IM7.{14-20,22} | Rheumatologic Disease Management — Summary & Reflection

KEY TAKEAWAYS

Rheumatologic disease management spans eight competencies: diagnosis communication (SPIKES framework, 'window of opportunity' for RA), treatment planning (treat-to-target), prescribing (disease-specific), biologic/DMARD basis, patient preferences, monitoring, and referral.

RA: Methotrexate (7.5–25 mg/week) + folic acid (5 mg/week, different day) ± bridging prednisolone → step up to biologic (TNF inhibitor first) or JAK inhibitor if DAS28 >3.2 at 6 months. Mandatory TB screen before biologics. Monitor CBC + LFT every 3 months. Contraindicated in pregnancy (MTX).

AS: NSAIDs (continuously, not as needed) + physiotherapy → biologic (TNF inhibitor or IL-17 inhibitor) for NSAID failure. csDMARDs are NOT effective for axial disease.

SLE: HCQ for all patients; prednisolone ± MMF or azathioprine for moderate disease; IV methylprednisolone + MMF/cyclophosphamide induction for proliferative lupus nephritis. Monitor anti-dsDNA, complement, urine PCR, BP at every visit.

Gout: Acute — colchicine OR NSAIDs OR prednisolone (depending on renal function, age); do NOT start allopurinol during attack. Prevention — allopurinol 100 mg/day started 2–4 weeks after resolution + prophylactic colchicine 0.5 mg twice daily for 3–6 months; target uric acid <6 mg/dL.

Referral triggers: Diagnostic uncertainty, biologic initiation, DAS28 >5.1 on methotrexate, lupus nephritis, drug toxicity, pregnancy counselling.

REFLECT

Return to Mrs Lakshmi from the opening hook. She is worried about side effects and has delayed treatment. Her DAS28 is 5.8 — high disease activity with ongoing cartilage and bone erosion occurring silently in her finger joints. How would you apply the SPIKES communication framework to explain her diagnosis and treatment plan to her in 5 minutes? What would you say about the 'window of opportunity'? How would you address her husband's question about fish oil and turmeric? Then reflect on the second patient — the man with a fused spine. At what point in his disease could that outcome have been prevented, and with what specific intervention? The skill of converting clinical knowledge into an effective patient conversation — accurate, empathic, and actionable — is the competency this module develops, and it can be practised on every patient you see in the clinic.