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Good evening everybody. Uh Thank you so much for joining this middle primary care network event. Um, delighted this evening to have Doctor Yara Cale with us. Um, tonight, we're going to be talking about all about arthritis. Um I'm really looking forward to it. I'm looking forward to getting an update um, about, about what's been going on Yara herself. Um, we were chatting before the meeting has just recently finished working with the NHS and is now living and working in Jordan, which is amazing. Um I'm looking forward to hearing from her very, very shortly. As usual, we're going to have, um, the presentation and we'll host AQ and a session um towards the end. Um, I draw your attention um, to the little message that Phil has popped in the, er, group in the, in the chat there, um, with the Med All app and Phil's going to chat in just a moment um, about some of the really cool updates that are happening there, um, and some of the new stuff on there which is kind of mind blowing and boggling. Um, a reminder that we have these primary care events happening almost every week and I'll give a little bit more information about what's upcoming um at the end of tonight's meeting. But Phil I'll let you have a chat. Thanks so much, Tim, everyone. You're so warmly. Welcome to the session. We're really passionate at Metal about making education like this radically accessible as well as making resources really easily accessible for you and your day to day work. And I just want to share a little bit of what we've been doing at Metal to try to keep making that easier to continue to integrate what uh these events are all about with your day to day as well. And I, I'm just sharing on my, my screen at the moment, the Metal app which you can get in the App store. I just want to orientate you to some of the things that we've been, we've been doing. You're able to get your certificate in the app, you're able to get any catch up content in the app. You're able to get all of the slides in the app. You just search, search for Metal primary care here and it's all right there. Um If you're a GP trainee with us this evening under question banks, we've also just launched a completely open access GP question bank for your exams. You're able to search for any of our events, videos and courses and really excitingly on the reference section. We've just pushed a really easy way to make it simple for you to share some really best practice resources with the patients that you're seeing in clinic as well. Right here, under patient leaflets, you're able to search for any patient leaflet from some of the world's best resources that you can share really easily with your patient and clinics. You don't need to hunt for a printer anymore or write down a web address for someone to look up. Um, you can now just give them a QR code to scan. So if I wanted to find one on this evening's topic like arthritis, I can just find an arthritis patient information leaflet. If you want to check it before you give it to the patient, you can do that just hit open patient view which will show you what the patient gets when they scan that QR code. So in this instance, it takes the patient to the NHS Arthritis patient information leaflet. So it's a really easy way to signpost patients during that consultation to some best practice resources. It's really easily accessible. Um It's on the app store for Android and for Apple, just scan the QR code on your screen right now. That will also be the place where you get your certificate. I hope you find it really helpful. It's completely open access, it's there to serve you. It's there to help you in your day to day. There are patient leaflets on pretty much every topic. You can actually filter them by primary care or the specialty that you're working in at the top as well to find the resources that are most applicable to you. I hope you have a really excellent event. Um I'm really excited about it. I know it's going to be amazing and I'm going to hand straight back to Tim to, to, to, to carry on with the rest of the event. I hope you have a really brilliant evening. Thank you. Thanks a million Phil. It's great to see that. I was just thinking how I can put that in my practice. So many people now have phones, even some of our older patients have phones. It's so easy for them just to get that information right at hand. It's great. Let's get our teeth into arthritis. Ya, I'm going to hand over to you if you want to pop your presentation on screen and I will slip into the background and I'll keep an eye on the chat. Please. Folks post your questions and as usual, I'll add them to the Q and A and we will answer them towards the end. Hello, good evening, everyone. And thanks for coming. Uh My name is Yara. I'm one of the rheumatology consultants based in Jordan in the Middle East and I trained in the NHS uh a couple of years ago. Um I decided to return back to Jordan. I worked in Birmingham and in Manchester and I think I might still be up to date with arthritis, um as far as the NHS is concerned, right? So I was asked to um deliver this presentation um with the following objectives. So, first of all, we're gonna try and um talking about enhancing diagnostic skills um for um primary care physicians and for junior doctors in general practice. And then we're gonna talk a little bit about the updates on treatment protocols. And as most of you are aware, um the market is full of uh medications um for um inflammatory um arthritic conditions and it's difficult to stay up to date with all of these. So, um it's better to try and group them according to mechanism of action or, or diseases or indications to try and understand when and what to prescribe. Um The next thing which has become, I think um the new modality of