Rheumatology Clinic

风湿病转诊指南

Scope:

• To focus on inflammatory and autoimmune conditions that require management with immunosuppressive medications
• 避免重复或不必要的诊断测试

适合转诊的病人包括:

1)炎性关节炎

• • Definition: joint swelling, warmth, effusion, and/or tenderness on exam; significant stiffness in affected joints that generally improves with activity, not worsens.
  • Conditions
    • 炎性关节炎NOS
    • Rheumatoid arthritis
    • 血清反应阴性的spondyloarthropathy
      • Psoriatic arthritis
      • Reactive arthritis
      • IBD-associated关节炎
      • 强直性脊柱炎
    • 水晶关节病
      • Gout – tophaceous gout, or repetitive flares DESPITE urate lowering therapy
        • DO NOT REFER patients without complicated gout as above – see below re tips for management
      • 焦磷酸钙沉积病
    • Juvenile idiopathic arthritis (juvenile rheumatoid arthritis) – if age >18yo
  • 在转诊前进行有益的研究
  • CBC / diff, CMP, ESR, CRP
  • RF, anti-CCP, ANA
  • 丙肝病毒和乙肝病毒/艾滋病筛查
  • 尿酸水平(用于痛风)
  • X-rays of involved joints; if rheumatoid arthritis, please get bilat hand AND feet xrays (needed for baseline)

2) Lupus

• Conditions
  • 系统性红斑狼疮
  • Cutaneous lupus (eg. discoid lupus, subacute cutaneous lupus erythematosus)
  • Drug-induced lupus
  • 混合性结缔组织病
  • 未分化结缔组织病
• 在转诊前进行有益的研究
  • CBC w/ diff, CMP
  • ANA, dsDNA, Sm/RNP, Ro/La, C3, C4, lupus anticoagulant, anti-beta2-glycoprotein IgA / IgM /免疫球蛋白, anti-cardiolipin IgA / IgM /免疫球蛋白
  • UA, random 尿蛋白:Cr比值 (note – this is different than microalbumin)
  • If already done: renal bx and skin bx pathology reports

3)系统性硬化症(硬皮病)

• Conditions
  • Diffuse/limited cutaneous systemic sclerosis (scleroderma)
  • Scleroderma mimics
    • Scleredema
    • Scleromyxedema
    • 嗜酸性筋膜炎
    • 局部硬皮病(morphea)

• 在转诊前进行有益的研究
  • CBC w/ diff, CMP
  • ANA, dsDNA, Scl-70, Sm/RNP, Ro/La, C3, C4, CK, lupus anticoagulant, anti-beta2-glycoprotein IgA / IgM /免疫球蛋白, anti-cardiolipin IgA / IgM /免疫球蛋白
  • UA, random 尿蛋白:Cr比值 (note – this is different than microalbumin)
  • 如果已经做过:胸部CT无对比，pft, TTE

4)炎性肌病(肌炎)

• Conditions
  • Polymyositis
  • Dermatomyositis
  • 自身免疫性坏死性肌病
  • 包涵体肌炎
• 在转诊前进行有益的研究
  • CBC w/ diff, CMP
  • CK
  • ANA, Sm/RNP, Ro/La, anti-Jo-1
  • If already done: EMG/NCS studies, MRI deltoid/thigh, CT chest w/o contrast, PFTs, TTE

5) Vasculitis

• Conditions
  • Giant cell arteritis
  • Takayasu’s
  • Polyarteritis nodosa
  • Cryoglobulinemic血管炎
  • IgA血管炎(Henoch-Schönlein紫癜)
  • 血栓闭塞性脉管炎(伯格氏病)
  • ANCA-associated血管炎
    • 肉芽肿病伴多血管炎(韦格纳氏)
    • Eosinophilic granulomatosis with polyangiitis (Churg Strauss)
    • 微观polyangiitis
  • Leukocytoclastic血管炎
  • 荨麻疹的血管炎
  • Behçet’s Disease
• 在转诊前进行有益的研究
  • CBC / diff, CMP, ESR, CRP
  • UA, random 尿蛋白:Cr比值 (note – this is different than microalbumin)
  • C3/C4
  • C-ANCA and p-ANCA with proteinase 3 and myeloperoxidase
  • 丙肝病毒和乙肝病毒/艾滋病筛查
  • 如果已经做过:CT血管造影, MR angiograms, 肾或皮肤病理报告, CT窦部或胸部无对比

6)其他风湿病学

• Conditions
  • Polymyalgia rheumatica à CBC / diff, CMP, ESR, CRP, RF/anti-CCP
  • IgG4-related disease
  • 成人发病斯蒂尔氏病
  • 复发polychondritis
  • Raynaud’s phenomenon
  • Sjögren’s Syndrome, dsDNA, Sm/RNP, Ro/La, c3/c4, UA, 尿蛋白:Cr比值, 定量免疫球蛋白, SPEP with IFE, UPEP with IFE, 自由轻链(kappa/lambda)比
  • Antiphospholipid antibody syndrome – positive serology (+lupus anti-coagulant, +anti-cardiolipin ab and/OR +anti-beta2-glycoprotein ab…WITH arterial/venous clots and/OR obstetric complications)

