Chapter 14: Rheumatologic Disorders

ANKYLOSING SPONDYLITIS AND SPONDYLOARTHRITIS

Management

Adults

Recommendations from

► ACR/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2019

• –Treat with scheduled NSAIDs and tumor necrosis factor inhibitor (TNFi) therapy.

• –Add slow-acting antirheumatic drugs when TNFi medications are contraindicated. Do not coadminister.

• –Do not discontinue/taper biologic with stable disease.

• –Use local parenteral corticosteroids for active sacroiliitis, active enthesitis, or peripheral arthritis for symptoms refractory to NSAIDs. Avoid systemic corticosteroid use.

• –Refer to an ophthalmologist for concomitant iritis.

• –Use TNFi monoclonal antibody therapy for ankylosing spondylitis with inflammatory bowel disease.

• –Refer for a physical therapy program: active and weight-bearing; avoid spine manipulation.

• –Do not routinely perform surveillance imaging of spine.

• –Screen for fall risk, osteoporosis.

Sources

• –Arthritis Rheumatol. 2016;68(2):282–298.

• –rheumatology.org; 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis.

GOUT

Management

Adults, Acute Gouty Attack

Recommendations from

► NICE 2022, ACR 2020, ACP 2017

• –Start NSAIDs, colchicine, or short course of oral steroid (ACP: prefer corticosteroids unless contraindications; prednisolone 35 mg/d × 5 d).

• –If using NSAIDs, consider concurrent PPI. (NICE)

• –If NSAIDs/colchicine contraindicated or ineffective, consider intra-articular or intramuscular corticosteroid.

• –Consider ice to the affected joint as adjunct.

Sources

• –2020 American College of Rheumatology Guideline for the Management of Gout. rhumatology.org/Portals/0/Files/Gout-Guideline-Final-2020.pdf

• –http://guidelines.gov/summaries/summary/50608/management-of-acute-and-recurrent-gout-a-clinical-practice-guideline-from-the-american-college-of-physicians?q=gout

• –www.nice.org.uk/guidance/ng219

• –Ann Intern Med. 2017;166(1):58–68.

Management

Adults, Chronic Gout

Recommendations from

► ACR 2020, NICE 2022

Evaluation

• –Confirm clinical diagnosis with a serum urate level ≥ 6 mg/dL. If serum urate < 6 mg/dL and gout is strongly suspected, repeat in >2 wk after flare. (NICE)

• –If diagnosis remains uncertain or unconfirmed, consider joint aspiration and evaluation for crystals. (NICE)

• –If joint aspiration cannot be performed, consider imaging with X-ray, ultrasound, or CT. (NICE)

  Therapies

• –Advise dietary restrictions: limit purine, high-fructose corn syrup, and EtOH intake. Weight loss is beneficial. Do not offer vitamin C supplementation.

• –Initiate urate lowering therapy (ULT) in the patients who have:

  • Frequent or troublesome gout flares (ACR ≥ 2/y).

  • Tophi.

  • CKD Stages 3–5.

  • Arthritis/evidence of radiographic damage (ie, bony erosions).

  • Serum urate > 9 mg/dL (ACR, conditional).

  • Urolithiasis (ACR, conditional).

• –Do not lower uric acid in asymptomatic hyperuricemia. (ACR)

• –When initiating ULT, use an anti-inflammatory (colchicine, NSAID, steroid) to prevent flares and continue for 3–6 mo. (ACR)

• –When initiating ULT, wait 2–4 wk after flare has subsided, unless flares are very frequent. (NICE)

• –Medications used in ULT:

  • Use allopurinol or febuxostat ...