The symptoms of rheumatological conditions have an impact beyond joint pain and mobility issues. On completion of this module, it is expected the reader will have an enhanced understanding of the most common rheumatological conditions, including acute conditions and pharmacological therapies, as well as initiation and escalation principles.
Introduction
Rheumatology is a branch of medicine that focuses on the diagnosis and management of conditions affecting the joints, muscles, bones, and connective tissues. It encompasses more than 100 disorders that affect the musculoskeletal system and, in many cases, internal organs.
These include inflammatory autoimmune diseases such as rheumatoid arthritis (RA) and ankylosing spondylitis, as well as non- autoimmune conditions like osteoarthritis (OA) and metabolic disorders such as gout.
The common feature across rheumatological conditions is their impact on the musculoskeletal system, causing pain, stiffness, and impaired function. However, their effect extends beyond joint pain and mobility issues. Many involve systemic inflammation, which may affect the eyes, skin, lungs, kidneys, and cardiovascular system. Rheumatological disorders are also linked with an increased risk of mental health disorders such as depression and anxiety.
In Ireland, rheumatological conditions are a significant cause of morbidity. OA affects an estimated 400,000 people, making it one of the most prevalent chronic diseases in the country. RA is less common, affecting around 40,000 people, while gout is rising in incidence due to ageing, obesity, and dietary factors. These conditions contribute significantly to disability, loss of independence, and reduced quality of life. They also place a considerable burden on healthcare resources through frequent GP visits, hospital admissions, and long- term pharmacological treatment.
Pharmacists have a critical role in rheumatology. Many of these conditions are chronic, progressive, and managed over decades. They can require multiple medicines, regular monitoring, and treatment adjustments. Pharmacists are often consulted during acute flare-ups, and patients are frequently prescribed complex medication regimens involving non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, disease- modifying anti-rheumatic drugs (DMARDs) or biologics, each with specific counselling points and monitoring needs.
This CPD module will examine the most common rheumatological conditions relevant to everyday pharmacy practice: RA, ankylosing spondylitis, OA, and gout. It will outline their presentation and management — and how pharmacists can optimise patient care and improve outcomes.
Overview of common rheumatological conditions
Rheumatological diseases comprise a wide range of disorders. Understanding their underlying mechanisms, clinical features, and progression is essential for effective management.
Rheumatoid arthritis
RA is a chronic, systemic autoimmune disease that primarily affects the synovial joints but can also involve other organs. It is characterised by persistent inflammation of the synovium, leading to joint destruction, deformity, and functional disability. The autoimmune process targets the synovial membrane, causing thickening and inflammation that gradually erodes adjacent cartilage and bone. The exact aetiology is not fully understood but is thought to involve a combination of genetic predisposition, environmental triggers (particularly smoking), and immune dysregulation, with cytokines such as tumour necrosis factor (TNF) and interleukins (ILs) playing a central role.
RA typically presents with symmetrical joint pain and inflammation that develops gradually. The small joints of the hands and feet are often affected first, followed by larger joints. A hallmark feature is morning stiffness lasting longer than 30 minutes, which tends to improve with movement. Patients frequently experience fatigue, generalised weakness, and low- grade fever. With disease progression, characteristic deformities may occur, including ulnar deviation, swan-neck, and Boutonnière deformities.
RA can have many extra-articular involvements, affecting multiple organ systems. Extra-articular manifestations include: Rheumatoid nodules, especially at pressure areas; pulmonary complications such as interstitial lung disease and pleural effusions; cardiovascular complications, including pericarditis and accelerated atherosclerosis; vasculitis affecting small and medium vessels; and ocular inflammation, such as scleritis and uveitis. These systemic complications contribute significantly to morbidity and mortality.
The burden of RA is considerable. In Ireland, it affects approximately 1 per cent of the population, with women more commonly affected and typical onset occurring between the ages of 30 and 60. Delayed diagnosis can result in irreversible joint damage within the first few years. Early recognition and referral to rheumatology are therefore essential for initiating disease-modifying therapy and reducing long-term complications.
Diagnosis is based on clinical presentation, serological markers (rheumatoid factor and anti-cyclic citrullinated peptide antibodies), and imaging techniques. Musculoskeletal ultrasound or magnetic resonance imaging (MRI) can detect synovitis and erosions earlier than x-rays.
