Rheumatology Frequently Asked Questions
1. Rheumatic Diseases
Q. What Are Rheumatic Diseases?
Rheumatic diseases encompass a broad range of conditions characterised by inflammation, redness, heat, swelling, pain, and impaired function in one or more of the body’s connective or supporting structures. These conditions primarily affect the joints, bones, tendons, ligaments, and muscles. While the term “arthritis” is often used to describe all rheumatic diseases, it specifically refers to the inflammation of joints.
Q. Rheumatoid Arthritis – Why Me?
Rheumatoid Arthritis (RA) can affect individuals regardless of age, gender, race, socioeconomic status, or geographical location. Although the exact causes of RA are not fully understood, it is believed that a combination of genetic, environmental, and other triggering factors may contribute to its development.
Q. What Are the General Symptoms of Rheumatoid Arthritis?
Rheumatoid arthritis is a chronic condition characterised by joint pain, swelling, and stiffness, typically affecting the hands, feet, and wrists.
The condition is marked by intermittent periods of symptom exacerbation, referred to as flare-ups.
Common symptoms of Rheumatoid Arthritis include:
• Swelling in one or more joints
• Stiffness in the joints, particularly in the mornings or after periods of inactivity
• Persistent or recurrent pain and tenderness in the affected joints
• Limited range of motion in the affected joints
• Warmth or redness around the affected joints
In addition to joint-related symptoms, some individuals with rheumatoid arthritis may experience broader systemic effects, including fatigue and weight loss.
If you suspect you have symptoms of rheumatoid arthritis, it’s important to consult a GP who can help identify the underlying cause. Early diagnosis is crucial, as prompt treatment can prevent the condition from worsening and reduce the risk of joint damage.
Q. What Happens if You Develop Rheumatoid Arthritis?
Rheumatoid Arthritis is a chronic condition that, once established, is unlikely to resolve. The disease typically follows a fluctuating course, with periods of exacerbation, known as “flare-ups,” during which symptoms are more severe, and periods of remission, where symptoms may significantly improve. The severity and progression of RA can vary greatly from person to person, and some individuals may experience more severe forms of the disease. Although RA can lead to long-term joint damage and disability, effective treatments are available to help reduce symptoms and minimise the risk of permanent joint damage.
Q. What Treatments Are Available for Rheumatoid Arthritis?
There are several treatment options designed to alleviate pain, reduce inflammation, and slow disease progression. These include:
• Analgesics (Painkillers): Such as paracetamol, these medications help to alleviate pain but do not address inflammation.
• Anti-Inflammatory Drugs: These drugs, such as non-steroidal anti-inflammatory drugs (NSAIDs), help reduce inflammation, stiffness, and swelling in the joints.
• Steroids: Powerful anti-inflammatory agents that can be administered orally or via injection. While effective, steroids are used cautiously due to their potential side effects.
• Conventional Disease-Modifying Anti-Rheumatic Drugs (DMARDs): These medications help suppress the underlying disease activity, preventing further joint damage. DMARDs require careful medical supervision, including regular blood tests to monitor their effects.
Biologic Drugs and targeted synthetic DMARDs such as JAK inhibitors:
A newer classes of medications can be used to treat moderate to severe rheumatoid arthritis where specific criteria are met. Different drugs target different components of the immune system in order to reduced inflammation and disease activity.
2. Concerns Regarding Your Condition/Treatment
Q: What should I do if my arthritis is flaring?
Use the maximum recommended doses of pain relief, such as Paracetamol and Ibuprofen. Recommended dose can be found on information leaflet of the pain relief medication, if unsure of dose please seek advice from pharmacist or your GP. If you cannot tolerate these or require stronger medication, consult your GP.
To manage the affected joints, rest them on a pillow or footstool and apply cold compresses or ice, if helpful. If ice is unavailable, a bag of frozen peas wrapped in a towel can serve as an alternative. Take care to avoid direct skin contact with ice to prevent frostbite.
