Advanced Rheumatology Nursing — Biologics & Complex Conditions

Inflammatory Arthritis

🦴 Rheumatoid Arthritis (RA)

ACR/EULAR 2010 Classification Criteria — Score ≥6/10 required Joint involvement, serology (RF/anti-CCP), acute-phase reactants (ESR/CRP), duration ≥6 weeks.

Key Features

Symmetrical small joint synovitis (MCPs, PIPs, wrists)
Morning stiffness >1 hour
RF positive — 70–80% sensitivity
Anti-CCP — >95% specificity, predicts erosive disease
Extra-articular: nodules, ILD, vasculitis, scleritis

DAS28 Disease Activity

Remission: <2.6
Low disease: 2.6–3.2
Moderate: 3.2–5.1
High: >5.1

Treat-to-Target (T2T) Goal = remission or low disease activity. Review every 1–3 months until target reached; escalate DMARDs if not at target.

Remission Index	Remission Threshold	Components
DAS28-ESR	<2.6	TJC28 + SJC28 + ESR + PGA
SDAI	≤3.3	TJC28 + SJC28 + PtGA + PhGA + CRP
CDAI	≤2.8	TJC28 + SJC28 + PtGA + PhGA (no labs)
Boolean	All ≤1	TJC ≤1, SJC ≤1, CRP ≤1 mg/dL, PtGA ≤1

🔬 Psoriatic Arthritis (PsA)

CASPAR Criteria — Score ≥3 in presence of inflammatory musculoskeletal disease Psoriasis (current/personal/family history), nail dystrophy, negative RF, dactylitis, juxta-articular new bone formation on X-ray.

Enthesitis — inflammation at tendon/ligament insertion (Achilles, plantar fascia)
Dactylitis — "sausage digit," diffuse swelling of entire finger/toe
Nail disease — pitting, onycholysis, subungual hyperkeratosis
Asymmetric oligoarthritis most common pattern
Axial involvement in ~25%

5 clinical patterns: oligoarticular, polyarticular, DIP predominant, arthritis mutilans, axial
Skin and joint activity may not correlate
IL-17 inhibitors particularly effective
NSAIDs for mild; DMARDs (methotrexate) for moderate; biologics for severe

📐 Ankylosing Spondylitis / axSpA

HLA-B27 present in ~90% of AS patients (vs ~8% general Caucasian population; lower in Arabs)

Inflammatory back pain: age <40, insidious onset, improves with exercise, not rest, night pain/early morning stiffness
Sacroiliitis on MRI (nr-axSpA) or X-ray (r-axSpA/AS)
BASDAI score — Bath AS Disease Activity Index (0–10); ≥4 = active disease, consider biologic
mSASSS — Modified Stoke AS Spine Score; assesses syndesmophytes, cervical + lumbar

Physiotherapy is ESSENTIAL Daily exercise programme mandatory — reduces spinal stiffness, maintains posture. Swimming and hydrotherapy recommended.

NSAIDs first-line (also diagnostic if rapid response)
TNF inhibitors or IL-17 inhibitors for active axial disease not responding to NSAIDs
No conventional DMARD evidence for axial disease
Monitor for uveitis (20–30%), IBD (5–10%), psoriasis

👶 Juvenile Idiopathic Arthritis (JIA)

Uveitis Screening is Critical Oligoarticular JIA + ANA positive = highest risk of asymptomatic chronic uveitis. Can cause blindness if untreated. Screen every 3 months.

JIA Subtype	Key Features	Uveitis Risk
Oligoarticular (persists)	≤4 joints, ANA+, young girls	High
Polyarticular RF–	≥5 joints, symmetric	Moderate
Polyarticular RF+	Adult RA equivalent	Low
Systemic (sJIA)	Fever + rash + arthritis, risk of MAS	Low
Enthesitis-related	HLA-B27+, axial involvement	Moderate
Psoriatic	Psoriasis + arthritis	Moderate

Connective Tissue Diseases

🔴 Systemic Lupus Erythematosus (SLE)

ACR/EULAR 2019 Criteria Entry criterion: ANA titre ≥1:80. Additive domains include constitutional, haematological, neuropsychiatric, mucocutaneous, serosal, musculoskeletal, renal. Score ≥10 = classified SLE.