Ankylosing spondylitis
Ankylosing spondylitis is a chronic inflammatory arthritis that primarily affects the axial skeleton, particularly the sacroiliac joints and spine. It is part of the broader group of spondyloarthropathies and typically presents in young adults, with peak onset between the ages of 20 and 30. There is a strong genetic association with the HLA-B27 allele, and the condition is more common in men.
The main features are chronic back pain and progressive spinal stiffness. Other musculoskeletal symptoms may include postural changes, hip pain, peripheral arthritis, enthesitis, and dactylitis. Extra-articular involvement is common and may include anterior uveitis, presenting as a painful red eye with photophobia; psoriasis; inflammatory bowel disease; and cardiovascular complications such as aortitis and conduction abnormalities.
Diagnosis is based on clinical features supported by imaging. X-rays may reveal sacroiliitis in later stages, while MRI is more sensitive for detecting early inflammatory changes. Laboratory findings often show elevated inflammatory markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Early recognition and intervention are essential to improve long-term outcomes.
Osteoarthritis
OA is the most common form of arthritis and a leading cause of disability worldwide. Although low-grade inflammation may be present, OA is primarily mechanical in origin, in contrast to the autoimmune-driven processes of rheumatoid arthritis and ankylosing spondylitis. Risk factors include increasing age, female sex, obesity, muscle weakness, and previous joint injury. It is a degenerative joint disease, characterised by progressive breakdown of articular cartilage, subchondral bone remodelling, and osteophyte formation.
The joints most frequently affected are the knees, hips, hands, and spine. Clinical features typically include joint pain that worsens with activity and improves with rest, stiffness after periods of inactivity, crepitus, and reduced range of motion. The burden of OA is substantial, particularly in older adults, with prevalence rising due to ageing populations and increasing obesity rates.
While OA lacks the systemic complications of inflammatory arthritis, it significantly limits mobility, reduces quality of life, and often contributes to polypharmacy, as patients require long-term pain management. Diagnosis is primarily clinical, with imaging used to confirm disease severity or exclude alternative diagnoses.
Gout
Gout is a common cause of chronic inflammatory arthritis, resulting from the deposition of monosodium urate crystals in joints and soft tissues due to chronic hyperuricaemia. It typically presents with sudden, severe pain and inflammation in a single joint, most often the first metatarsophalangeal joint (big toe).
If uric acid levels remain uncontrolled, the disease may progress from acute intermittent attacks to chronic gout, leading to joint damage, deformity, and the formation of tophi — solid deposits
of urate crystals in soft tissues, joints, or bones. Genetic predisposition is a key risk factor for gout. Additional factors include older age, male sex, obesity, a purine-rich diet, alcohol consumption, and the use of certain medicines such as diuretics.
Diagnosis is usually clinical but can be confirmed by identifying monosodium urate crystals under compensated polarised light microscopy. Serum uric acid levels may be normal during acute attacks, so the timing of measurement is important. Gout is frequently associated with comorbidities such as hypertension, metabolic syndrome, diabetes, and renal impairment. Management focuses on relieving pain and inflammation during acute flares, while long-term strategies aim to reduce serum urate levels through urate-lowering therapy and lifestyle modification to prevent future attacks.
Pharmacological management
Pharmacological management is central to the treatment of rheumatological conditions. Its objectives are to control symptoms, reduce inflammation, slow disease progression, and prevent joint damage. Treatment is individualised and depends on the condition, disease severity, comorbidities, and patient factors such as age, tolerance, and preference. Symptomatic relief is important, particularly during acute flares.
In inflammatory disease, early and aggressive use of DMARDs is key to metabolic arthropathies such as gout, urate-lowering therapy forms the cornerstone of long-term management. Pharmacists play a vital role in supporting adherence, monitoring for adverse effects, and educating patients to maximise therapeutic benefit while minimising harm.
Acute treatment
Acute treatment in rheumatology refers to short-term pharmacological interventions to control pain, inflammation, and functional loss during disease flares. NICE guidance emphasises using the lowest effective dose for the shortest possible duration to reduce the risk of adverse effects.
NSAIDs are the cornerstone of acute symptom management in RA, ankylosing spondylitis, OA, and gout. They reduce pain and inflammation by inhibiting cyclo-oxygenase (COX) enzymes, thereby decreasing prostaglandin synthesis. Common examples include naproxen, ibuprofen, diclofenac, etoricoxib, and celecoxib.
