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  • 27 year-old male
  • History of rheumatoid arthritis with acute exacerbation of back pain after injury in prison
  • PCP submitted eConsult to seek advice on whether this pain should be treated as musculoskeletal strain given history of RA

eConsult Transcript

PCP submission

27 year old male with RA on humira. It took several years to make the dx, apparently. He only occasionally has extremity pain; mostly it is in his back. Sees a rheumatologist but has not followed up recently as incarcerated; I am the primary at the prison. He was coaxed into doing deadlifts about a month ago and has had severe back pain since. It is easy enough for me to treat this as an acute back pain exacerbation… rest, pt, nsaids, flexeril… the usual. 

My question is that given the underlying hx of RA, should I do anything differently? Would he benefit more than the average back strain patient from a course of oral steroids? Should I try and prioritize f/u with the rheumatologist… Other thoughts?

Specialist response

Thank you for this consult, appreciate the involvement and information you provided. This young gentleman with a history of RA on humira did some deadlifts and had back pain afterwards. Completely agree with avoiding deadlifts going forward. RA often spares the spine, and when spinal involvement occurs it is only in C1 and C2. So his back pain can be treated as musculoskeletal in perhaps a slightly more vulnerable or inflamed patient. Your plan of rest, PT, NSAIDs, and flexeril is absolutely appropriate. If he is no longer regularly following up with rheum then I would get labs every 3 months or so including: – CBC with diff, CMP – ESR, CRP – Clean-catch UA (every 6-12 months is fine for this) Note if he has inflammatory back pain, worse in the morning, better with activity, this young gentleman may actually have a seronegative spondyloarthropathy such as ankylosing spondylitis. If you don’t have documentation of his RF and CCP autoantibodies I would check these as well. Then note that patients with RA or any inflammatory disease who are also on a DMARD get a better response to their biologics such as humira. But if he’s doing well there’s no need right now to start low-dose methotrexate. Feel free to follow up with additional questions or data and thank you for this consult!

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