Key Autoantibodies

ANA — sensitive (95%) but not specific
Anti-dsDNA — highly specific, correlates with disease activity/nephritis
Anti-Sm — highly specific for SLE
Anti-Ro/La — neonatal lupus, congenital heart block risk
Antiphospholipid antibodies — thrombosis/pregnancy loss
Low C3/C4 — active disease

SLEDAI Score

Systemic Lupus Erythematosus Disease Activity Index
0 = inactive; >4 = clinically active
High-yield domains: renal (casts, haematuria, pyuria, proteinuria), CNS (seizure, psychosis)

Pregnancy in SLE High-risk pregnancy. Anti-Ro/La = fetal heart monitoring. Hydroxychloroquine continues in pregnancy (protective). Avoid MMF, methotrexate, cyclophosphamide.

Lupus Nephritis Class	Pathology	Treatment
Class I — Minimal mesangial	Mesangial deposits only	No specific treatment
Class II — Mesangial proliferative	Mesangial hypercellularity	Low-dose steroids if proteinuric
Class III — Focal	<50% glomeruli involved	MMF or IV cyclophosphamide + steroids
Class IV — Diffuse Most severe	≥50% glomeruli involved	MMF or IV cyclophosphamide + steroids
Class V — Membranous	Subepithelial deposits	MMF, consider calcineurin inhibitors
Class VI — Sclerotic	>90% sclerosed	Renal replacement therapy

Hydroxychloroquine (HCQ) Monitoring — Nurse Responsibility Baseline ophthalmology assessment, then ANNUAL retinal screening after 5 years (earlier if risk factors). Max dose 5mg/kg/day. Eye toxicity irreversible — early detection critical.

💧 Sjögren's Syndrome

Sicca symptoms: dry eyes (keratoconjunctivitis sicca), dry mouth (xerostomia)
Anti-Ro/SSA and anti-La/SSB antibodies
Schirmer's test, salivary flow measurement, lip biopsy (focus score ≥1)
Fatigue, arthralgia, peripheral neuropathy, lymphoma risk (40× increased)

Dry Eye Management Artificial tears (preservative-free), cyclosporin eye drops, punctal plugs. Avoid anticholinergic drugs.

Dry Mouth Management Pilocarpine 5mg TDS (muscarinic agonist — stimulates secretion). Artificial saliva, meticulous dental hygiene, fluoride treatment.

🔗 Systemic Sclerosis (SSc)

Feature	Limited SSc (lcSSc)	Diffuse SSc (dcSSc)
Skin involvement	Distal to elbows/knees + face	Proximal limbs + trunk
Onset of Raynaud's	Years before other features	Within 1 year of skin changes
Key antibody	Anti-centromere (ACA)	Anti-Scl-70 (anti-topoisomerase)
Pulmonary HTN	Higher risk (CREST)	ILD more common
Renal crisis	Rare	Risk ~15% in first 5 years

Raynaud's Phenomenon Triphasic colour change (white→blue→red). First-line: nifedipine (calcium channel blocker). Severe: IV prostacyclin (iloprost). In GCC climate: heat is protective.

Scleroderma Renal Crisis (SRC) Hypertensive emergency + microangiopathic haemolytic anaemia. ACE inhibitors are treatment of choice (captopril). Do NOT wait — renal failure can develop rapidly.

Pulmonary Hypertension Screening Annual echocardiography in all SSc. If Echo PAP >40mmHg → right heart catheterisation. Treat with endothelin antagonists (bosentan) or PDE5 inhibitors (sildenafil).

Oesophageal Dysmotility Affects ~90% of SSc. Symptoms: dysphagia, GORD, early satiety. Management: PPI, small frequent meals, avoid lying flat after meals, prokinetics.

💪 Inflammatory Myositis

Dermatomyositis (DM)

Heliotrope rash (periorbital violaceous)
Gottron's papules (knuckles)
Mechanic's hands
Malignancy association — screen at diagnosis and annually
Anti-Jo-1 / Anti-MDA5 antibodies

Polymyositis (PM)

Proximal muscle weakness (difficulty rising from chair, climbing stairs, lifting arms)
No skin rash (differentiates from DM)

Monitoring Priorities Creatine Kinase (CK) — monitor activity and treatment response. ILD risk — annual PFTs. Swallowing assessment — dysphagia risk of aspiration pneumonia.

