psoriatic arthritis.

IMG_3698Many patient with psoriasis show rapid and marked response in their skin lesions with TNFi therapy. This is what I as a rheumatologist would expect and tell my patients with psoriatic arthritis when I commence them on TNFi therapy.

Paradoxically, some patients, even when their psoriatic arthritis manifestations improve (these include spinal pain, joint swelling, enthesitis and tendon inflammation), develop worsening psoriasis or new psoriasis-type skin lesions.

These psoriasis-type or psoriasiform lesions have been reported in patients with the range of different diseases treated with these TNFi agents. They’ve also occurred with the full range of different TNFi medications.

The most common lesions are plaque and palmopustular psoriasis but a small number of patients have also presented with guttate lesions.

IMG_3700The lesions can occur anytime following initiation of the TNFi, weeks or years after.

You can appreciate that in the small minority who do develop these skin lesions that the management can be difficult, especially if the drug is working effectively to control whichever disease it was started for.

Management options include:

  • Making the diagnosis. Infection needs to be rules out and we need to work with a dermatologist as a skin biopsy may be very useful.
  • A variety of topical treatment (corticosteroid or vitamin D derivative creams or ointments) are often required.
  • If the psoriasiform lesions are severe or distressing for the patients, discontinuation of the TNFi is recommended.
  • Therapies including phototherapy, methotrexate, acitretin and cyclosporine may be required.
  • If the lesions are less severe, a switch to another TNFi medication can result in improvement. This response varies from patient to patient and is not predictable.
  •  Swapping to a different class of medication with a different mode of action, ie non-TNFi

Have you experience paradoxical psoriasiform lesions on TNFi therapy?

How did you deal with it?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
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