NICE guidelines recommend oral administration as first-line for acute flares, although topical preparations have a particular role in knee OA. Gastrointestinal protection with a proton pump inhibitor (PPI) should be considered alongside oral NSAIDs, with risk factors for adverse events reviewed regularly. Caution is required in patients with cardiovascular disease, chronic kidney disease, or uncontrolled hypertension. Adverse effects include gastrointestinal bleeding or ulceration, cardiovascular events, renal impairment, and fluid retention.
Corticosteroids provide rapid anti- inflammatory effects and are useful in severe flares or when NSAIDs are contraindicated. According to NICE guidelines, short-term courses of oral prednisolone may be considered in RA, ankylosing spondylitis, and gout. However, systemic corticosteroids should be avoided for long-term maintenance due to risks such as osteoporosis, infection, hyperglycaemia, hypertension, and mood disturbances.
Intra-articular injections may be considered in RA, OA, ankylosing spondylitis, and gout as adjunctive treatment, although repeated injections can cause local joint damage. Corticosteroids may also be used as bridging therapy until DMARDs become effective.
Paracetamol offers mild-to-moderate analgesia and may be considered in OA if they are used infrequently and other pharmacological treatments are contraindicated or ineffective. It is generally well tolerated but hepatotoxicity can occur with overdose or prolonged high doses, especially in patients with chronic alcohol use or liver disease. Weak opioids such as codeine and tramadol are sometimes used in the short-term for severe acute pain when other agents are unsuitable. However, NICE does not recommend their use because of limited efficacy, risk of dependence, and adverse effects.
Colchicine is recommended by NICE as an alternative to NSAIDs for first- line treatment of acute gout flares, depending on comorbidities, concomitant medicines, and patient preference. It should be started within 24 hours of flare onset. Colchicine acts by disrupting microtubule function, thereby reducing crystal-induced inflammation. It can also be used to prevent flares when urate- lowering therapy is initiated, while target serum urate levels are being achieved. Gastrointestinal adverse effects are common, and dose reduction is necessary in renal impairment. Colchicine should be used cautiously with CYP3A4 or P-glycoprotein inhibitors due to increased risk of toxicity.
Urate-lowering therapy
Urate-lowering therapy is used in gout to reduce serum uric acid and prevent recurrent flares, tophi formation, and urate-related complications. Urate- lowering therapy is typically initiated at least two-to-four weeks after a flare has settled and is generally continued life-long. The target serum urate level is <360micromol/L (<6mg/dL) for most patients, or <300micromol/L (<5mg/dL) for patients with tophi or who continue to have flares.
Allopurinol is first-line treatment for patients who have major cardiovascular disease, including previous myocardial infarction, stroke, or unstable angina. Febuxostat may also be considered as a first-line option, although it carries a higher cardiovascular risk. Both drugs are xanthine oxidase inhibitors, which reduce uric acid production. Common adverse effects include rash, gastrointestinal upset, and abnormal liver function tests. Initiation of urate-lowering therapy may trigger acute gout flares, and short-term prophylaxis with colchicine or an NSAID may be required.
Disease-modifying anti-rheumatic drugs DMARDs are used in the long- term treatment of inflammatory rheumatological conditions. Unlike symptomatic treatments, DMARDs
aim to halt or slow disease progression by targeting the underlying immune- mediated inflammation, thereby reducing joint damage and preserving function. The choice of DMARD depends on the condition, severity of disease, comorbidities, and prior treatment response. Although all DMARD classes share the goal of slowing disease progression, their mechanisms, routes of administration, and monitoring requirements differ. They are broadly categorised into conventional synthetic DMARDs (csDMARDs), biologic DMARDs (bDMARDs), and targeted synthetic DMARDs (tsDMARDs).
Conventional synthetic DMARDs csDMARDs remain the first-line disease- modifying therapy for RA. These small- molecule drugs act through different mechanisms and should ideally be
started within three months of persistent symptom onset to prevent irreversible joint damage and preserve function. Their effects develop gradually, often taking six- to-12 weeks for noticeable improvement.
NICE guidelines recommend methotrexate, leflunomide, or sulfasalazine as first-line therapy for RA, while hydroxychloroquine may be considered as an alternative in mild disease.
Methotrexate is regarded as the cornerstone csDMARD for RA. It inhibits dihydrofolate reductase and other folate- dependent enzymes, disrupting DNA synthesis and reducing inflammatory cytokine production. It can be given orally or by subcutaneous injection. Oral administration is preferred, although subcutaneous dosing is useful in patients with gastrointestinal intolerance or an inadequate response to oral therapy.
