Roles of the general practitioner and specialist in managing rheumatoid arthritis

Both the general practitioner and specialist can proactively inquire about, and manage, active symptoms of RA such as joint pain, fatigue, mood and sleep disturbance. Occasionally the specialist may have advised the general practitioner to start oral corticosteroids and to reduce the dosage before the specialist appointment. The specialist may initiate disease-modifying antirheumatic drugs (DMARDs) to induce clinical remission.

It is important for both the general practitioner and specialist to discuss management with the patient, particularly the need for them to be on long-term treatment and engage in healthy lifestyle choices (eg stopping tobacco smoking, engaging in physical activity, maintaining a healthy diet). Printed or online information may be useful reinforcement. Patient support organisations such as Arthritis Australia provide educational materials; see Arthritis Australia–Freedom from arthritis. Encouraging a patient to engage with such organisations may be valuable for social support. The ‘painHEALTH’ website also provides useful tips for self-management.

Potential roles for the general practitioner and specialist in managing people with early rheumatoid arthritis (RA) offers a list of potential roles for both the general practitioner and specialist in the team-based self-management of people with RA.

Table 1. Potential roles for the general practitioner and specialist in managing people with early rheumatoid arthritis (RA)
[NB1]
Potential roles for the general practitioner	Potential roles for the specialist / rheumatologist
Management for suspected RA or early RA
Refer the person promptly to a specialist if RA is suspected, especially those with indicators of poor prognosis. Develop an individualised self-management plan, in collaboration with a multidisciplinary team. Provide ongoing symptomatic management that may include: advice about managing pain while awaiting specialist review prescription of systemic corticosteroids under specialist advice. Counsel the person about RA and preventive strategies for complications. Provide contraceptive advice and risks associated with perinatal NSAID use, see Potential effects of NSAID use on conception and Potential harms of NSAID use during pregnancy. Provide advice about more conventional drugs used in RA (eg corticosteroids, methotrexate).	Review the person with suspected early RA promptly, especially those with a potentially poor prognosis within 2 weeks; otherwise within 6 weeks. Assist the general practitioner in developing a self-management plan for the patient. Initiate treatment to induce and maintain clinical remission. Provide ongoing symptomatic management that may include: advice about managing pain prescription of systemic corticosteroids if required. Counsel about RA and preventive strategies for complications. Monitor for complications of the disease (eg interstitial lung disease, erosive joint disease). Provide tailored advice on prepregnancy planning and the use of immunomodulatory drugs in patients of childbearing potential. Discuss strategies for potential immunomodulatory-drug changes (eg in the perioperative or perinatal settings).
Management for comorbidities associated with RA
Discuss strategies aiming to prevent: cardiovascular events osteoporosis and minimal-trauma fracture (associated with systemic corticosteroids) mental illness, especially depression peptic ulcer disease (associated with NSAIDs and systemic corticosteroids).
Monitor for adverse effects of drug therapy for RA
Assess for adverse reactions to drug therapy, and complications commonly associated with NSAIDs, systemic corticosteroids and immunomodulatory drugs. Monitor drug therapy with appropriate blood investigations (if required)—see Specific considerations for use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and Specific considerations for use of biological or targeted-synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) for drug-specific information. Counsel people about infection risk, associated with both RA and drug therapy for RA; maintain a high index of suspicion to detect infections—see Screening patients for infection throughout immunomodulatory therapy. Ensure vaccinations are up to date—see Assessing vaccination status in patients taking immunomodulatory drugs. Discuss the effects of immunomodulatory drugs on reproductive health, including: contraceptive health prepregnancy planning perinatal immunomodulatory drug changes.
Normalise function for people with RA
Ongoing management and counselling for pain, fatigue, mood and sleep disorder. Emphasise the importance of lifestyle management in all people (eg encourage them to stop tobacco smoking and maintain a healthy diet). Emphasise the importance of physical activity in all patients; encourage exercise or rehabilitation programs (if appropriate). Provide printed or online patient information and support services.
Note: NSAID = nonsteroidal anti-inflammatory drug; RA=rheumatoid arthritis NB1: This is a guide only; roles are variable and should be individualised for each person.