Rheumatology 

• It is possible to self-manage flares with a few days of rest, taking prescribed painkillers – i.e. Paracetamol and anti-inflammatory medications such as ibuprofen.
• Sometimes it can help to apply an ice pack or a heat pack (you can buy these at your local chemist) to an individual joint that is causing pain.
• If there is no improvement of flare within 5 to 7 days, please contact your GP or us for further guidance. This can include short-term management with steroids, or if your flares are persistent or occur on a regular basis you may need your treatment plan revisiting.

• Cold packs can assist in reducing swelling.
• If you have a flare of a single joint, an injection of the joint may help.
• 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.

• Discuss with the Rheumatology Team before planning pregnancy or breastfeeding while on biologic/DMARD treatments. Some treatments may be safe, but it’s essential to tailor decisions to your individual circumstances.
• If you unexpectedly become pregnant, contact your consultant immediately for advice.

While some biologics/DMARDs may be considered safe for men who want to father children, it is important to discuss this with the Rheumatology Team to make an informed decision based on your personal health and treatment needs.

Most disease-modifying medications (DMARDs) typically require 8 to 12 weeks to show full effectiveness, particularly when a gradual dose increase is necessary. Some individuals may notice improvements sooner.

Mild side effects: If you experience mild side effects, stop the medication until the side effects settle, then retry the drug.

Serious side effects: If side effects are severe, stop taking the medication and contact us immediately.

Feeling sick (nausea) is a common side effect of methotrexate, especially when treatment starts. This normally gets better, but for some people it may continue.

This feeling may be helped by:

• Taking the methotrexate with or after food
• Taking the methotrexate just before you go to bed, you may be able to sleep through this feeling of sickness
• Making sure you take your folic acid on a different day to the day you take the methotrexate
• Splitting the dose of methotrexate over a 24 hour period.

Sometimes, the dose of folic acid can be changed but this should only be done after speaking to a doctor/nurse. Your doctor may tell you to take another tablet to reduce the feeling of sickness. The Rheumatology Team may also change your methotrexate tablets to an injection once a week.

It is important that you take your methotrexate regularly, so do not stop the drug without discussing it with the rheumatology team or your doctor first.

The information leaflet provided with your medication will list the potential side effects with your specific b/tsDMARD and some information on the likeliness of them occurring.

Generally, the most common side effects are changes to your blood tests (which is why we monitor them) or increased frequency or severity of infections (which is why it is important that you don’t inject if you have an infection – see ‘when to not have your injection’ section).

There is no conclusive evidence to suggest an increased risk of cancer with bDMARDs, but data regarding risk of skin cancers are less clear and we recommend using a high SPF sun cream with UVA/B and 5* rating.

If you are on a tsDMARD, it is important to report any signs or symptoms of a blood clot, for example chest pain, breathlessness, coughing up blood, leg pain, tenderness or swelling in your thigh or calf. If this occurs out of hours please contact emergency department or 111, do not wait.

You may experience injection site reactions to medicines you inject yourself. Applying a cold compress can help. Usually this reduces when you get more experienced at injecting. If you have a severe injection site reaction or a reaction hasn’t gone away when you are due to inject again, please get in touch with us as you may need to stop your treatment.

It is important you let your Rheumatology Team know if you are suffering with side effects to your medication.

If you develop any anaphylaxis or severe side effects, stop the medication and seek urgent medical attention (e.g. contact the usual out of hours emergency medical care).

Please inform the Rheumatology Team of any severe side effects to enable us to report accordingly.

If you forget to give an injection then you should give a dose as soon as you remember and then make sure that you take the next dose at the correct interval to make sure that you do not give the next dose too early.

For further advice on the specific medicine you are taking please contact the Rheumatology Advice Line.

If you forget to take a tablet (tsDMARD), do not take a double dose to make up for the forgotten dose. Take your next tablet at the usual time and continue as before.

If the pen or syringe slips when you are giving your injection or if the device does not work properly for any reason please contact us on the Rheumatology Advice Line for more help on the particular problem you have experienced.

Do not try and inject another dose in case some of the first dose was given.

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 reduce these symptoms, you may try the following:

• Remove injections from the fridge at least 30 minutes before use.
• Ensure injections are administered as taught by the 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 or application of hydrocortisone cream after consulting with your GP/the Rheumatology Advice line .

If you experience side effects that persist despite these measures, or if the reaction is large, please contact the Rheumatology advice line for further guidance.

When to seek 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.

If you are unwell or taking antibiotics, it is advised to delay your medication. Restart treatment once you feel better and are infection-free.

Rheumatology medications that need to be stopped if you have an infection, as they suppress your immune system:

Disease Modifying Anti-Rheumatic Drugs (DMARDs)

• Azathioprine
• Ciclosporin
• Cyclophosphamide
• Leflunomide
• Methotrexate
• Mycophenolate
• Sulfasalazine
• Tacrolimus

Biologics

• Abatacept
• Adalimumab
• Anakinra
• Apremilast
• Belimumab
• Bimzekizumab
• Certolizumab pegol
• Etanercept
• Golimumab
• Infliximab
• Ixekizumab
• Rituximab
• Sarilumab
• Secukinumab
• Tocilizumab
• Ustekinumab

JAK-inhibitors

• Baricitinib
• Filgotinib
• Tofacitinib
• Upadacitinib

Contact with someone with chickenpox/shingles: Stop your biologic (and any other DMARDs) and contact the Rheumatology Nurse on 01634 833903 and follow phone prompts/ GP or 111.

Close contact means:

• being in the same room as someone who has shingles for more than 15 minutes; or
• having immediate contact with someone who has shingles on many parts of their body or where it is exposed, e.g. on the face.

If you get chickenpox/shingles: Stop your biologic (and any other DMARDs) and seek medical attention immediately. Out of hours – contact your on-call GP who can liaise with our medical team.