delivering um um medical care um worldwide is trying to uh do it via an interdisciplinary management approach. So MDT S and involving um physicians, nurses and um allied health professionals. And lastly, we're gonna talk a bit about patient education, how to involve them and get them to self manage their conditions as much as possible. So, first of all, and I think most of you are aware of this, but we're gonna talk um a little bit um about how to try and um differentiate between um inflammatory and noninflammatory arthritic conditions in general practice or in A&E um for instance, so when it comes to inflammation we all think of the, um, uh, main signs and symptoms of inflammation. So, it's pain, it's redness, it's hotness, it's swelling and it's limitation in movement. So, if at least three of these, um, are present in, uh, any number of joints, then you would suspect that the patient has an inflammatory arthritis, uh, as opposed to, uh, osteoarthritis, uh, for instance, um, patients with inflammatory arthritis as well, um, are well known to have morning stiffness and this likely lasts more than 30 minutes because many patients with osteoarthritis will present to you with some degree of stiffness after a period of inactivity. And this usually lasts about 5 to 10 minutes, not more. Uh, but if, if the duration of stiffness is more than 30 minutes and in many cases, it's, it's much longer than that than this is more likely to be inflammatory in the region. Um, swollen hot joints could be, um, could well be an inflammation as opposed to uh simple osteoarthritis, but sometimes uh even an osteoarthritic joint will become swollen and can be warm. Um, but this usually is a localized inflammation as opposed to systemic inflammation. And hence, in, in this particular group of patients, we um either try to aspirate the, the joint and see uh what comes or we perform a simpler task which is send blood tests and if the inflammatory markers are normal, then this is more likely to be a, a non inflammatory condition. Um But a localized um inflammation within the joint uh itself. Um And this is uh a small um uh group of uh osteoarthritic patients where they have what we call the inflammatory osteoarthritis. Um, patients with inflammatory joint disease respond favorably to nonsteroidals. That is an improvement in the pain um scale, uh a decrease um in their swelling and sometimes an improvement in the stiffness and range of movement. And we've mentioned um that many patients with inflammation will have raised ESR and CRP. So now that you've um come to the conclusion that this patient has an inflammation, what to do and when to refer and where to refer. So, if you think the patient has an inflammation, then it's best if you refer them to a rheumatologist. But we have two different uh clinics in rheumatology. One is for the early arthritis uh patients and the other one is the general rheumatology patients. So you come to ask the patient about the duration of the symptoms if um the patient has had those symptoms for less than the six months. Um but more than four weeks, then this is more likely to be an early uh arthritis, um or e early inflammatory arthritis pathway. Um and if it was more than six months with on and off symptoms, then this is a referral to general rheumatology. However, sometimes those patients will end up in er M SK or TN O. If you suspect an inflammation, it's best to refer them to rheumatology. However, if you think the patient might have um tendonitis uh caused by the um activities, the exercise, the work typing, um then those patients can be referred to the um earliest clinic with them, either rheumatology, M SK or TNL, whichever comes first. Um So, uh when, when it comes to keeping up to date with um rheumatology, uh and with arthritis, we always like to refer to guidelines because this is what helps people um understand the pathways and what to do in a, in a stepwise manner. And this helps us uh avoid um uh individualized uh or biased decisions. So, according to the latest r rheumatology recommendations from 2021 when it comes to rheumatoid arthritis, and this is the commonest uh inflammatory joint disease that we see in rheumatology. And I'm sure in GP you might have noticed that rheumatoid is more common than other inflammatory conditions. Um in western countries, it accounts for 1 to 2% um of the general population. So um once you've made the diagnosis, you have to start edema and preferably that should be methotrexate. Um you have to monitor the patients and review them routinely in clinic um every 1 to 3 months and monitor their improvement. If those patients achieved er disease remission within the first three months, then the medicine is working and then you can't carry on. However, if the patients did not achieve the target that we wanted, then you have to reconsider either add another do or step up to a biologic depending on um the um uh the disease outlook. For example, if the patient has other um uh features, um for instance, and inflammation in the eyes and uveitis, then this um will escalate the treatment fairly quickly. Now, if the patients did not tolerate methotrexate or somehow had um um a contraindication, then you can choose leflunomide or sulfaSALAzine as part of the first treatment strategy. And if uh patients have come to you with angry looking swollen joints and they are in so much pain, then you can give them a short course of oral steroids or injectable such as im steroids only for a short period. And um for me, my, my routine prescription is to start off with 20 mgs daily. That's four tablets um uh for the first week and then decrease by one tablet uh every week. Um over a duration of four weeks, this is usually enough for patients to feel better. Alternatively, if you feel the patient has multiple angry