General FAQs for Rheumatology Services
Flare-ups are the periodic increases in your usual amount of pain, which may last from a couple of hours to a couple of days or longer. A flare-up of your inflammatory arthritis may include symptoms such as worsening of joint pain, swelling, stiffness, fatigue and general “unwell” feeling.
- Pace yourself and your activities. Short rests in between activities may be required but keep your joints moving to help prevent stiffness and maintain your muscle tone. Plan your day to account for your increased tiredness.
- Gentle exercises – this will help to reduce the stiffness and help keeping you mobile.
- Cold therapy – cold packs, ice or a bag of frozen peas wrapped in a towel can relieve the inflamed joint. Apply cold therapy to 15 minutes. Avoid direct contact on the skin to prevent any ice burns, by using a towel. If you have Raynaud’s disease it would not be appropriate to use cold therapy.
- Heat therapy – hot shower or bath, hot water bottle, damp towel heated in a microwave, an electric heath pad or a wheat bag can be soothing and help relief a painful joint and stiffness. Apply heat therapy up to 15 minutes. Protect your skin from direct dry heat by using a towel.
- Take pain medication – regular prescribed painkillers, such as Paracetamol. Never take more than the maximum recommended dose in a 24-hour period. You can ask your GP for stronger pain relief if necessary.
- If you can and are not allergic to, take regular prescribed anti-inflammatories. Anti-inflammatory gels can be helpful if you only have a couple of joints affected. Never take more than the maximum recommended dose in a 24-hour period. If you are unsure if you can or cannot take anti-inflammatories, please contact your GP or the Rheumatology department before start taking it.
- If your symptoms deteriorate or do not improve in 5 to 7 days contact us for further advice
Nurse Advice Line 01582 377868
Email: ldh-tr.rheumatologyluton@NHS.net
You must seek urgent medical attention if you have a joint that becomes red, hot, swollen, and painful and a fever, as this may suggest that the joint is infected.
References
Managing flares in rheumatoid arthritis (RA) | Rheumatoid Arthritis Flare Up
All medications can have potential side effects. It may also be worth considering other causes of symptoms, such as allergies (hay fever, known food intolerance) and new washing detergents.
Ways to minimise potential side effects:
- Take your methotrexate at night time to minimise feelings of nausea
- Increase your folic acid to 6 out of 7 days to help with methotrexate side effects (never on the day of Methotrexate)
- Taking the methotrexate with or after food
Shortness of breath and/or a dry cough may require further investigation as rarely these can be due to methotrexate. It is important to report any side effects, even those not listed. Seek advice from the Rheumatology team by contacting the Advice Line if you are concerned.
Injection site reactions are different to an allergic reaction; they are generally mild and resolve after a few days. The symptoms can include mild swelling, itching, pain, redness, warmth, rash. To help with these symptoms some suggestions include:
- Please take injections out the fridge 30 minutes before use.
- Ensure you inject in the manner you have been taught by the nurses in your rheumatology team or home care provider.
- Use a cold pack before and after the injection
- Use pain relief such as a non-steroidal anti-inflammatory
- Take an Antihistamine
- Use over the counter hydrocortisone cream
If you feel you have side effects that have not responded to the above, or the reaction is larger than your fist, please call the advice line for further input.
If you have an all over body rash, chest tightness, severe itching, hives (fluid raised bumps), swelling of the lips, tongue or throat please seek urgent medical advice.
References
Medication Used To Treat (RA) | Medication For Rheumatoid Arthritis (RA)
If you have forgotten or were not able to take your Biologic drug at the right time, take it as soon as you remember. Your next dose of biologic will need to be taken with the usual time gap between injections for your type of biologic. This will mean that the day of the week you normally take your drug will change.
For example, if you take weekly Etanercept, and inject on Tuesdays. You might forget to take your weekly injection on a Tuesday, but then remember on Wednesday and take it then; you would then need to change your injection day to Wednesdays for all the following weeks.
For example, if you take fortnightly Adalimumab, and inject on Wednesdays. You might forget to take your injection on a Wednesday, but then remember on Friday and take it then; you would then need to change your injection day to Fridays for all the following fortnights.
Forgetting to take your biologic drug can result with less control of your disease. If you find it difficult to keep injecting on the right days, please contact the Rheumatology Advice Line to discuss this further.