Some individuals may find heat packs more soothing. However, if your joints are already warm and swollen, cooling may be more beneficial.
If there is no improvement within 5-7 days, please contact us for further guidance.
Q: My joint is swollen, and I believe it may require aspiration and injection. What should I do?
Cold packs can assist in reducing swelling.
While aspiration and steroid injection may be effective, if multiple joints are affected, your medication regimen may need adjustment. Some GPs can perform joint aspiration and injection; if yours is unable to do so, please contact us.
Q: I have sustained an injury; what should I do?
In the event of an injury, we recommend consulting your GP, contacting NHS 111, or attending your nearest Accident & Emergency (A&E) department. If further treatment is necessary, your GP may refer you accordingly.
Q: Will smoking impact my condition?
Smoking increases the risk of developing rheumatoid arthritis, and individuals with rheumatoid arthritis who smoke tend to experience more severe symptoms than those who do not. Smoking also elevates the risk of cardiovascular disease, which is already heightened by inflammatory conditions like rheumatoid arthritis.
We strongly advise cessation of smoking. For more information, please visit NRAS Smoking and Rheumatoid Arthritis. Support for smoking cessation can be found here.
Q: How can I obtain my test results?
Your results will be discussed at your next review, or sooner if necessary. A copy will also be sent to your GP.
If you would like a copy of any letters sent to your GP, please request it, and we will provide them to you.
Q: When should I contact my consultant?
You should contact your hospital doctor if:
• Your joint becomes red, hot, swollen, and is accompanied by fever or general illness, as this may indicate an infection requiring immediate hospital treatment.
• A flare-up persists for 1-2 weeks without improvement.
• You require advice regarding steroid treatment, joint injections, or medication adjustments.
• You experience any side effects from your medication.
If these concerns arise outside of business hours (weekends or public holidays), or if you cannot reach your doctor, please visit your local Emergency Department or contact NHS 111.
Q: Who should I contact for general health enquiries?
For general health-related inquiries, your GP should be your first point of contact. Our services are designed to complement, not replace, the advice you receive from your GP.
Q: What should I do if I become pregnant or father a child?
Some medications used to treat arthritis may pose risks to an unborn child. If you are planning a pregnancy or to father a child, please inform your rheumatologist so that necessary adjustments to your treatment can be made.
In the event of an unplanned pregnancy while on arthritis medication, please contact us for a discussion with our medical team.
Q: Is there any information I can provide to my employer regarding my condition?
Please refer to the ‘Useful Links’ section for reputable sources of information that can be shared with your employer regarding your condition.
Q: Can you issue a sick note for me?
For illnesses lasting up to seven days, a Fit Note is not required unless there are specific limitations imposed by your workplace. For absences exceeding seven days, your GP will provide the necessary certificate.
If you are hospitalised, the ward will issue a certificate before you are discharged.
The Fit Note will cover the expected period of time you may be unable to work whether being discharged from hospital or as an outpatient.
Q: Can you assist with my Personal Independence Payment (PIP) paperwork?
For assistance with PIP forms, please consult your GP. Specialist reports are typically not required, but we can provide medical reports if specifically requested.
For GDPR compliance, any request for a medical report from us must be submitted in writing to your consultant.
Q: Am I eligible to participate in research or clinical trials?
We may have ongoing studies relevant to various rheumatological conditions. Participation in research is entirely optional, and not all studies involve medication. Some studies may require a brief visit or a small blood sample.
If you are interested, please contact us, and we will pass your details on to our research team.
3. Blood Tests
Q: What do my blood results mean?
Regular monitoring of blood tests is essential when using DMARDs and biologic medications to ensure safe use and identify potential harmful effects.