looking swollen joints, they are unable to use their hands properly, they can't walk, then you can give them an im depo and we normally give um depo-medrol 100 and 20 mg, right. Um If patients um had had methotrexate and it wasn't enough and then they had another uh da such as leflunomide or sulfaSALAzine and the combination was not enough. Um then you will escalate to biologics. And the first line biologics we use are on anti TNF because A um they cover um a big number of uh diseases and B because they are the cheapest uh biologics we have in hand. And recently most of you are aware that uh we have started uh moving on to biosimilars which is much cheaper. However, it's the same formula um uh uh when compared to uh the originators. So this allows um us to give access to more patients um for um less um money, right? Um The recent uh psoriatic arthritis, you have recommendations are similar to those um of rheumatoid arthritis. However, the difference is that you can start treating patients with nonsteroidals um as soon as you make the diagnosis. So with rheumatoid, you have to start methotrexate or, or um if it was contraindicated, then you can uh choose another da but it has to be a da first line. Uh Whilst in um psoriatic arthritis, you can start um nonsteroidals as first line. Um or you could use um local injection of uh steroids if it was tendonitis, enteritis or a single inflamed joint if the patient with enthesitis, tendonitis. Um So, enthesitis is the tendon sheath inflammation uh or tendonitis as the inflammation within the tendon itself. Those patients who um uh trialed nonsteroidals um and had topical or injectable steroids. Um and they didn't respond and they will qualify for biologics straight away because they do not respond to DMARDS. Now, um as you are probably aware, uh psoriatic arthritis can also affect the axial skeleton um in a fashion similar to ankylosing spondylitis. So these patients will either get um nonsteroidals. Um And if they do not respond to that, then they will um go on to uh biologics straight away if the disease activity score is high enough. Um Of course, if the patient has skin psoriasis as well, that's not well controlled with a topical treatment as well as some um arthritic or uh periarthritic uh symptoms, then it methotrexate is preferable over any other da Right. Now, we've mentioned uh referring patients to early arthritis uh clinic and some trusts across the country and have designed their own performer to make things easier for themselves for the patients and for our colleagues in primary care to try and limit their time. Um and the number of unnecessary or rejected referrals. Um So I've got two performers here. The first one I got from North Bristol and this one is slightly longer. So it comes in two pages. Um and it states um the duration of the symptoms, number of involved joints, whether these are small or large joints, um the duration of early morning stiffness and whether the patients have inflammatory markers and then um uh things that you will get from um taking uh history that's constitutional symptoms, other features of arthritis, for instance, rash, eye inflammation, um bowel symptoms, um, et cetera, family history of similar condition or autoimmune condition and family history of psoriasis. Um, and then finally, you will have, um, enough room to mention, um, the blood tests and investigations that you've, uh carried out and whether or not you've, uh, carried out any x-rays and then you fill that in and you send it over. This one is a simpler and a shorter one, from the Manchester Foundation Trust. Uh and it just mentions whether patients have had any swollen joints um over the past six months, whether morning stiffness is more than 30 minutes, uh whether there is pain on a squeezing test, um whether patients have responded to nonsteroidals having positive um inflammatory markers, rheumatoid factor or CC P and any swollen small joints within the hands or feet. Um If you take three out of these boxes and the patients will go automatically uh and will try out into the arthritis clinic and the aim across the country. Um according to be si is to try to see these patients within three weeks of referral. Um and a very small number of er trusts were able to achieve this goal. Unfortunately. Now, um what we are all trying to do is to implement a strategy uh of treat to target. So, um this has become um a trend if you would in medicine nowadays and trying to put targets for patients with heart disease, with diabetes. And now, um in rheumatology as well. So our target that we explained to our patients on the first visit, um and um we make it clear to everybody that we achieve to uh we aim to achieve no disease activity that is remission or er if that was not possible, then uh low disease activity, if patients have peripheral arthritis, then the aim is to start edema. As soon as you've made the diagnosis with methotrexate being the cornerstone. Some studies um not published yet, but um from where I used to work in uh Manchester, they are trialing using triple therapy with methotrexate, sulfaSALAzine and hydroxychloroquine on the first visit. And they found that these will treat me, treat early rheumatoid arthritis aggressively um enough to um achieve earlier remission and to avoid um complications such as erosions and joint deformities. And when it comes to um aponin arthropathy, um the aim is to start the highest tolerated dose of nonsteroidals. Try these for two weeks if that didn't work, switch to another and if that doesn't work and the patient still has active disease and the BA I score is more than four, then they will qualify for a biologic, right? And once you've made the diagnosis with early arthritis, regardless of what the early arthritis was, what, whether it was rheumatoid psoriatic