If the closest rheumatologist is in the next state over – or farther – you may have to rely on your primary care physician to treat your arthritis. While primary care physicians are not arthritis specialists, they can certainly fill in and manage the day-to-day problems of people with arthritis when a specialist is not available.
Whether they are general internists or family physicians, primary care doctors acquire the knowledge and skills to treat arthritis and related conditions as part of their medical training. Most also gain experience in managing patients with arthritis in their clinical practices.
If you find that your primary care doctor is also your arthritis doctor, there are several things you can do to help ensure you get the best care possible. Experts offer seven pieces of advice.
1. Bring arthritis to the forefront. Your primary care doctor must keep up with all aspects of your health – Is your sore throat due to the common cold or strep? Have you had the recommended cancer screenings? Are you taking your blood pressure medicine as prescribed? – and may not be focused on your arthritis specifically. If your arthritis is the reason for you visit, make that known up front, says John FitzGerald, MD, interim chief of rheumatology and associate clinical professor at the University of California, Los Angeles. “Tell your doctor if the arthritis is doing something unexpected or unusual,” he says. “Joint swelling is important to mention as are hot or swollen joints and morning stiffness that lasts more than an hour.”
2. Ask about vaccinations. If your doctor has recommended a disease-modifying antirheumatic drug (either a traditional DMARD or a biologic) ask about getting any needed vaccinations. Generally speaking, any “live” vaccines – for example, the herpes zoster (shingles) vaccine or the intranasal (spray) flu vaccine – should be given before starting these drugs. But “inactivated” vaccines, including the injected flu vaccine, may be safely taken with a DMARD or a biologic. If your primary care doctor doesn’t bring it up, you should. A bonus: You can probably have your vaccinations right there at your primary care doctor’s office.
3. Ask about lab and screening tests. If your doctor prescribes a biologic or the disease-modifying drug tofacitinib (Xeljanz), make sure she screens you for tuberculosis (TB) and other infections before starting the drug. Other drugs require additional tests to monitor for side effects. If you are taking hydroxychloroquine (Plaquenil), for example, you should have an eye exam when starting the drug and every six to 12 months thereafter; for methotrexate (Rheumatrex, Trexall) and leflunomide (Arava) you should have periodic liver function tests; and for cyclosporine (Neoral, Gengraf) you should have regular monitoring of blood pressure and kidney function. Read about the specific tests needed (and their frequency) for the drugs you are prescribed here and be sure to follow through.
4. Make sure your doc “treats to target.” Setting and getting to your treatment goal is called “treating to target,” says Eric Matteson, MD, chair of the division of rheumatology at Mayo Clinic in Rochester, Minn. In inflammatory diseases like rheumatoid arthritis and psoriatic arthritis, the goal is to have little or no inflammation in the joints and other organs such as the blood vessels, eyes, lungs and kidneys, he says. Your doctor should have a good understanding of the importance of this goal and how to reach it though traditional DMARDs and, if necessary, biologic drugs.
In gout, treating to target involves increasing the dose of uric acid lowering drugs such as allopurinol (Zyloprim) or febuxostat (Uloric), until the serum uric acid level falls below 6mg/dl. If you have gout and your doctor isn’t doing this, make sure that he or she starts, says Daniel Clauw, MD, professor of anesthesiology, rheumatology and psychiatry at the University of Michigan Medical School, in Ann Arbor. Many doctors are unaware of these new guidelines for treating gout, he says. Previously it was very common to use a fixed dose of allopurinol regardless of how well serum uric acid was controlled.
Also, because any change in uric acid can precipitate a gout attack, it is important to take an anti-inflammatory drug such as an nonsteroidal anti-inflammatory drug or colchicine (Colcrys) when uric-acid-lowering drugs are started or when the dose is increased, to prevent flares.
5. Be willing to wait out back pain. Back pain could be a symptom of arthritis, or it could be the result of a simple sprain or strain that will resolve on its own. “Most episodes of acute low back pain – 90 to 95 percent – resolve spontaneously and need no specific medical care,” says Dr. Clauw, who specializes in chronic pain. If you experience acute back pain and your doctor recommends X-rays, MRIs, surgery or injections, ask to wait it out for three months – unless you have symptoms such as loss of bowel or bladder function, severe weakness, fever or weight loss that suggest a more serious problem.
6. Don’t be too quick to accept pain meds. Doctors once assumed that since opioid (narcotic) analgesics worked well for acute pain, they would be effective for chronic pain as well. “This is simply false,” says Dr. Clauw. “In fact there are many pain conditions, such as fibromyalgia, where opioids have never been shown to be effective, although they are widely used. “Furthermore, many physicians are not aware that opioids can make some types of pain worse by leading to a condition called opioid-induced hyperalgesia. If your doctor recommends an opioid or narcotic analgesic, ask about other methods of pain relief, such as exercise, meditation, non-narcotic analgesics or other medications that have been shown to relieve pain for your condition.
7. As for a consultation with a rheumatologist. While your primary care doctor can provide much of your arthritis treatment, your doctor may not be comfortable with the more complex aspects or treatments for your disease, says Dr. FitzGerald. Many primary care physicians have little if any experience in prescribing biologics, he says, and may want to consult a rheumatologist if biologics are necessary.
Similarly, there may be times when you feel more comfortable seeing a rheumatologist, even if it requires a long drive once or twice a year to do so. If you are willing to make that trip – at least occasionally – let your doctor know, says Dr. FitzGerald.
Some primary care doctors have a specialist they work with. Ask if yours does. Rheumatologists can partner with your primary care doctor to provide you the best and most comprehensive care for you and for your condition, says Dr. Matteson.