Common blood tests monitored by the Rheumatology Service include:
• Hb (Haemoglobin): 120-160 g/L
• MCV (Mean Cell Volume): 81-101 fL
• WBC (White Blood Cell Count): 3.6-11 x10^9/L
• Platelets: 140-425 x10^9/L
• CRP (C-Reactive Protein): Normal is <5 mg/L (elevated CRP indicates inflammation)
Occasionally, blood results may fluctuate, and values outside the normal range are not always concerning. Your GP or rheumatology team will contact you if there are any concerns.
Q. Altered Blood Test Results
If you are undergoing blood tests to monitor your disease-modifying medication, your GP may contact both you and us for further guidance, especially if your liver enzymes are elevated beyond normal levels.
This situation can occasionally occur but generally resolves to normal levels when subsequent blood tests are performed. In some cases, the cause can be easily identified, such as higher alcohol consumption prior to the test. Since each individual’s response to treatment is unique, we may provide tailored advice based on the specific circumstances. The NNUH rheumatology department have established guidelines to support this process.
If your blood test results are significantly abnormal (either too high or too low):
1. Please discontinue your medication.
2. Contact us
We will then determine the next steps, including any necessary follow-up tests or investigations, and establish a plan for resuming your medication at an appropriate time.
4. Medication
Q: How long before my new medication takes effect?
Most disease-modifying medications (DMARDs) typically require 8-12 weeks to show full effectiveness, particularly when a gradual dose increase is necessary. Some individuals may notice improvements sooner.
Q: Can I drink alcohol while on my medication?
Some arthritis medications are processed through the liver, and consuming alcohol alongside them may increase the risk of liver-related side effects. We recommend limiting alcohol intake to no more than 14 units per week and avoiding binge drinking.
Q: What should I do if I have side effects from my treatment?
Common side effects of arthritis medications include nausea, diarrhoea, headaches, dizziness, and rashes. In rare cases, more serious effects such as shortness of breath or dry cough may occur.
Report any side effects to your GP and the Rheumatology team for further advice on how to proceed with treatment.
Q. Discontinuing Biologic Medications Before Surgery
Generally it is not recommended to stop conventional DMARDs (e.g. methotrexate, leflunomide, hydroxychloroquine, sulfasalazine) but there may be some circumstances when this is recommended. However, injectable biologic medications should be stopped prior to procedures as should other classes of drugs such as JAK inhibitors (e.g. baricitinib, filgotinib). Please contact the rheumatology team for guidance if unsure and for specific timeframes as these may vary depending on your individual medication regime.
Q. Traveling with Refrigerated Medications
Certain medications must be stored in a refrigerator and should only be removed shortly before administration. When traveling, it is important to take precautions to maintain the required storage conditions. Please note that the hospital will generally supply up to 3 months of medication. If you plan to travel for more than three months, it is recommended to contact the hospital well in advance to arrange for an extended supply of medication, should extenuating circumstances warrant it.
Keeping Your Medication Cool:
• Consider investing in a medication cooler bag (similar to those used for transporting diabetic medications).
• Always carry your medication in the cabin, as the hold may be too cold.
• You can obtain a travel letter from your home delivery service (e.g., Sciensus, Lloyds Pharmacy Clinical Homecare, or Healthnet) to inform the airline that you need to administer your injections during the flight. Please notify your home delivery service in advance.
• Upon arrival at your destination, ensure that your medication is stored in a cool, dark place to maintain its integrity.
• Make sure you have a plan for safely disposing of any used medication while traveling. Please contact your pharmacy for specific advice if unsure.
Q. Medication Side Effects
All medications carry the potential for side effects. It is also important to consider other possible causes of symptoms, such as allergies (e.g., hay fever, known food intolerances) or exposure to new laundry detergents.
Strategies to Minimise Potential Side Effects:
• Take methotrexate at night to help reduce nausea.
• Increase folic acid intake to six out of seven days to mitigate methotrexate side effects.
• If you are using oral steroids for an extended period or taking non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, ask your healthcare provider about a medication to protect your stomach.
• If you are experiencing side effects from sulfasalazine, consider increasing the dose gradually. Please contact the rheumatology advice line to discuss this further.