or axial sponder arthropathy, then you need to arrange for them to be seen frequently. And by er, saying frequently that should be a review once every month to once every three months depending on available resources, available appointments and them uh disease activity itself. Um So, um that normally is done uh by our um clinical nurse specialists. So they have the early arthritis follow up clinic. Um And I'm sure most of the trusts have some form of um uh fr routine um frequent appointments. Um I mean, frequent appointment clinic for those uh patients who have uh the arthritis disease. Um Now, once the plan is agreed, that is the plan on uh what medication, what dose? Um and the frequency of um uh appointments, reviews and the frequency of uh uh blood tests, then the patient um will be uh shared that the care of the patients will be shared with primary care physicians and we have what we call the shared care agreement. So I will show you a sample of that. So this is um an agreement that is um designed by um local trusts or local GS where um it is a uh a number of pages. The first part is filled uh by the um rheumatologist. Um It's a, it's a tick box where they ticker, the things that they've done. So they've made their diagnosed, they've started the medication, they've escalated the treatment, they've done the blood tests and the plan was agreed and the patient has achieved um uh the treatment um the target goal. So um then those patients will be sent to their GPS where they will carry on prescribing and monitoring their medications. Um, right. Some uh GPS and some GS will say I cannot accept that the patient until the patient has been stable on the current dose of medication. And their blood tests are nearly normal for at least three months before they accept them. And this is really, this really depends on um, er, patients um O on GP themselves and resources uh and their expertise as well. And the last line is important where it states that responsibility of the drug and the consequences of its use remain legally with the rheumatologist. So any side effects, any issues with prescribing, any issues with delivery uh is really a legal responsibility of their rheumatologist, right? So this part is the G P's responsibilities. So, um it, it, it's more than responsibilities but rather um uh AFA few in information that they, they should follow in order to avoid um uh issues with, with a patient prescription. So, for instance, uh methotrexate comes in 10 mg tablets and 2.5 mg tablets. So we, we are asking all GPS to prescribe 2.5 mg tablets only because most patients will remember the number of tablets they take as opposed to the dose. Uh and um some pharmacies will be giving 2.5 and sometimes we will give 10 and that will confuse the patients and uh to avoid um overdose or under treatment, we need to stick to a single, single, agreed upon uh dose, which is the 2.5 mg tablets. Um, if the patient is prescribed paratra meth, then um, the patient should have had enough um, er, training, whether they will self administer or someone in the family, they should be um, good enough at doing that. And then, um, most of the times the nurses would have um explained on how to get rid of the, uh the sharps. And um they, they should be given um a yellow uh sharp spin with, with a purple uh lid to state that this is chemotherapy. So normally we will see patients coming holding the, their yellow uh sharp boxes and walking onto the department. So that's not the GPS job basically. Um And uh we normally um write in our uh clinic letters that for instance, could you please increase the dose, decrease the dose um repeat the bloods, et cetera, er because patients will work closely with their GPS, they live closer to them and it's sometimes easier for them to access um their GPS geographically as opposed to coming to um rheumatology units. Um but uh rheumatology units are very accessible to our GP colleagues and they can always um um try and reach out whether um bleeping the on call reg um by phone or even uh advice and guidance online. Um And of course, um if patients come to you with side effects, please uh report that to um the prescribing rheumatologist and to the M HRA as well. Um And if, if the patient um develops serious side effects, for example, um leukopenia, uh anemia, uh very abnormal LFT S, then um you, you will know to stop it, right? Ok. So we come to the last part of our um presentation today, which is patient education and we know that um getting the diagnosis of a chronic condition is not a very pleasant surprise to uh to all of us. Um So, uh taking in all the information and trying to understand the disease itself, the behavior of the disease, all the medications that come with it. All the people who will get involved into managing the patient, the back and forth um trips to uh hospitals and pharmacies, et cetera is something that many, many patients will not be happy with. Um and will not take unlikely. So that's where the patient education sessions come. So normally patients are um uh patients are uh um joined by um an educator, whether that's a nurse or sometimes a pharmacist. So they all sit in a group and those groups are either based on medication or based on uh the condition and they will have time to ask um their questions and each question will be addressed um in the correct way. Um And um, as I mentioned before, if the patient is prescribed an injectable medicine, then they will receive enough education. Uh, some patients will come weekly to have their injection um until they master the injection and what to do if it's pills, what to do if they um administer the wrong dose, what to do if they miss the dose and what to do. Um um to, to uh um rightly dispose of the sharps. Once that's done, there is a tick box for the nurses to fill