Vasculitis

⚠ VISUAL EMERGENCY — Giant Cell Arteritis

Jaw claudication + temporal headache + visual symptoms = SAME-DAY EMERGENCY. Start high-dose prednisolone BEFORE biopsy. Do NOT delay treatment waiting for biopsy result — permanent blindness can occur within hours.

🔥 Giant Cell Arteritis (GCA)

Emergency Pathway Jaw claudication → temporal headache → visual symptoms: Start prednisolone 40–60mg/day (IV methylprednisolone 500mg–1g/day if visual loss) → Same-day ophthalmology → Temporal artery biopsy within 2 weeks → Tocilizumab for relapsing/refractory disease

Age >50, ESR typically >50mm/hr (but can be normal)
Scalp tenderness, non-pulsatile temporal artery
Polymyalgia rheumatica (PMR) association in 40–50%
CRP often markedly elevated

Glucocorticoid Side-effect Prevention Aspirin 75mg (antiplatelet). PPI gastroprotection. Bone protection: calcium + vitamin D + bisphosphonate. Diabetes monitoring. Osteoporosis DEXA scanning.

🫀 Takayasu Arteritis

Large vessel vasculitis affecting aorta and major branches
Predominantly affects young Asian women (age <40)
"Pulseless disease" — absent upper limb pulses, blood pressure discrepancy between arms
GCC relevance — higher incidence reported in Middle Eastern populations
Symptoms: claudication, dizziness, visual changes, bruits on auscultation
Imaging: MRI/MRA, PET-CT for active inflammation
Treatment: high-dose corticosteroids; tocilizumab, methotrexate, azathioprine for steroid-sparing

🧪 ANCA-Associated Vasculitis (AAV)

Condition	ANCA	Key Features
GPA (Granulomatosis with Polyangiitis)	c-ANCA / PR3	ENT (saddle-nose, sinusitis), lung, kidney; granulomas
MPA (Microscopic Polyangiitis)	p-ANCA / MPO	Glomerulonephritis, pulmonary haemorrhage; no granulomas
EGPA (Eosinophilic GPA)	p-ANCA / MPO	Asthma, eosinophilia, allergic rhinitis, cardiac involvement

Induction Therapy Cyclophosphamide (IV/oral) + high-dose corticosteroids OR Rituximab + corticosteroids (preferred in relapsing/refractory or younger patients).

Essential Prophylaxis PCP prophylaxis: Co-trimoxazole (trimethoprim-sulfamethoxazole) 960mg 3×/week while on cyclophosphamide/rituximab + steroids. Also provides protection against Wegener's relapse (GPA).

Maintenance Therapy Rituximab 500mg every 6 months (preferred) OR azathioprine/methotrexate. Duration: minimum 24 months after remission. Monitor ANCA titres (especially PR3 — rising titres predict relapse).

🟣 IgA Vasculitis (Henoch-Schönlein Purpura)

Classic Tetrad (especially in children) Palpable purpura (buttocks/lower limbs) + Arthritis (large joint, transient) + Nephritis (haematuria/proteinuria — monitor BP and urine) + Abdominal pain (bowel ischaemia risk)

Most common vasculitis in children; peak age 4–6 years; often follows URTI
IgA immune complexes deposited in small vessels and mesangium
Usually self-limiting; renal involvement determines long-term prognosis
NSAIDs for joint pain; steroids for severe abdominal pain/nephritis
Adults tend to have more severe and persistent renal disease

Biologics Nursing

Pre-Biologic Screening Checklist

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Screening Test	Rationale	Action if Positive
TB (Mantoux/IGRA + CXR)	Reactivation risk — especially TNF inhibitors	Treat latent TB (9 months isoniazid) before starting biologic; delay 2–3 months
Hepatitis B (HBsAg, HBcAb, HBsAb)	Reactivation can be fatal	Prophylactic antiviral (tenofovir/entecavir) if HBcAb+ or HBsAg+
Hepatitis C (anti-HCV)	Immunosuppression may worsen	Hepatology review; treat HCV first if possible
HIV	Biologic use in HIV complex	Infectious disease review; generally avoid if untreated
Varicella (VZV IgG)	Risk of disseminated varicella	If seronegative: vaccinate BEFORE biologic (live vaccine — wait 4 weeks)
FBC, LFTs, renal function	Baseline for monitoring	Correct abnormalities before initiating
Pregnancy test	Teratogenic potential	Reliable contraception; refer to obstetric rheumatology

LIVE VACCINES CONTRAINDICATED during biologic therapy MMR, varicella, yellow fever, oral typhoid, BCG. Inactivated vaccines (influenza, pneumococcal, COVID-19) are RECOMMENDED and safe.