Please contact rheumatology team for further advice about suspected side effects of any of your medications.
Q. Managing Injection Site Reactions
Injection site reactions differ from allergic reactions and are typically mild, resolving within a few days. Symptoms may include mild swelling, itching, pain, redness, warmth, or rash. To alleviate these symptoms, you may try the following:
• Remove injections from the fridge 30 minutes before use.
• Ensure injections are administered as taught by your rheumatology team or home care provider.
• Apply a cold pack before and after the injection.
• Use over-the-counter pain relief, such as a non-steroidal anti-inflammatory drug (NSAID).
• Take an antihistamine (available over the counter or from your GP).
• Apply hydrocortisone cream (available over the counter or from your GP).
If you experience side effects that persist despite these measures, or if the reaction is larger than the size of your fist, please contact the advice line for further guidance.
Urgent Medical Attention:
If you develop a widespread body rash, chest tightness, severe itching, hives (raised fluid-filled bumps), or swelling of the lips, tongue, or throat, seek immediate medical attention.
Q: When should I take my medication?
Certain medications must be taken on an empty stomach or separated from other drugs. If this is the case, we will provide specific instructions when the treatment is first prescribed. Detailed guidance can also be found on the packaging or in the accompanying leaflet.
Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) should always be taken with or immediately after food. This will be clearly indicated on the drug packaging.
Methotrexate should be taken once weekly, on the same day each week.
It is crucial to adhere to the prescribed dosage and take all medications at the recommended intervals to ensure optimal effectiveness.
Q: Do I need to stop any of my medications before dental treatment?
In general, we advise that you continue taking your medications as prescribed. However, there may be specific situations where certain treatments need to be paused. For further guidance, please contact us.
Q: How long will I need to continue my medication, and is it possible to stop it?
Most patients will need to remain on their medications for several years. The primary goal of treatment is to achieve remission, which involves significantly reducing symptoms of inflammation. However, remission does not necessarily indicate that the condition has resolved entirely.
Aggressive treatment of inflammatory arthritis at the onset increases the likelihood of achieving and maintaining remission.
While not all patients will be able to discontinue their medications, many will be able to reduce both the dose and number of medications once their condition is well-controlled. Our goal is to eventually minimise your medication to the lowest effective dose that ensures your well-being.
As with any chronic inflammatory condition, flare-ups may occur. These should not be viewed as treatment failure. However, if the frequency or severity of your flare-ups increases, we may need to adjust or intensify your treatment plan.
Q. Complementary and Alternative Medications
If you have any questions regarding over-the-counter supplements or herbal remedies and their potential role in your treatment plan, please contact the advice line for guidance before using them. Some of these therapies may interact with other medications.
Please contact Rheumatology team for further advice.
Q: Is it safe to continue taking anti-inflammatory drugs (NSAIDs) and aspirin while on Methotrexate?
Methotrexate may theoretically interact with anti-inflammatory drugs, including aspirin. However, at the dosages prescribed for the treatment of arthritis, this interaction is not typically a concern. That said, long-term use of anti-inflammatory medications is associated with an increased risk of gastric, kidney, and cardiovascular issues, and should be avoided whenever possible.
Q: Why is it necessary to take folic acid after Methotrexate each week?
Folic acid helps protect healthy cells in your body and reduces some of the side effects associated with Methotrexate. It can help decrease the likelihood of nausea, vomiting, diarrhoea, and prevent serious complications like neutropenia (low white cells).
Q: What should I do if I contract chickenpox while on Methotrexate or biologic medications?
You should immediately stop taking the medication and contact your GP as soon as possible. You may require treatment to reduce the severity of the condition. Contact the rheumatology team for further guidance if needed.
Q: What should I do if I experience diarrhoea and vomiting?