and when that's done, then the patient is ready to uh to perform their injections at home. Um um as Tim uh mentioned before, um there is um plenty of platelets available for, for patients and for um um physicians as well um to get the necessary information. So we in uh rheumatology refer to the versus arthritis ones and some of them are still called arthritis UK. And um you can always refer to the NHS website as well for um some simplified uh but excellent information uh resources for patients and for clinicians um as well. It is online. Um and it is free. Um and um for the non-english uh speaking, uh minorities within the country work is being done to translate information um on the main or the most prescribed medications and conditions. Uh but this needs plenty of time um to be perfected. Um and um patients are advised to be an active um part of their decision making. So whenever we, we uh want to prescribe a medicine, we always give them the available options. So whether, for example, if it's bic, whether they prefer to take a biologic once a week or once every two weeks, um It's, it's totally up to them. Um And also we treat, we teach them how to self manage their conditions. Um And to use the online tools and apps um that have become available nowadays um to measure their disease activity. Some trusts across the country have developed their own apps where their patients will input their disease activity and their symptoms. And then this will get sent to someone who monitors their input in the trust. For example, um a specialist nurse where she will um the high disease activity patients will ping and then the the nurse will contact the patient to discuss their symptoms and to decide whether or not they need to be seen in an, in an emergency clinic. So I think having an app or an online tool is, is really beneficial. Um because um like what you've already mentioned, guys, most people have mobile phones and have access to internet and to um um the the recent advances in technology. And um you will be surprised that even what we call the elderly. But yeah, the the older people know how to use um phones and smart apps, et cetera. And um the people who develop these apps try to make it simple and not too complicated for um the majority of people to use, right? Um What um so, so this, this um discussion was about the inflammatory conditions, but if the patient has non inflammatory conditions, then uh there is a, a lot of debate on, on where, where these patients should be seen. So, um as I mentioned before, those can be seen by um the musculoskeletal specialist that is a consultant physiotherapists or specialist physiotherapists, either in the community or in hospitals. Um, and um for me, if, if someone has, er, a chronic back pain, then I would refer that straight away to a SCA because they are very, er, capable of, of um, er, diagnosing or differentiating whether this is an inflammatory back pain or not. Um, speaking as a GP now. And um, uh if, um, if someone, uh for instance, has symptoms of osteoarthritis, then those can be managed by um either rheumatology TN or M SK. Uh, and I would, um, gauge on whether uh, II believe the patient might need uh um, uh a joint replacement therapy, then, then this should go straight to TN O, some GPS and you, you all know more than me, um, have an interest in uh M SK or in rheumatology and some of them um, hold surgeries to um perform uh some injections, um intraarticular or um, or uh periarticular injections. So those can be um AAA fair point if, if you are, if you work in a, in a group of uh GP surgeries, right. Um And finally the take home messages. Well, we've got a few here. Um If you are suspecting inflammatory arthritis, you have to confirm with a patient the duration of the symptoms, whether or not um they have morning stiffness and duration of that, whether they've responded to nsaids, um uh presence of personal or family history of psoriasis. Um Next, you will need to perform a physical examination, focusing on swollen joints, the number of swollen joints, number of tender joints and to perform a squeeze test. And then um you will arrange some blood tests that should include ESR Crp rheumatoid factor or CCP. And then as a GP, um you will prescribe nonsteroidals uh if not otherwise contraindicated. And then if you feel the patient fulfills the performer of early arthritis, then uh refer them to the early arthritis clinic. Um Also, uh da prescription should be continued unless stated by uh a specialist. Um We've encountered a number of patients who had uh their prescription discontinued for no particular reason. So, um we know that discontinuing the treatment um will result in uh worsening of the symptoms and um uh deformities and erosions delays um in doing so, as I mentioned, will risk disease progression, drug resistance when it comes to the biologics and joint deformities, most units are easily accessible through. Um as I mentioned before, advice, lines, Red Leaves or online advice and guidance. And thank you very much. And that's the last slide of my presentation tonight. That is fantastic. Yeah, let me just get my microphone down again so you can hear me. Um We had a couple of questions coming through at the start and then I popped a little message in to try and encourage a few more and now we have plenty of questions to run through. So what I want to do is I'm gonna, I'm going to pop these up onto the screen. You should be able to see them coming up on the screen in front of you. And we'll start at the beginning. The first one was with regards to starting methotrexate in general practice and whether that should be done by GPS or should they wait until they've been referred to rheumatology? Yeah. So, so no GP should start methotrexate. That's the job of uh rheumatology. Methotrexate is