Drugs used in rheumatology practice

The Oxford Handbook of Rheumatology, 4th edition, emphasizes the importance of evidence-based therapeutics and therefore devotes a whole chapter to medications used to treat rheumatological and bone disease (‘Drugs used in rheumatological disease’). Details about treatments are cross-referenced to specific use of medications for specific diseases and conditions elsewhere in the book. There are chapter sections on analgesics including opiate-based medications, NSAIDs, conventional synthetic disease-modifying antirheumatic drugs (DMARDs), biologic DMARDs, intravenous immunoglobulin, and other immunosuppressants. There is a specific focus in the chapter on drugs used for Raynaud’s disease, osteoporosis (e.g. bisphosphonates), pulmonary hypertension, gout, and hyperuricaemia. Overall there is reference to both adult and paediatric disease treatments in the chapter.

Chronic pain syndromes

The Oxford Handbook of Rheumatology 4th edition, has been extensively updated to thoroughly review aspects of musculoskeletal pain. Pain pathophysiology is reviewed. Chronic pain and fibromyalgia in adults and in children and adolescents is dealt with in detail. The reader is advised to cross reference from this chapter to Chapters 1–3 in the Handbook, where regional musculoskeletal pain conditions are listed and reviewed. In localized pain syndromes, the chapter has an overview of complex regional pain syndrome (CRPS), which is not infrequently encountered in rheumatology and musculoskeletal clinics. Included in detail for this edition, is the assessment and management of pain in children, which is a highly specialized clinical area of medicine and will be of use to the adult rheumatologist and general practitioner as well as paediatric specialists. Readers should cross reference to Chapter 23 on medications, for ‘pain medications’ in the Handbook

Common upper limb musculoskeletal lesions

This chapter introduces readers to some common upper limb musculoskeletal lesions, including subacromial (shoulder) impingement syndrome, adhesive capsulitis, and lateral epicondylitis (tennis elbow). The epidemiology, aetiopathogenesis, clinical presentation, and management of these conditions are presented. Algorithms for their management are provided. Other disorders presenting with a subacromial impingement pattern of pain are detailed and optimal diagnostic imaging methods proposed. These include supraspinatus/cuff tendonitis, subacromial bursitis, rotator cuff tear, long head of biceps tendonitis, osteophyte impingement on the rotator cuff tendon, glenohumeral instability due to labral trauma (e.g. SLAP lesion), arthritis of the glenohumeral joint, enthesitis related to spondyloarthritis, and lesions at the suprascapular notch.

Antiphospholipid syndrome

This chapter describes the clinical and laboratory classification criteria for antiphospholipid syndrome. It highlights the complexity and diagnostic challenges of antiphospholipid syndrome and discusses potential mimics of the disease that need to be excluded. Current therapeutic targets as well as novel therapeutic avenues are explored. The chapter finishes with a section on catastrophic antiphospholipid syndrome, which constitutes a rheumatological emergency. The clinical presentation, laboratory features, treatment, and outcomes of this life-threatening presentation of antiphospholipid syndrome are also discussed.

Rheumatoid arthritis

This chapter describes the presenting features, clinical manifestations, and management of rheumatoid arthritis. Commonly used investigations, their indication and interpretation, as well as the holistic treatment of rheumatoid arthritis are outlined. A summary of the commonly used drugs for the treatment of rheumatoid arthritis, their mechanism of action, and key points for starting and monitoring their use is included. Special circumstances including the management of rheumatoid arthritis in pregnancy, surgery, vaccinations, and during infections are also discussed.

The spectrum of disorders associated with adult rheumatic and musculoskeletal diseases

The Oxford Handbook of Rheumatology, 4th edition, takes the reader through a pragmatic and realistic way of assessing musculoskeletal and rheumatological disease presentation in its first four chapters. The text reflects real life, with differential diagnoses suggested as information becomes available through the details from history, then examination, then investigations. The chapters focus on patterns of, and focal regional, symptoms in adults and children. In this chapter, the book considers musculoskeletal and rheumatic conditions which occur in, or are closely associated with, other conditions of the skin, eye, heart, lung, kidney, and in hormonal, neurological, and gastrointestinal systems. Such an approach should help general practitioners and rheumatology trainees caring for their patients across their medical comorbidities and in general medicine. There is also a section on musculoskeletal–rheumatological features in patients with neoplasia. The chapter focuses primarily on adult disease.

Evaluating rheumatological and musculoskeletal symptoms

General rheumatological assessment is for musculoskeletal pain, stiffness or swelling, weakness, fever, rashes, and fatigue. This chapter describes both the nature of those symptoms helpful in making a diagnosis and also the subjective elements influenced by exertion, loss of function, anxiety, cultural norms, and other symptoms. In children and adolescents, symptoms are also influenced by developmental stage and may present simply as a limp or loss of limb function. Other referrals are for symptom complexes (such as Raynaud’s disease) or isolated abnormal investigations (such as elevated erythrocyte sedimentation rate or antinuclear antibody). Both paediatric and adult assessment requires the effective use of the (p)GALS screening examination tool described here. The nature of symptoms requiring rheumatological assessment varies according to diagnosis and has a subjective element influenced by exertion, impact, anxiety, cultural norms, and associated symptoms. They include musculoskeletal pain and stiffness, weakness or loss of limb function, fever, and also fatigue. Other referrals require assessment of symptom complexes or isolated abnormal investigations.

Rheumatological emergencies

This chapter covers commonly encountered rheumatological emergencies, including septic arthritis (for both adults and paediatrics), infections in patients taking biologic therapy, acute systemic lupus erythematosus (SLE), systemic vasculitis, systemic sclerosis-related crises, methotrexate-induced pneumonitis, macrophage activation syndrome (MAS), and paediatric osteomyelitis. Malignancies presenting with musculoskeletal symptoms in children are also covered. Several of these topics are covered in more detail in other chapters of this handbook, with links provided from this chapter as appropriate.

Spinal disorders and back pain

The Oxford Handbook of Rheumatology, 4th edition, chapter on ‘Spinal disorders and back pain’ brings together a pragmatic approach to categorizing back pain, how to investigate disorders presenting with back pain, and how to treat adults, children, and adolescents with back pain. In the chapter, the management of back pain is separated into acute, subacute, and chronic presenting scenarios and the text makes reference to other chapters in the book where there may be some additional useful information (e.g. spondyloarthritis-associated back pain in Chapter 8 and chronic pain syndromes in Chapter 22). Notably the chapter is best read in conjunction with relevant sections in Chapter 3 (‘Regional musculoskeletal symptoms: making a working diagnosis’). The chapter makes reference to the need for a rigorous diagnostic approach to all the conditions which cause back pain, and at whatever age. There are subsections on how to assess paediatric spinal disorders and how to take a broad holistic approach to managing chronic back pain where there is no specific diagnosis.

Hereditary disorders of connective tissue

The Oxford Handbook of Rheumatology, 4th edition, includes a chapter on the hereditary diseases of connective tissue. Of importance, up-to-date genetic information and classification of subtypes of osteogenesis imperfecta is reviewed. There is a summary of a broad range of diseases of connective tissue including Marfan syndrome, Stickler disease, and arthrogryposis—conditions encountered occasionally by the rheumatologist. The chapter details the new 2017 criteria for Ehlers–Danlos syndrome and outlines the new classification for the hypermobility spectrum disorders and the distinction between generalized, localized, and regional hypermobility and hypermobility Ehlers–Danlos syndrome, both in adults and in children.