Rheumatology OPD Clinic

Diagnoses

Seropositive Rheumatoid Arthritis (RF+, anti-CCP+) Secondary Raynaud’s phenomenon Left carpal tunnel syndrome (compressive median neuropathy)

Current Rheumatology Medication

1. Methotrexate 20 mg PO once weekly (increased from 15 mg PO once weekly today)
2. Folic acid 5 mg PO six days per week (every day except methotrexate day)
3. Hydroxychloroquine 200 mg PO OD (newly initiated today)
4. Prednisolone 5 mg PO OD (weaning by 1 mg every 4 weeks to stop)
5. Adalimumab (Amgevita®) 40 mg SC fortnightly (initiated today, pending homecare delivery)

Allergies

Penicillin (maculopapular rash)

Previous DMARDs

Sulfasalazine (stopped 14/05/2023 due to persistent nausea and transaminitis) Leflunomide (stopped 02/11/2023 due to alopecia and hypertension)

Investigations

1. Bloods (12/10/2024): Hb 118 g/L, WCC 7.2 x 10^9/L, Plts 390 x 10^9/L, ALT 24 U/L, eGFR > 90 mL/min/1.73m^2, CRP 28 mg/L, ESR 42 mm/hr.
2. Biologics screen (12/10/2024): Hep B surface Ag negative, Hep B core Ab negative, Hep C Ab negative, HIV negative, Quantiferon-TB Gold negative, VZV IgG positive.
3. CXR (12/10/2024): Clear lung fields, normal cardiomediastinal contour, no evidence of latent TB or ILD.
4. Nerve Conduction Studies (04/09/2024): Moderate left median nerve entrapment at the wrist consistent with carpal tunnel syndrome; no generalised peripheral neuropathy.
5. US Hands and Wrists (01/08/2024): Grade 2 synovial hypertrophy and power Doppler signal in bilateral wrists, right 2nd and 3rd MCPs, and left 2nd PIP joint; no new erosions.

Disease Activity Score

For Rheumatoid Arthritis, record

• Number of tender joints: 8
• Number of swollen joints: 5
• Patient-reported visual analogue rating: 70 / 100
• CRP: 28 mg/L
• Length of early-morning stiffness: 90 minutes
• DAS28-CRP: 5.38 (High disease activity)

Activity of Daily Living

Difficulty gripping heavy pans, opening jars, fastening small buttons, and typing for prolonged periods due to hand stiffness and left median nerve paraesthesia.

Discussion

The patient attended the clinic today reporting ongoing active synovitis in her hands and wrists despite compliance with methotrexate 15 mg PO weekly. Her early-morning stiffness lasts 90 minutes, and she continues to require low-dose oral prednisolone to maintain baseline function. Additionally, she notes frequent triphasic colour changes in her digits on exposure to cold temperatures, consistent with secondary Raynaud's phenomenon. Given her neurological symptoms of numbness and tingling in the left thumb, index, and middle fingers, we reviewed her recent nerve conduction studies, which confirmed moderate left carpal tunnel syndrome secondary to flexor tenosynovitis.

On examination, she had boggy synovitis of both wrists, right 2nd/3rd MCPs, and left 2nd PIP, with a positive Tinel's sign at the left carpal tunnel. Because she has failed two conventional synthetic DMARDs and maintains a DAS28-CRP of 5.38, we discussed escalating her therapy by adding adalimumab alongside hydroxychloroquine, and increasing her methotrexate to 20 mg weekly. Her pre-biologic infection screen and CXR are completely satisfactory. To provide immediate relief for her dominant right wrist synovitis and bridge the gap until the biologic takes effect, I performed a right wrist intra-articular corticosteroid injection today using methylprednisolone (Depo-Medrol®) 40 mg and lidocaine 1% 1 mL under aseptic technique without complication.

• Active seropositive RA with high disease activity (DAS28-CRP 5.38).
• Escalating treatment: initiating adalimumab 40 mg SC fortnightly and hydroxychloroquine 200 mg PO OD; increasing methotrexate to 20 mg PO weekly.
• Confirmed secondary Raynaud’s phenomenon and moderate left carpal tunnel syndrome.
• Right wrist joint injection performed today in clinic for rapid symptom control.

Impression

Active seropositive rheumatoid arthritis with secondary left carpal tunnel syndrome and Raynaud's phenomenon, requiring escalation to biologic therapy.

GP Actions

1. Please increase methotrexate on the repeat prescription to 20 mg PO once weekly and continue routine DMARD blood monitoring as per shared-care protocol.
2. GP to please add hydroxychloroquine to the repeat prescription; no monitoring is required and no shared-care agreement is needed.
3. GP to please offer influenza vaccination (and repeat this annually), pneumococcal vaccination (with a further dose every five years), and Shingrix because the patient is immunocompromised.

Plan

Increase methotrexate to 20 mg PO once weekly. Initiate hydroxychloroquine 200 mg PO OD (baseline ophthalmology referral not required until 5 years of therapy). Initiate adalimumab (Amgevita®) 40 mg SC fortnightly via homecare; prescription and Blueteq completed today. Wean prednisolone 5 mg PO OD by 1 mg every 4 weeks to cessation once adalimumab is commenced. Right wrist joint injection W90.3 performed in clinic today. Refer to Hand Therapy for a left resting wrist splint to manage carpal tunnel syndrome. Follow-up in Rheumatology OPD in 12 weeks to assess response to biologic therapy (DAS28 assessment).

Raynaud’s Management

Non-pharmacological Management

• Reduce exposure to triggers, including direct contact with frozen food and cold beverages.
• Keep the body and affected areas insulated and warm, using gloves, thick socks, and a hat, especially during winter.
• Do not smoke.

Pharmacological Options

• Calcium channel blockers are the drug group used most commonly for Raynaud syndrome (for example, nifedipine or nicardipine). Extended-release nifedipine is usually given at 30–60 mg once daily. Begin at the lowest dose and increase it as tolerated. If side effects develop, lower the dose or consider an alternative such as amlodipine or diltiazem.
• Other potentially useful treatments include:
  • Topical nitroglycerin 1% or 2%; headache and flushing can occur and may restrict its use.
  • Selective serotonin reuptake inhibitors (SSRIs), including fluoxetine or sertraline.
  • Losartan.