The drug is administered once weekly, and daily dosing must be strictly avoided due to the risk of severe toxicity. Folic acid supplementation, usually 5mg once weekly on a different day, is recommended, as it reduces adverse effects without diminishing efficacy.
Common adverse effects include gastrointestinal upset, mucositis, and alopecia, while serious risks include hepatotoxicity, bone marrow suppression, and pulmonary toxicity. Excessive alcohol should be avoided due to the risk of liver damage, and the drug is contraindicated during pregnancy and breastfeeding because of its teratogenicity.
Sulfasalazine modulates inflammatory mediators and has both anti- inflammatory and immunomodulatory effects, although its precise mechanism in RA is not fully understood. It is given orally and is generally well tolerated, making it a common choice when methotrexate is unsuitable or in combination therapy. Adverse effects are usually mild and include gastrointestinal disturbance, headache, rash, and reversible oligospermia in men.
Leflunomide inhibits pyrimidine synthesis, reducing lymphocyte proliferation and suppressing autoimmune-driven inflammation. It is an effective alternative to methotrexate or may be used in combination therapy. Adverse effects include diarrhoea, hypertension, weight loss, and hepatotoxicity. Strict contraception is required for both men and women during treatment and for a prolonged period after stopping, owing to the drug’s long half-life.
Hydroxychloroquine is an antimalarial drug with immunomodulatory properties. It interferes with antigen presentation and toll-like receptor signalling, thereby reducing autoimmune activity. Hydroxychloroquine is less potent as monotherapy for aggressive inflammatory arthritis but is useful in milder disease or in combination regimens with other csDMARDs. It is generally well tolerated, with adverse effects including gastrointestinal upset, rash, and skin pigmentation changes. The most important long-term risk is retinal toxicity, which is dose and duration dependent.
Biologic DMARDs
bDMARDs are large protein molecules produced by recombinant DNA technology. They are designed to target specific immune pathways involved in inflammation and joint destruction. They are usually reserved for patients with moderate-to-severe RA, psoriatic arthritis, or ankylosing spondylitis who have not responded adequately to csDMARDs. In addition to improving symptoms, bDMARDs can slow or halt structural joint damage.
TNF inhibitors are the most widely used bDMARD class. Tumour necrosis factor alpha (TNF-?) is a pro-inflammatory cytokine central to the pathogenesis of RA and other inflammatory conditions. TNF inhibitors bind to TNF-?, preventing its action, thereby reducing inflammation and slowing disease progression. Examples include infliximab, adalimumab, golimumab, certolizumab pegol, and etanercept. These agents are given by subcutaneous injection or intravenous infusion, usually every two to four weeks, depending on the drug.
They are highly effective in improving symptoms, function, and quality of life, but carry an increased risk of infections, particularly reactivation of latent tuberculosis and hepatitis B. NICE recommends TNF inhibitors for severe RA, ankylosing spondylitis, and psoriatic arthritis with inadequate response to conventional therapy. Treatment is initiated and monitored in specialist settings, with regular safety and efficacy review.
IL inhibitors block key cytokines that drive inflammation. Tocilizumab and sarilumab are monoclonal antibodies against the IL-6 receptor, reducing synovial inflammation, systemic symptoms, and joint destruction in RA. NICE recommends these agents for moderate-to-severe RA when csDMARDs have failed.
IL-17 inhibitors such as secukinumab and ixekizumab are effective in ankylosing spondylitis and psoriatic arthritis, particularly when TNF inhibitors are inadequate or poorly tolerated.
IL-17 blockade reduces inflammation at the entheses and axial skeleton, improving pain and mobility. These drugs are usually given by subcutaneous injection, although some formulations are available for intravenous infusion. Adverse effects of IL inhibitors include increased risk of infections, neutropenia, and dyslipidaemia.
Rituximab is a chimeric monoclonal antibody targeting CD20 on B lymphocytes, leading to B-cell depletion. B cells contribute to autoantibody production and pro-inflammatory cytokine release, which are central to the pathogenesis of RA. Benefits of rituximab include efficacy in patients with failed TNF inhibition therapy and sustained disease control between courses. The drug is administered via intravenous infusion, with the dosing schedule depending on disease activity. Adverse effects include infusion reactions and increased risk of infection. NICE recommends rituximab in combination with methotrexate for RA with inadequate response to TNF inhibitors.