started by us and then it, it goes back to you once we've stabilized the dose and we're happy with the side effect profile, et cetera. Brilliant. So that's a nice concise answer there. Fantastic, interesting question about rheumatoid factor. I know whenever I um recently finished medical school, admittedly um about the sensitivity of rheumatoid factor. Is it any good for monitoring or is it only good as a diagnostic tool? Yeah. So I only do rheumatoid factor once just the one, it's just a one off to, to a yes, no answer. If you are positive, then you're positive. If you're negative, then you're negative. There is no benefit of, of repeating that it's um the up and down changes in the level do not reflect disease activity. So we don't need to repeat it. Brilliant. OK. Uh And a couple of duplicate questions here that I'm going to skip through um with regards to monitoring, I'm guessing perhaps Stella this question is maybe from somewhere where that's a bit of a challenge. What alternatives are there if blood tests can't be done to monitor treatment? Right? So many of our patients will not turn up for their monitoring bloods. So we normally will have to contact them and say that it's not safe for us to continue prescribing the medication. If they're not turning up for um, the blood test and communication is, is important in, in these circumstances. Um If, and I'm talking about England or the UK, if the patient cannot access the, the unit where they, where they have their bloods performed for morbidity reasons, then phlebotomists, the people who perform the blood test can go to their home and take the blood samples or sometimes GPS will arrange for a taxi to go get the patient to, to the GP surgery. That's when we talk about er, the United Kingdom. Now, I'm aware that many people are um, are watching us from outside um, the United Kingdom. So this again needs to be communicated with patients, try to um minimize the number of blood tests that you are ordering. For example, if the patient will pay for er, sodium potassium urea and creatinine. I'm interested in creatinine. So I will only arrange for creatinine if the patient will pay for the detailed er, t so I will, for instance, um, request alt and alk alkaline phosphatase. So this will make it a bit cheaper for them. Um, but they will need to understand that if they can't do the blood tests, then they unfortunately can't take these medications because they come with side effects and we can't tell whether they have it or not without doing the necessary blood tests. Sure. And I guess it's a balance of that risk, then that's when the risk kind of outweighs the benefit. Excellent, as always. Yeah, absolutely. Harris has asked about the thought. Oh, sorry, apologies. It was the next one I was actually reading there. Um, apart from blood tests, do we need to check A N A? And this question has come up a couple of times there any role for antinuclear antibody testing? Yeah. So A N A is always done if you have a pediatric patient. So if, if it's someone who's younger than 16 A N A is a must. Yeah, because, uh, most of, um, rheumatoid arthritis patients or what we call juvenile arthritis, um, in, um, the younger will have A N A, er, positive. That's one thing, um, in the adults, if patients have symptoms of connective tissue disease as well, then you can perform the A N A. Um, and in that case, uh some patients will have an overlap, what we call an overlap between connective tissue disease. And for instance, rheumatoid arthritis. Um a third indication for A N A is if you've prescribed a patient, a biologic that is um an anti TNF. And they developed features of lupus, for instance, skin rash, photosensitivity, oral ulcers, et cetera, then they've developed drug induced lupus. So they will have a positive ana and when that's the case, you have to stop the biologic and switch to an alternative. Sure, sure thing. Um The shared care plan I know here, I'm also based in the UK and I know that that is something that does happen, but as guidelines change is that sort of updating with the times. Uh I think the Shira plans sometimes lag behind. So um uh if you are a GP and you feel that the, the shared care agreement is not up to date, then you have to contact the Rheumatology department. Um Normally this, this takes a, a few years after a recent guideline has been released to be updated. Sure, I suppose the advice there in your local area would be to, to, you know, look into that if, if it's something you feel is out of date. Um A couple of questions coming in here with regards to allied health professionals in the road. So there's a couple of folks asking about what your opinion is with regards to exercise and what we should be recommending to patients in terms of exercise, physiotherapy. Yeah, of course. So, um for instance, if you're talking about an inflammatory back condition such as ank spon, ankylosing spondylitis or inflammatory, uh what we call um axial arthropathy. Then what I advise my patients is exercise as your friend. This is your treatment for life. Um You can um take nonsteroidals when the pain is there, but you should not stop exercising. This should be like your morning coffee. Um It's, it is what, what's gonna keep you moving? Uh That's when it comes to inflammatory back pain. Um uh and uh ii overemphasize that because it is a very important part of managing back pain, inflammatory back pain is exercise and peripheral arthropathy as well. Every patient will er, benefit from um physiotherapy advice or even simple exercise such as walking or youtube. They, there's plenty of um youtube channels where they can access her advice. Sure. Uh, some other question kind of related to that coming in. Um, about if someone has, you know, a particular inflammatory arthritis of, say their, their metatarsophalangeal