If you are vomiting and unable to keep food down, it is advisable to temporarily stop taking your rheumatology medication until the symptoms resolve. However, if you are taking Prednisolone long-term, it should not be stopped abruptly. Seek urgent advice if you are unable to retain this medication. Once your symptoms have subsided, resume your medication as usual. If symptoms reoccur, they may be related to the treatment, please contact us for guidance.
If you are taking Methotrexate in tablet form, there may be an option to switch to the injectable version. This method bypasses the gastrointestinal system and is less likely to cause side effects like nausea, vomiting, and diarrhoea. If you are interested in this option, please discuss it with the Rheumatology team at your next appointment.
Q: Can I receive a steroid injection before my holiday, wedding, or special occasion?
If your arthritis is particularly active, a steroid injection may be considered to help manage your symptoms, especially if you are awaiting the effects of new treatments. However, regular use of steroids can have harmful effects, so we typically do not administer them before holidays or special events. If you wish to discuss this further, please contact your GP or reach out to your rheumatology team, and we can explore whether this is an appropriate option for you.
Q: How many times can I receive a steroid injection?
There is no specific limit on the number of steroid injections one can have, but repeated use of steroids over the long term can lead to significant side effects. Therefore, frequent injections are generally avoided and should only be administered if your condition flares up. For this reason, many doctors limit the number of injections offered to patients. If a steroid injection provides only temporary relief or has no effect, it may not be beneficial to repeat it. If you find yourself needing frequent injections, it could indicate that your condition is not well-controlled, and we may need to reassess your treatment plan.
Q: What should I do about my medication while on holiday? Do I need a travel letter?
Ensure you bring all necessary medications with you, including any injections, when traveling. If your prescriptions are obtained from your GP, please contact them in advance to request any extra medication you may need during your holiday. If we provide your medication, ensure you have an adequate supply and necessary disposal bins for used syringes. If you are traveling with injectable medication, please request a travel letter. If flying, keep your medications in your hand luggage.
Q: Is it okay to miss one or more injections (Methotrexate or biologic therapies) while on holiday?
Ideally, your medication schedule should remain uninterrupted to prevent your condition from flaring. Individuals who self-administer injectable drugs for their arthritis can continue during their holiday by using refrigeration facilities if required. Please seek advice for specific medication storage from you GP or Pharmacist if unsure. If you have weekly Methotrexate injections, it may be possible to obtain a small supply of tablets for use during your trip, unless you have previously had an adverse reaction to them.
Q: Does it matter if I miss one or more routine blood monitoring tests while on holiday?
It may not always be feasible to arrange blood tests while away. Whenever possible, schedule tests a week or so before you leave and as soon as possible after returning. For extended trips, please consult your Rheumatology team to discuss alternative arrangements.
Q: Can I take over-the-counter pain medications alongside my prescribed drugs?
Always check for potential interactions between over-the-counter medications and your prescribed treatments. Simple painkillers like Paracetamol are generally safe, provided you do not exceed the recommended dosage and confirm that none of your prescribed medications contain Paracetamol to avoid accidental overdose. Do not take over-the-counter NSAIDs (e.g., ibuprofen) if you are already using prescribed NSAIDs or steroids. Avoid NSAIDs if you have a history of gastritis, stomach ulcers, asthma, high blood pressure, or are on anticoagulant medications, unless specifically advised by your GP or Rheumatology team.
Q: Will my arthritis medications interfere with my other prescribed medications?
Please bring a list of all medications to each appointment. We take all of your medications into consideration when making prescribing decisions to ensure there are no harmful interactions.
Q: My prescription has expired – can my general practitioner (GP) renew it for me?
Yes, your GP will be notified of any changes to your treatment plan made during your clinic visits and will be able to renew your prescription. However, within the first six weeks of starting a “conventional” DMARD (e.g. methotrexate, sulfasalazine, leflunomide), your medication will be supplied by the hospital team until we confirm that it is well-tolerated.