💉 TNF Inhibitors

Drug	Route	Indications	Key Points
Adalimumab (Humira)	SC every 2 weeks	RA, PsA, AS, IBD, uveitis	Anti-drug antibodies; rotate injection sites
Etanercept (Enbrel)	SC weekly	RA, PsA, AS, JIA	Soluble receptor; less IBD/uveitis coverage
Infliximab (Remicade)	IV infusion	RA, PsA, AS, IBD, GCA	Infusion reactions — monitor for 1hr post-infusion
Certolizumab (Cimzia)	SC every 2 weeks	RA, PsA, AS	PEGylated; minimal placental transfer — safe in pregnancy
Golimumab (Simponi)	SC monthly or IV	RA, PsA, AS	Monthly dosing convenient

TNF Inhibitor Contraindications Active infection, sepsis, active TB, hepatitis B (without prophylaxis), severe heart failure (NYHA III/IV), demyelinating disease, lymphoma history. Caution: moderate heart failure.

🔵 IL-6 Inhibitors

Tocilizumab (IV/SC) — RA, GCA, sJIA, cytokine release syndrome
Sarilumab (SC) — RA
Both block IL-6 receptor signalling

Critical Nursing Alert — IL-6 Inhibitors IL-6 mediates fever response. Tocilizumab/sarilumab MASKS FEVER as a sign of infection. Patients and nurses must recognise alternative infection signs: malaise, hypotension, tachycardia, raised CRP.

Monitor LFTs — elevated transaminases common; hold if AST/ALT >5× ULN
Monitor lipid profile — LDL, HDL, triglycerides at baseline and 4–8 weeks after starting
Neutropaenia monitoring — hold if ANC <500 cells/mm³

🟢 IL-17 Inhibitors

Secukinumab (Cosentyx) — PsA, AS/axSpA, psoriasis
Ixekizumab (Taltz) — PsA, AS/axSpA, psoriasis
Highly effective for axial disease and enthesitis
IBD CAUTION — IL-17 inhibitors can exacerbate or trigger inflammatory bowel disease. Screen for IBD symptoms before prescribing; contraindicated in active IBD.
Mucocutaneous candidiasis risk — counsel patients to report oral/vaginal candidiasis

⚡ JAK Inhibitors

Drug	JAK Selectivity	Indications
Tofacitinib (Xeljanz)	JAK1/JAK3	RA, PsA, UC, JIA
Baricitinib (Olumiant)	JAK1/JAK2	RA, alopecia areata, atopic dermatitis
Upadacitinib (Rinvoq)	JAK1 selective	RA, PsA, AS, atopic dermatitis, UC, Crohn's

DVT / VTE Risk Class warning for all JAK inhibitors. Higher dose tofacitinib associated with increased thrombotic risk (ORAL Surveillance trial). Avoid in patients with prior VTE, immobility, known thrombophilia. VTE prophylaxis assessment essential.

Herpes Zoster Reactivation JAK inhibitors significantly increase risk of herpes zoster. Pre-treatment: Shingrix (recombinant zoster vaccine — non-live) recommended for adults ≥50 years BEFORE starting JAK inhibitor. Monitor for dermatomal pain/rash.

Oral daily dosing — convenient but compliance monitoring important
Avoid in patients with active serious infections
MACE (major adverse cardiovascular events) risk — cardiovascular risk assessment before prescribing
Malignancy risk — lung cancer signal in ORAL Surveillance trial

💜 Rituximab (B-Cell Depletion)

Anti-CD20 monoclonal antibody — depletes B-cells
Indications: RA (anti-TNF inadequate response), AAV induction/maintenance, pemphigus
Given as 2 × 1g IV infusions 2 weeks apart, then every 6 months

Hypogammaglobulinaemia Monitor immunoglobulin levels (IgG, IgM, IgA) every 6 months. If IgG <6g/L = increased infection risk. Consider immunoglobulin replacement therapy if recurrent serious infections.

Infusion Reactions Premedicate with methylprednisolone 100mg IV + paracetamol + antihistamine 30 minutes before infusion. First infusion starts slowly (50mg/hr); increase every 30 mins if tolerated. Monitor BP, HR, O₂ sats throughout.