joint. Is there a role for podiatry there for sort of, you know, orthotic insoles, things like that. Yep. Yeah, we do it all the time. So if the patient has a, a localized um, joint inflammation or deformity, then um we refer them to podiatry. Um And sometimes we refer them for um, as well orthotics for, for hand splints and things like that. So, yes, we do it all the time. Um, things are becoming less, less available nowadays because of, you know, financial challenges, challenges and, and, and very, very swiftly moved into the next question I had, which is from um Adnan. Um, in terms of finances, do you know GP surgeries often operating as independent businesses? Is there financial incentive for running the shared care schemes for arthritis management, inflammatory management? Yeah. So when, when the CCD S have agreed that er all GP surgeries should take on um er managing the patients, then yes, er, every surgery will get um its funding however limited, this funding is er, I'm sure it's not enough. It's not, it's not easy. One of my take home messages there from your talk was with regard of referring to rheumatology because in my particular trust, I know that the waiting list is, is exceptionally high, which makes it very, very tricky. Um A question from Puja about um hypermobile joints. Is there any way of diagnosing them apart from clinical examination? Is there any, you know, um quantitative test that we can do? Right. So um many patient, many GP S are capable of making the diagnosis and some, some of them just send the patient to us for confirmation just, just to give the label. Um So you, you um mainly have to make the diagnosis clinically. Now, if the patient has other features such as um uh very elastic skin Um And you are suspecting the patient has uh the vascular uh EDS and the patient has another family member who, for instance, um developed um uh an aneurysm at a young age or died because of aneurysm. Then in this case, those patients can be referred to genetics for um a, a detailed study of the family. But the simple A DS, you don't need to do that. There we go. No. Brilliant. Um I don't know if you're happy to perhaps demonstrate. Um, someone's asking about how to actually perform a squeeze. Test it. Yeah, it's, it's, it's as, as you squeeze a lemon, it's just squeezing this area across the Yeah, because, because, because you can't, because you can't uh examine these, these bones here, there's no way you can examine them. So you squeeze and if you want to, to examine the MCP joints, so we have to use three fingers, one at the top, one on either side and then you squeeze it. And if it's an inflammation, it should feel like um, sponge, not a soft sponge, but a sponge that is soaked with water. Uh like uh like the sponge you use to, to rub your dishes. It, it should feel like that. If it feels like bone, then it's osteoarthritis. So if it's enlarged and it feels bony, then it's osteoarthritis. And if, if any of you would feel there is a small dip between, um, between the two bones, if, if you can't feel the dip and it's full then then there is an inflammation, there is swelling. Is there? Ok. Brilliant. Um We're still going if you're happy to take a couple more. Yeah, if that's alright, there are still a few coming through. Um someone Robby is asking patient with negative rheumatoid factor, rheumatoid factors being on DMARD. Um Do we need to switch to methotrexate if it's been in remission for years? If the patient has been in in remission, uh then you don't need to um to, to change the treatment really. Um when patients have achieved remission for many years, uh your job as a clinician is to try and decrease the dose slowly. So we taper it slowly, the recent guidelines say taper it but keep it, don't stop it. So keep the minimal dose um that, that the patient can tolerate to keep, to keep them symptoms free. Um So it's just a case of kind of titer that down as much as, as, as as possible. Um Another question with regards to the blood tests, E SR versus C RP. Mhm. Right. So we er you can use either because the um disease activity scores can use either. So they've developed the DAS score which we use for rheumatoid arthritis. You can use it for uh with either E SR or C RP. Um So yeah, you can use whatever is available for you, cheaper or easier for, for, for you to perform a and as you say, yeah, I guess um we do have an international audience. So again, it could come down to, you know, whichever is more cost effective for the patient as well. Sure. Um uh she says liking to know um complications of long term effects of rheumatoid arthritis. Could you give us a quick overview of that? Yeah. So some of these are related to the joints themselves and some of these are systemic. Uh if you're talking about the joints, then joint deformities, um persistent pain limitation in the movement. Um and systemic. Um any patient with um a chronic untreated inflammation, regardless of the source are at a higher risk for early and aggressive peripheral vascular disease and cardiovascular disease and um strokes. Um any patients with untreated inflammation with high levels of inflammation are at higher risk for malignancies as well. So we need to control the inflammation. Sure. Um alternative therapy can dry, needling help with arthritis. Is there any evidence to suggest suggest that there is uh no evidence for alternative therapy helping arthritis? Really. Um And I know many patients will, will try to go for diet or uh certain uh homeo therapy, et cetera. This can be done alongside the medications but not as an alternative, not a stand alone. But I guess if it works, if they find it works for them, I suppose, then if it helps with the pain, then yes, but I don't think it really treats the inflammation. Yes, the disease process as