Abatacept is a fusion protein that inhibits T-cell activation, thereby reducing downstream cytokine release and inflammation in RA. It is given either as a monthly intravenous infusion (after loading doses) or as a weekly subcutaneous injection. Adverse effects include headache, infusion reactions, and an increased risk of respiratory and urinary tract infections. NICE supports its use in RA after inadequate response to csDMARDs or other bDMARDs, usually alongside methotrexate, unless methotrexate is contraindicated or not tolerated.
Targeted synthetic DMARDs (tsDMARDs) tsDMARDs are a newer class of small-molecule agents designed to block specific intracellular signalling pathways involved in inflammation. The most widely used are Janus kinase (JAK) inhibitors, including tofacitinib, baricitinib, and upadacitinib. By interfering with cytokine-mediated signalling, these drugs dampen immune activation and inflammation.
Unlike biologics, which require parenteral administration, tsDMARDs are taken orally. Adverse effects include an increased risk of infections (notably herpes zoster), dyslipidaemia, elevated liver enzymes, and, more rarely, cardiovascular complications and thromboembolic events. NICE guidelines support the use of JAK inhibitors in moderate-to-severe RA and ankylosing spondylitis, after csDMARDs and bDMARDs have failed.
Initiation and escalation principles
Management of rheumatological conditions follows a stepwise, treat-to- target approach, with early initiation of effective therapy recommended to prevent irreversible joint damage and disability. NICE guidelines emphasise starting appropriate treatment promptly and adjusting therapy if disease activity persists.
- Rheumatoid arthritis: NICE recommends methotrexate, either alone or in combination with another csDMARD, as first-line therapy. Short-term corticosteroids may be used as bridging treatment while waiting for csDMARDs to take effect, but long-term use should be avoided due to adverse effects. If the response is inadequate, escalation to a bDMARD or tsDMARD is advised, usually in combination with methotrexate.
- Ankylosing spondylitis: NSAIDs are recommended first-line for pain and stiffness. If response is inadequate, escalation to a biologic agent may be considered.
- Gout: Acute flares are managed with NSAIDs, colchicine, or corticosteroids. Urate-lowering therapy should be considered for long-term prevention of recurrent flares and complications.
De-escalation strategies, while less- frequently applied, may be considered in patients who sustain prolonged remission. Cautious tapering — rather than abrupt withdrawal — reduces the risk of flare while minimising unnecessary drug exposure. NICE stresses that treatment should always be individualised — balancing efficacy, safety, and patient preference.
Safety considerations and monitoring
Safe and effective management of rheumatological conditions requires structured monitoring and early recognition of adverse effects. Regular safety checks are essential to maintain therapeutic benefit and minimise harm.
Routine blood tests are essential for csDMARDs. Methotrexate requires full blood count, liver, and renal function tests at baseline and at regular intervals. Leflunomide therapy necessitates monitoring for hepatotoxicity and blood pressure, while hydroxychloroquine requires baseline ophthalmologic assessment and ongoing eye screening to detect retinopathy. Sulfasalazine may cause hematologic effects and therefore requires regular blood counts.
bDMARDs and JAK inhibitors carry a high risk of infection, including opportunistic infections and reactivation of latent tuberculosis or hepatitis B. NICE recommends screening for latent infections before initiating treatment, with ongoing vigilance for signs of infection. Vaccination status should be optimised before starting immunosuppressive therapy.
Corticosteroids and NSAIDs also have their own safety considerations. Long- term corticosteroid use is associated with osteoporosis, hyperglycaemia, and adrenal suppression, while NSAIDs increase the risk of gastrointestinal, renal, and cardiovascular toxicity. NICE guidance highlights the importance of using the lowest effective dose for the shortest possible duration.
PPI therapy may be co-prescribed with NSAIDs or corticosteroids to reduce gastrointestinal complications. Patients on long-term corticosteroids are at increased risk of osteoporosis — guidelines recommend calcium and vitamin D supplementation, with bisphosphonates considered for those at higher risk.
Role of the pharmacist
Pharmacists play a central role in ensuring safe and effective use of medicines in rheumatology. As accessible healthcare professionals, they are often the first point of contact for patients experiencing adverse effects. Key responsibilities include patient education about complex treatment regimens, reinforcing the importance of adherence, identifying early warning signs, and advising timely referral when needed.
Pharmacists also contribute to safety optimisation through medication reviews, checking for drug interactions, and ensuring vaccinations are up to date prior to immunosuppressive therapy.
By combining clinical expertise with accessibility, pharmacists are an integral part of the multidisciplinary team, significantly improving outcomes and reducing risks in the management of rheumatological conditions.
References available upon request