Biologic injections and some high-cost oral “targeted synthertic” DMARDs (e.g. JAK inhibitors such as baricitinib) are exceptions, as these are only prescribed through the rheumatology department at the hospital. You will need to attend your clinic appointments and undergo any necessary blood tests as requested for the prescription to be managed appropriately. The medication will then be coordinated with the relevant homecare delivery provider or outpatient hospital pharmacy as needed.
Q: The delivery company has informed me that my prescription has expired – what should I do?
Your prescription is managed by the rheumatology nurses in collaboration with the delivery companies and NNUH Pharmacy Home Care Team. Typically, the delivery company will request a prescription renewal from the nurses well in advance of the expiry date; however, there are occasional delays.
The Rheumatology nurses will renew your prescription if you have attended your scheduled clinic appointments and completed any required blood tests, typically on a quarterly basis.
Failure to attend appointments or undergo the required blood tests could result in the discontinuation of your biologic medication prescription. In such cases, please contact the rheumatology team to discuss your prescription renewal.
Q: My medication has not been delivered – what should I do?
Please contact the delivery company directly to reschedule the delivery and ensure you are available during the assigned delivery window.
You may request that your medications be delivered to an alternative address, such as your workplace, as long as refrigeration is available at the delivery location.
If you encounter unresolved delivery issues that cannot be addressed directly with the company, please contact the rheumatology team for further assistance.
5. Infections
Q: I have an infection and I am taking antibiotics – should I stop taking my other medications?
While undergoing antibiotic treatment for an infection, you should discontinue conventional disease-modifying drugs (with the exception of Hydroxychloroquine and Sulfasalazine). JAK inhibitors and any biologic therapies should also be discontinued. However, it is important not to stop taking corticosteroids, such as prednisolone, during an infection.
You may resume your usual medications once the infection has resolved and the course of antibiotics has been completed. If you are uncertain, please contact the rheumatology team for guidance.
Q: I have been in contact with someone who has shingles. What should I do?
If you have not previously had chickenpox and are on immunosuppressive medication, it is important to contact your GP if you have had close contact with someone who has chickenpox or shingles, as treatment may be necessary.
“Close contact” refers to being in the same room for over 15 minutes or having direct contact with areas affected by shingles, particularly if it involves exposed skin, such as the face.
If you have never had chickenpox, it is advisable to avoid close contact with individuals who have either chickenpox or shingles.
6. Vaccinations
Q: Can I receive vaccinations while on medication for my condition?
If you are taking immunosuppressive medications, it is crucial to ensure you are adequately protected against preventable diseases. You should avoid live vaccines, such as the oral polio vaccine, yellow fever vaccine, and rubella (German measles) vaccine. If necessary, an inactivated polio vaccine can be used as an alternative.
Additionally, avoid close contact with individuals who have received a live oral polio vaccine for up to six weeks, as they may excrete the live virus. Specifically, you should refrain from changing the nappies of infants, as they may shed the virus in their stool.
If you need a yellow fever vaccine for travel, consult your GP beforehand, as some countries require it. It is recommended to seek travel-related vaccination advice at least six weeks prior to departure, as some vaccines may require special ordering.
Q: Should I receive flu, COVID-19, or pneumonia vaccinations?
If you are on immunosuppressive medications such as Methotrexate or biologic therapies, it is strongly recommended to receive the flu vaccine (inactivated) annually. COVID-19 vaccinations are also recommended.
Additionally, the pneumonia (pneumococcal) vaccine is advised for all patients with rheumatological conditions who are on immunosuppressive therapy. This vaccine should be repeated every five years, with a maximum of two doses over a lifetime.
Q. Fly Vaccine
Flu vaccines are inactivated (non-live) vaccines and are recommended for individuals undergoing disease-modifying treatment.
If you require a live vaccine, such as for travel purposes, please contact the rheumatology advice line. Live vaccines should not be administered to individuals on disease-modifying medications or biologic therapies.
Live vaccines include: Shingles, Varicella (chicken pox), MMR, TB, oral polio, yellow fever, and rotavirus.