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.

Let your surgeon know you are on biologic therapy. For most surgeries, you should stop your biologic 2 weeks before surgery. If you’re on Rituximab, surgery should be planned at least 4 weeks after your last infusion. Re-commencement of treatment can only begin once the wound is healed, and there is no sign of infection.

For emergency surgeries: Inform the surgical team about your biologic treatment, carry your biologic alert card, and follow up for antibiotic guidance.

Regular blood tests are crucial to ensure your safety while on these treatments. Blood tests will be more frequent in the first 6 months and will then drop to every three months. Frequency may change based on medication or abnormal 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 there is any derangement.

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.

If your blood test results are significantly abnormal (either too high or too low): Medications may be discontinued.

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.

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 of 3 months or more, please consult the Rheumatology Team to discuss alternative arrangements.

• We recommend the pneumococcal vaccine (one-time vaccine) and the annual flu vaccine as well as COVID-19 while on immunosuppressive treatment such as Methotrexate or biologic therapies.
• If you are on Rituximab, your flu vaccine should be given 4 to 6 weeks before your next infusion or at least 6 months after.
• Live vaccines (e.g., Yellow Fever, Shingles*) should be avoided while on biologic therapy. Always consult with your travel nurse or rheumatology nurse if you are unsure about any vaccinations

*If you are in your 70s and are offered the shingles vaccination, please check with the GP surgery that they are offering the non-live shingles vaccine which is safe for you to have. You cannot have the live shingles vaccine.

• We recommend that you carry a copy of your last clinic letter or repeat prescription with you, and if flying, carry your medication in your hand luggage. It is recommended all medicines are clearly labelled and in their original packaging.
• Some medications need to be kept in the fridge and only taken out shortly before the injection is due. This means you need to take precautions when travelling.
• Keeping your medication cool – Whilst travelling you should invest in a medications cool bag (such as ones made to transport diabetic medications).
• You need to take your medication in the cabin as the hold can be too cold.
• You can get a travel letter from your home delivery company (Sciensus, Lloyds pharmacy clinical homecare, Healthnet) which lets your airline know that you should be taking your injections on board a flight. Please let your home delivery company know in advance.
• When you are at your destination you need to make sure your items are kept in a cool, dark space to ensure the integrity of the drug.
• Please ensure you can dispose of your medication safely whilst travelling.

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 the Rheumatology Team, and we can explore whether this is an appropriate option for you.

• Biologic/DMARD medicines are delivered to your home. Contact your homecare provider for any delivery issues or medication changes.
• Ensure medications are stored correctly, generally in a fridge (2 to 8°C), unless otherwise instructed.

If this happens then you will need to contact the homecare delivery company who deliver your medicine and let them know so that they can arrange for the affected medication to be replaced.

You will also need to let the Rheumatology Department know by calling the Rheumatology Biologic Coordinator in case we need to provide the homecare delivery company with another prescription.

tsDMARD medicines do not need to be stored in the fridge.

If you think that your pen or syringe is faulty for any reason please make a note of the batch number and expiry date (this information can be found on the box containing your medicine).

Please report any faulty pens or syringes to your home care delivery company.

You will be supplied with a sharps bin for disposing of your injections. When your sharps bin is full with used pens/syringes, contact your homecare company to arrange a collection for disposal.

Please contact the company that delivers your medications to reorganise the delivery.

If you have ongoing delivery problems that you cannot solve yourself with the company, please contact the Rheumatology Biologics Coordinator on 01634 833903 and follow telephone prompts.

Patient Enquiries Telephone:

• Sciensus (Previously known as Healthcare At Home): 0333 103 9499
• Lloyds Pharmacy Clinical Homecare: 0345 263 6135
• Healthnet: 0800 083 3060

If you are unsure about the date of your next appointment, please call 01634 969800.

To change an existing follow up appointment or if you have a query about your next appointment, please call 01634 833903 and follow the telephone prompts for relevant secretaries.

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 this with the GP practice. Please do not contact the Rheumatology secretaries for this.

For general health-related enquiries, your GP should be your first point of contact. Our services are designed to complement, not replace, the advice you receive from your GP.

Please refer to Arthritis UK for information that can be shared with your employer regarding your condition.

• Rheumatoid arthritis
• Inflammatory Spondyloarthropathy
• Psoriatic arthritis

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.

For assistance with PIP forms, please contact your GP.

Contact your homecare provider if you:

• have any problem with deliveries
• run out of supplies
• leave medication out of the fridge by mistake (you will also need to contact the rheumatology advice line)
• have a faulty pen or syringe
• have a full sharps bin that needs collecting
• need to change your delivery address.

Sciensus: 0333 103 9499

Lloyds Pharmacy Clinical Homecare: 0345 263 6135

Healthnet: 0800 083 3060

• any questions about your medication
• any side effects
• unsure whether you should have your b/tsDMARD (e.g. if you feel unwell)
• left medication out of the fridge by mistake (home care provider needs to be updated)
• Planning a pregnancy
• feel your medicine has stopped working
• you are planning a holiday.

Rheumatology Advice Line: 016348 33903 and follow telephone prompts.

Contact Biologics Coordinator:

• have run out of medication and your homecare provider are telling you they do not have a prescription.
• Require blood tests essential to continue your biological medications.

Rheumatology Biologics Coordinator: 01634 833903 and follow telephone prompts.

Contact secretaries:

• If would like to change a remote consultation to be seen face-to-face or vice versa.
• If you are expecting to be seen by the hospital but have not received an appointment letter.

Contact your GP:

• To arrange your blood tests and let them know once you’ve had your first dose of b/tsDMARD.

If you have an allergic reaction to your medication or severe side effect, please your GP or call 111.