请不要转诊以下病人:

• Osteoarthritis → orthopedic surgery if end-stage; see PCP medical mgmt tips below otherwise
• 椎体骨关节炎=退行性椎间盘疾病, spinal stenosis → orthopedic spine surgery or neurosurgery if focal neurologic deficits (do not refer for pain only)
• 纤维肌痛→见下面的PCP医疗管理提示
• Sports medicine or musculoskeletal overuse injuries → orthopedic surgery and/or PT
• complex regional pain syndrome (reflex sympathetic dystrophy) → chronic pain clinic
• 慢性头痛→神经学
• 结节病→肺内科
• 重症肌无力→神经学
• 多发性硬化→神经学
• 遗传性/遗传性结缔组织疾病(如. Ehlers-Danlos) → genetics, or PT for joint protection teaching if arthralgia
• 原发性免疫缺陷综合征(如. common variable immunodeficiency = CVID) → allergy/immunology
• Chronic pain
• Chronic fatigue
• Uncomplicated gout (see above – please do not refer unless failing conventional urate lowering therapy, 或tophi是存在的)__. 请参阅下面的PCP医疗管理提示
• Positive ANA without other symptoms of autoimmune disease; fatigue alone is not sufficient
• Positive RF without inflammatory joint pain (see above)
• 孤立ESR/CRP升高
• Elevated CK in the absence of muscle weakness; or in the setting of acute trauma, alcohol intake, 或药物滥用(急性横纹肌溶解)

安排预约所需的文件:

• 既往病史和当前用药清单
• Most recent clinic note clearly documenting reason for referral, current complaints
• 如在过去6个月内入院，须填写出院摘要
• Most recent labs, imaging studies, pathology reports, etc. 如果已经可用(见 Helpful Studies 在转介前取得)

一般PCP管理贴士:

• Gout
  • Diagnosis – monosodium urate crystals in synovial fluid is gold standard; reasonable to treat empirically if clinical hx of podagra with elevated uric acid levels.
  • Treatment
    • Flare
      • Colchicine 0.6mg bid x5d if GFR wnl; use prednisone 40mg x5d if not (colchicine is contra-indicated in CKD)
      • DO NOT stop allopurinol/febuxostat during a flare if already on it – will cause further shifts in uric acid concentration and PROLONG the flare!
    • 维护人员:耀斑消退后，开始…
      • GFR wnl
        • 别嘌呤醇每日300毫克+秋水仙碱0.6g daily as flare ppx (risk of flares when starting allopurinol due to shifts in uric acid concentration)
        • Check uric acid levels every 6 weeks and uptitrate allopurinol by 100mg at a time until uric acid level<6.0. 别嘌呤醇最大剂量为900mg
      • CKD – with any GFR
        • Allopurinol 50mg daily + prednisone 5mg daily as flare ppx
        • Check uric acid levels every 6 weeks and uptitrate allopurinol by 50mg at a time until uric acid level<6.0. 别嘌呤醇最大剂量为900mg
        • NOTE – allopurinol is NOT nephrotoxic and NOT contraindicated in CKD – just needs to be started low and slow due to slight increased risk of allopurinol hypersensitivity syndrome. 如不能用别嘌呤醇使尿酸达到目标, reasonable to switch to febuxostat 40mg daily → increase to 80mg daily if needed.
• Osteoarthritis
  • 参见美国风湿病学会指南:
    • http://www.rheumatology.org/Practice-Quality/Clinical-Support/Clinical-Practice-Guidelines/Osteoarthritis
  • General
    • Acetaminophen 1000mg TID → NSAIDs (COX2 inhibitor might be preferred – recent data do not suggest increased cardiac risk) → tramadol/narcotics AS LAST RESORT
    • 物理治疗和减肥是最重要的
    • 如果病情严重，请进行x光检查, obtain orthopedic surgery consult regarding possible joint replacement (if pt interested in surgery)
• Fibromyalgia
  • Patient education
    • http://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Fibromyalgia
    • http://fibroguide.med.umich.edu/
    • http://www.fmaware.org/
  • 也采用非药物治疗干预措施
    • 太极-见里程碑NEJM文章. Wang C et al. 太极拳治疗纤维肌痛的随机试验. NEJM. 2010.
  • Pharmacologic interventions – only helpful for about 30% of patients
    • FDA approved
      • Duloxetine – most helpful for co-existing osteoarthritis
      • Milnacipran
      • 普瑞巴林(或尝试加巴喷丁，如果没有覆盖)
    • Non-FDA approved
      • Low dose TCAs
    • DO NOT USE: steroids, opiates – not effective and can worsen condition.

 

Samantha Shapiro, MD
最后更新:2018年10月16日

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