To start MTX for RA or not...

[CaliOne]

I would love the advice from anyone, especially  Rheumatology PAs. 

 

I have a patient that I am referring to rheum, but the appt. is over 8 weeks out (that's the first avail for NP).  30 something male with "bones hurt" (shoulders, elbows, wrists, PIP, knees, ankles) complaint for 3 years.  Positive RF of 71, CCP >250, ESR wnl, CRP 20, ANA negative, Hepatitis/HIV negative.  Awaiting hand imaging. 

 

Would you start on the MTX protocol or wait until rheum eval?  We are in a different situation as I work in an ICE detention center.  Not sure how long the patient will be in custody, could be many weeks to many months.

 

Any suggestions would be very appreciated. 

 

Thanks

[south]

Wait if you can.  MTX is not really a small hammer or without problems and would rather have the experts that do it daily dealing with it.  May want to try a smaller step like NSAIDs/Steroids and maybe even plaquenil ... (also a DMARD but generally considered to be less aggressive )

 

this also has the advantage of them going to the appt with a failure or success of a smaller step...

 

I mean it's been 3 years so...

[ventana]

In an ICE setting

 

Nope no way

 

You have no idea what follow up care is

 

Are they detoxing? If so you have PAWS for 3-6 months

Labs are mildly convincing

 

You have filled your obligation by labs and referral.....

[sas5814]

I would love the advice from anyone, especially  Rheumatology PAs. 

 

I have a patient that I am referring to rheum, but the appt. is over 8 weeks out (that's the first avail for NP).  30 something male with "bones hurt" (shoulders, elbows, wrists, PIP, knees, ankles) complaint for 3 years.  Positive RF of 71, CCP >250, ESR wnl, CRP 20, ANA negative, Hepatitis/HIV negative.  Awaiting hand imaging. 

 

Would you start on the MTX protocol or wait until rheum eval?  We are in a different situation as I work in an ICE detention center.  Not sure how long the patient will be in custody, could be many weeks to many months.

 

Any suggestions would be very appreciated. 

 

Thanks

It depends...is prescribing MT for the diagnosis in your training and skill set and your SP's training and skills? If not you are off the reservation. You are not a rheumatologist and MT is essentially a poison we use to offset the effects of a terrible disease. Will you do the monitoring required? If something goes wrong with your treatment will you be able to sit in the docket and justify your treatment to a jury?  

[south]

Yeah - good points here.  Labs and referral.  

 

As I pressed send I remembered that Plaquenil buys you eye exam screening and follow up.  In your setting...labs and referral...

[CaliOne]

Thanks for all the advice.  It feels right to hold off until the specialist appt to me.  My SP is at another facility and suggested starting DMARD prior to appt, however he isn't on site to help manage if problems arise.   Rheum referral is already set and patient is happy to have a possible diagnosis to his long time complaints. Thanks again.