PCP Prophylaxis with Rituximab Co-trimoxazole 960mg 3×/week recommended during and for 6–12 months after rituximab courses, especially when combined with other immunosuppression. Also consider PJP prophylaxis with dapsone if sulfa-allergic.

Nursing Assessments & Education

🧮 DAS28 Disease Activity Calculator

Enter values below to calculate the DAS28 score and determine disease activity category.

28 Tender Joint Count (TJC28) — 0 to 28

28 Swollen Joint Count (SJC28) — 0 to 28

Patient Global Assessment VAS (0–100 mm)

Inflammatory Marker — select type

ESR value (mm/hr)

Methotrexate Monitoring Protocol & Patient Education Card

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Monitoring Schedule

Timepoint	Tests Required
Baseline	FBC, LFTs, U&E, CXR, hepatitis B/C, weight
Monthly × 3	FBC, LFTs, U&E, CRP
Every 3 months (stable)	FBC, LFTs, U&E, CRP
Annual	As above + hepatitis screening if risk factors

HOLD Methotrexate if: WBC <3.5 × 10⁹/L, Neutrophils <2 × 10⁹/L, Platelets <150 × 10⁹/L, ALT/AST >3× ULN, eGFR <30ml/min, active infection, mucositis.

Patient Education — Key Points

ONCE WEEKLY dosing — NOT daily (risk of fatal overdose)
Folic acid 5mg ONCE WEEKLY — taken on a DIFFERENT day to methotrexate; reduces side effects
ALCOHOL AVOIDANCE — potentiates hepatotoxicity; advise strict avoidance
Teratogenicity — reliable contraception required for BOTH men AND women; continue for 3–6 months after stopping methotrexate
Report immediately: sore throat, unusual bruising/bleeding, shortness of breath, mouth ulcers, nausea/vomiting, jaundice
Sun protection — photosensitivity increased
Do not take OTC NSAIDs without medical advice (increases toxicity)
Carry methotrexate treatment card at all times

GCA Visual Threat — Emergency Pathway

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⚠ GCA EMERGENCY NURSING PATHWAY

Recognition: Jaw claudication, new headache (temporal/occipital), scalp tenderness, diplopia, amaurosis fugax, vision loss in patient >50 years
Immediate action: Do NOT delay — alert medical team URGENTLY
Same-day: Blood tests (ESR, CRP, FBC, glucose, LFTs) + Commence high-dose prednisolone 40–60mg/day (IV methylprednisolone 500mg–1g/day if visual involvement)
Same-day: Refer to ophthalmology — formal visual acuity, visual fields, fundoscopy
Within 1–2 weeks: Temporal artery biopsy (does not affect result if taken within 2 weeks of starting steroids)
Ongoing: Aspirin 75mg + PPI gastroprotection. Bone protection (bisphosphonate + Ca/VitD). Blood glucose monitoring. Blood pressure monitoring.
Steroid taper: Slow over 1–2 years. Consider tocilizumab for relapsing/steroid-dependent disease.

Nurse Education — GCA Patient Educate patient to return IMMEDIATELY if any visual symptoms develop (even on treatment). Explain long-term steroid side effects and importance of never stopping abruptly. Carry steroid emergency card.

💉 Joint Injection Nursing Care

Procedure Preparation

Strict aseptic non-touch technique (ANTT)
Confirm written consent; assess for contraindications (active infection, anticoagulation, prosthetic joint)
Skin preparation: chlorhexidine or iodine
Position patient comfortably; identify anatomical landmarks
Document: joint injected, drug/dose, lot number, patient tolerance

Post-Injection Advice

Relative rest / weight-bearing restriction for 48–72 hours (intraarticular steroid)
Expect post-injection flare (crystalline steroid) — peaks 6–12 hours, resolves 24–48 hours; ice pack helps
Return if: increasing pain, fever, redness, warmth after 48 hours (exclude septic arthritis)
Maximum 3–4 intraarticular steroid injections per joint per year

🌡️ Infection Recognition During Biologics — Patient Education

ACTION: Temperature >38°C while on biologic therapy HOLD biologic dose. Seek urgent medical review — do NOT give next injection until reviewed. Provide written card with this instruction.