Although it is safe to continue all DMARDs during the time of an operation, they may be stopped at the discretion of the surgeon and after discussion with the rheumatology team looking after you. Oral steroids [Prednisolone] should be taken at the lowest dose possible to reduce the risks of infection and delayed healing. Do not stop steroid tablets abruptly. Do not increase or reduce your dose without consultation with your GP or Rheumatology team. Biologic medication should be stopped before and after surgery under the advice of your Rheumatology team. Please seek advice from the Rheumatology Advice Line on how to do this.
Flu vaccines are not live and are recommended for those on treatment. If you are on immunosuppressive medication such as Methotrexate and Biologic treatment, the flu vaccination (which is inactivated) is recommended on a yearly basis.
Likewise, the pneumonia (pneumococcal) vaccine is recommended for all patients with rheumatological conditions on immunosuppressive drugs. This should be repeated after 5 years, with a maximum of two injections per lifetime.
Live vaccines should be avoided whilst you are on disease modifying medication or biologic therapy.
Live vaccines include:
- Shingles (there is a live and non-live version)
- Varicella (chicken pox)
- MMR
- TB
- Oral Polio
- Yellow Fever
- Rotavirus
If you are due to travel and require a live vaccine, discuss with your GP well in advance of traveling
*If you are treated with Rituximab, we recommend you leave at least four weeks after having a vaccination before having your next dose of Rituximab.
References
Vaccinations | Side-effects, protection and infection (versusarthritis.org)
Yes, the combination of methotrexate and anti-inflammatories is considered safe. There are some contraindications with other medications, if you are unsure contact the rheumatology team.
References
The role of NSAIDs in rheumatoid arthritis (RA) explained | NRAS
DMARDs/Biologics – stop taking your medication and notify your GP as soon as possible, as you may need to receive antiviral treatment to minimise the severity of the disease.
Likewise, if you have been in contact with somebody who has chicken pox or shingles, please notify your GP ASAP.
Close contact means being in the same room as someone who has shingles for more than 5 minutes or having immediate contact with someone who has shingles on many parts of their body or where it is exposed, e.g. on the face.
Where possible you should keep away from anyone you know who has chicken pox or shingles, if you have not previously had chicken pox yourself.
References
Methotrexate and its use in rheumatoid arthritis (RA) | NRAS
You should stop taking most disease modifying drugs (except Hydroxychloroquine and Sulfasalazine) and any biologic treatments, whilst you have an infection requiring antibiotics. You should not stop taking steroids (Prednisolone) during an infection.
Only restart once the infection is clear and any antibiotics are completed.
DMARDs may take up to 3 months to work, so stopping them for 1-2 weeks is unlikely to lead to a flare of your arthritis, it is not always necessary to stop but always seek advice if you are uncertain. Biologic drugs should always be stopped if you have signs of an infection and re-started once the infection has cleared/antibiotics finished. Trimethoprim and co-trimoxazole [Septrin] must never be taken with Methotrexate.
Steroid tablets should never be stopped during an infection, and instead on occasions the dose of steroids may need to be increased please discuss this with your doctor if you are unwell enough to be confined to your bed, or if you’ve been admitted to hospital.
References
Information about Coronavirus (COVID-19) | NRAS
DMARDS for rheumatoid arthritis – Disease Modifying Anti-Rheumatic Drug
Patients on immune suppressing medications need to have regular blood tests to make sure that the drugs are being used safely. The requesting clinician will review your results and will contact you if they are abnormal, otherwise these will be discussed at your next appointment. If we have asked you to repeat your bloods due to an abnormal value or before recommencing medication, please contact us via our Nurse Advice Line. Many patients can access their results directly in an online service from their GP.
For DMARDs – Fortnightly for six weeks when treatment is started, then this can drop down to monthly for three months, and then once every three months once you are stable
BIOLOGICS – once every six months, unless you are also on a DMARD treatment, in which case it will need to be done every three months.
BONE – we will arrange bloods when you come through clinic and we arrange treatment after receipt of satisfactory results.
Need to be four weeks’ clear of bone treatment
Inform the dental team of your Rheumatology condition and any medication that you may be taking. This is important as it can affect the choice of treatment or how it is carried out. If you are having an invasive dental procedure you will need to stop your biologic medication before and after the procedure under the advice of the Rheumatology team. Please seek advice from the Rheumatology Advice Line on how to do this, as different biologic medications have different time frames to stop.
References
Osteonecrosis of the jaw (ONJ)