such. Um, rheumatoid arthritis, I know we'd mentioned at the start and one of the things that I had picked up on there was about tendonitis and it being a potential referral to rheumatology. MSK or T um Robbie is asking, can rheumatoid arthritis affect tendons and ligaments or would that need MRI um investigation to kind of prove that? So rheumatoid arthritis is primarily a joint disease alongside the joints, you can have some tendons. But if you feel that the tendons are the main er or the ligaments are the main um components of the condition, then you have to revise your diagnosis. You have to think towards the uh the psoriatic arthritis more, more than the rheumatoid, a more a more sort of systemic rheumatological thing. Pardon me? Um The ideal, so we were talking there about how to manage um rheumatoid arthritis in GPS. And we were saying about how the waiting list can you know, delay that first referral to rheumatology? I think currently where I am it's a number of years um which is, which is quite scary what would be you'd mentioned in your talk, what you personally do um What would be just to go over the ideal dose of oral steroids for relapse um or if there is going to be that delay. Yeah. So um commenting on the delay, if the patient has symptoms of early inflammatory arthritis, the the waiting list shouldn't be two years. So it, it will be a few months, um, at, at most. But even then, yeah, ma many, many of the GPS will struggle with the patients. So I don't know what to do. You keep coming back with pain and swelling. II honestly don't know what to offer. So if the, if you are capable of, um, injecting the joints, uh, especially if it's a large joint such as the knee, um uh or for instance, if, if you're happy with injecting the wrist, uh or the ankle, then go for it. Um If you can't and you want to, to give um systemic steroids, I would give an im depo as opposed to oral. Um because of all the side effects that come with repeated oral medications, oral steroids specifically. Yeah, for sure. And I mean, I know a lot of, a lot of areas now have GPS with enhanced interest with that sort of MSK ability to do to do joint injections. So that I suppose is an option too. Um Interesting question from sort of an emergency medicine perspective, what would be the things we're looking out for? Um with regards to methotrexate toxicity if they present to Ed, I've recently managed a lady with methotrexate toxicity who had a change of her dose. So she took the dose daily instead of weekly. Um So she came, yeah, she came with um lots of oral ulcers, bleeding gums, bleeding, tongue, uh bleeding lips, um, and she had some bruises and she had pancytopenia, so she had bone marrow shut down. Um, so you can send a methotrexate level in A&E straight away before you start treating her. And then, um, you will start by hydration. Of course, you will do the blood tests and then, um, you will, um, think of, uh, whether you have the available, if you have the antidote available as well. Sure. Um, I'm gonna finish with uh with three and then I'm gonna, I'm gonna wrap things up because we're, we're getting close to our time here. Um Is there association between high BMI obviously, obesity very, very common in, in the western world. Is there an association with that and progression worsening of symptoms? Yes, there is. Um not, not because of um the mechanical burden of, of the extra weight but also having fat, especially around the belly. This is associated with higher levels of inflammation, higher levels of E sr So, no matter how many medications you take, if your weight is uh is uh within the higher BM I um category, then your, your um disease optimization is not gonna be the best. Sure. Sure. Um Is there a gender association with arthritis? I think from what I remember learning, there may be walls. Yeah. So um unfortunately, most of autoimmune conditions favor woman because of the hormones. Um uh a small number of conditions. Uh We see them equally in both genders. And even a smaller number, um, is more, is commoner in males. Sure. Um And the last question I'm going to pose is an interesting one. Can cracking knuckles cause arthritis. Is there any evidence rheumatologically for that? No, no, no, there is not. There's not, hopefully, hopefully that's a, that's a perhaps reassuring and light note to finish the Q and A on um, for our folks listening. Um Yeah, thank you so much. I want to quickly pop up on the screen, just a QR code again. Um for the audience to scan um The Me All app is where you can get your certificate for tonight's presentation. The QR code is there for both the Apple Store and Play Store. I'd really encourage you to hop on that. I'm also going to draw your attention quickly towards our two upcoming um middle primary care network sessions. The first of which is by actually one of my old lectures. Um and it will be navigating ophthalmology that's going to be on the ninth of May um at 730 and the next of which is going to be CO PD and making a good diagnosis with doctor Steve Holmes. Um I've popped the links to those event pages in the chat there for the audience. Um Please register for them. I look forward to seeing you then and can I just finish off this evening by once again? Saying a massive thank you to Gareth for giving her time this evening for what was a really comprehensive talk um and a really robust Q and A I think we really quizzed you there. Yeah. Thank you so much. It's a pleasure. It's a pleasure. Thank you very much for arranging this and thanks for everyone who attended and I hope you benefited from it as much as I did. Amazing folks with that. Um We will sign off and I look forward to seeing you on the ninth of May at our next middle primary care session. Um, have a great week. You too. Thank you. Goodnight everyone. Bye bye.