Warn Patients About

Fever >38°C — hold drug, seek review
Productive cough / chest symptoms
Dysuria / urinary symptoms
Skin infections, cellulitis, abscesses
Unusual fatigue, night sweats, weight loss (TB symptoms)
IL-6 users: no fever even with serious infection — extra vigilance

Nurse Responsibilities

Provide written biologic alert card at initiation
Annual influenza vaccine (all patients)
Pneumococcal vaccine (Prevnar 13 + Pneumovax 23) before biologic
Document vaccination dates and next due dates
Pre-procedure antibiotic prophylaxis discussion with team
Surgical/dental procedures — discuss biologic hold period with rheumatologist

GCC Context & Exam Preparation

🌍 Rheumatic Disease Epidemiology in the GCC

Disease	GCC / Arab Populations	Clinical Implication
SLE	Higher prevalence in Arab women vs European; earlier onset, more severe renal disease	High vigilance for lupus nephritis; anti-dsDNA monitoring essential
Ankylosing Spondylitis	HLA-B27 lower prevalence in Arabs (<3%) vs Caucasians (8–12%)	Do not exclude axSpA based on HLA-B27 negativity alone; MRI sacroiliac joints critical
Familial Mediterranean Fever	High prevalence in Arabs, Turks, Armenians, Sephardic Jews	MEFV gene mutation; colchicine treatment
Takayasu Arteritis	Higher incidence in GCC/Middle East; young women	Delayed diagnosis common; consider in young women with constitutional symptoms + diminished pulses
Behçet's Disease	Higher along "Silk Road" including Turkey, Iran, parts of GCC	Oral ulcers + genital ulcers + uveitis triad; HLA-B51 association
Raynaud's Phenomenon	Secondary to SSc/SLE more common; primary Raynaud's less symptomatic in warm GCC climate	Heat is protective — reduced vasospasm triggers; important patient education in GCC context

🏥 Familial Mediterranean Fever (FMF)

Autosomal Recessive Autoinflammatory Disease MEFV gene mutation on chromosome 16 — encodes pyrin protein. High prevalence: Arabs, Turks, Armenians, Sephardic Jews. Diagnosis: clinical + genetic (M694V, M680I, V726A common mutations).

Clinical Features

Recurrent febrile attacks lasting 12–72 hours
Peritonitis — severe abdominal pain (can mimic acute abdomen)
Pleuritis — chest pain, friction rub
Arthritis — large joint monoarthritis (knee, ankle)
Erysipelas-like skin rash (lower leg)
Attacks self-limiting but recurrent

Treatment

Colchicine — First-Line 0.5–1mg twice daily. Prevents attacks AND prevents amyloidosis (most serious complication). Must be lifelong. Monitor: diarrhoea (most common side effect), myopathy, neuropathy.

Refractory FMF Anakinra (IL-1 inhibitor) or canakinumab. Used when colchicine inadequate or not tolerated. Also prevents AA amyloidosis.

📋 GCC Regulatory Bodies — Rheumatology Nursing

Country/Body	Exam Board	Rheumatology Nursing Competencies
Dubai / UAE	DHA — Dubai Health Authority	HAAD (Abu Dhabi) / DOH competency framework; biologics administration certification; clinical governance standards
Saudi Arabia	SCFHS — Saudi Commission for Health Specialties	Rheumatology nursing specialty certification; continuing education credits (CME/CPD); NCBE exam
Qatar	QCHP — Qatar Council for Healthcare Practitioners	Nurse licensing + specialty endorsement; biologic infusion competency
Oman	OMSB — Oman Medical Specialty Board	Specialty nursing programs; rheumatology specialty training pathways

🌙 Ramadan & GCC-Specific Considerations

Biologic Injection Timing During Ramadan Many GCC Muslim patients prefer to self-inject biologics at Iftar time (sunset). Subcutaneous biologics may be timed flexibly. Discuss with patient and rheumatologist. Fasting does not affect biologic pharmacokinetics. IV infusions: schedule before Iftar or after Suhoor if facility allows.

Oral Medications During Ramadan Methotrexate (once weekly) and hydroxychloroquine can be taken at Suhoor or Iftar. Colchicine dosing adjustable. NSAIDs: take with Iftar food. Always discuss with the rheumatology team before Ramadan begins.

Heat & Raynaud's Phenomenon in GCC Climate The warm GCC climate is generally PROTECTIVE for Raynaud's phenomenon (fewer cold-triggered vasospastic attacks). However, patients with severe secondary Raynaud's (SSc) still need education on air-conditioned environments (malls, offices) as triggers. Always carry a light cardigan/jacket in air-conditioned spaces.

GCC Exam Prep — MCQs (DHA/MOH/SCFHS/QCHP Style)

Q1. A 52-year-old woman presents with jaw pain when chewing, new-onset temporal headache, and sudden blurring of vision in her right eye. ESR is 85mm/hr. What is the MOST IMPORTANT immediate nursing/medical action?

A. Schedule temporal artery biopsy for next available slot B. Start prednisolone 40–60mg immediately and arrange same-day ophthalmology C. Order MRI head and wait for results before starting treatment D. Start aspirin only and refer to neurology

Correct Answer: B
GCA with visual involvement is a medical emergency. Treatment (high-dose prednisolone) must NOT wait for biopsy. Vision loss can be permanent within hours. Biopsy remains valid up to 2 weeks after commencing steroids.

Q2. A nurse is preparing a patient for rituximab infusion for ANCA-associated vasculitis. Which prophylactic medication should be prescribed alongside immunosuppressive therapy to prevent Pneumocystis jirovecii pneumonia (PJP/PCP)?

A. Azithromycin 250mg once daily B. Ciprofloxacin 500mg twice daily C. Co-trimoxazole (trimethoprim-sulfamethoxazole) 960mg three times weekly D. Aciclovir 400mg twice daily

Correct Answer: C
Co-trimoxazole 960mg three times weekly is the standard PCP prophylaxis for patients on rituximab + cyclophosphamide + corticosteroids. It also reduces GPA relapse risk. Dapsone is an alternative if sulfa-allergic.

Q3. A 35-year-old Jordanian woman presents with recurrent attacks of severe abdominal pain lasting 24–48 hours since childhood, associated with fever, and resolving spontaneously. Her father had similar episodes. Genetic testing reveals MEFV M694V homozygous mutation. What is the FIRST-LINE treatment to prevent attacks AND amyloidosis?

A. Prednisolone 20mg daily B. Colchicine 0.5–1mg twice daily (lifelong) C. Methotrexate 15mg weekly D. Anakinra 100mg daily

Correct Answer: B
Familial Mediterranean Fever (FMF) — autosomal recessive, high prevalence in Arabs (MEFV gene). Colchicine is first-line treatment: prevents febrile attacks and, critically, prevents AA amyloidosis (major cause of renal failure and death in FMF). Anakinra is reserved for colchicine-refractory cases.

Q4. A patient with rheumatoid arthritis is started on a JAK inhibitor (baricitinib). Which of the following is a SPECIFIC nursing education point unique to JAK inhibitors compared to TNF inhibitors?

A. Screen for latent TB before starting treatment B. Avoid live vaccines during treatment C. Increased risk of herpes zoster reactivation — offer Shingrix vaccine before starting D. Monitor FBC and LFTs regularly

Correct Answer: C
While A, B and D apply to most biologics/immunosuppressants, herpes zoster reactivation is a SPECIFIC major risk with JAK inhibitors (not seen to the same degree with TNF inhibitors). Shingrix (recombinant — non-live, safe to give before starting) is recommended, especially in patients ≥50 years. Also counsel about VTE risk — unique to JAK inhibitors class.

Q5. A patient on tocilizumab (IL-6 inhibitor) for rheumatoid arthritis calls the rheumatology nurse helpline complaining of feeling "unwell" and "off" for 2 days. Her temperature is 37.3°C. She asks if she should be worried as she has no fever. What is the CORRECT nursing response?

A. Reassure her that without fever there is no serious infection; continue tocilizumab as normal B. Advise her to take paracetamol and call back if temperature rises above 38°C C. Advise her that tocilizumab masks fever; she should hold the injection, seek urgent medical review, and report any other infection symptoms D. Tell her to restart antibiotics she has at home and continue tocilizumab

Correct Answer: C
IL-6 inhibitors (tocilizumab, sarilumab) suppress the IL-6-mediated fever response, meaning patients can have serious infections WITHOUT fever. Absence of fever does NOT exclude serious infection. Patients must be educated to recognise alternative infection signs (malaise, tachycardia, hypotension). Always hold biologic and seek urgent review when unwell.