While at
the EULAR Annual Meeting 2015 in Rome I've been asked for my Magic Eight
Questions. I've chosen these eight questions out of safety concerns. In real
life you can't spend as much time as you would do under study conditions. But
nevertheless we have to make sure; our patients are not at risk of unnoticed
side effects.
The eight
questions cover quite a lot of, but not every possible side effect. You have to
add one or two open questions. I ask these questions at every visit and always
keep to the same order. By and by the patients learn what I want to know and
help with telling me, even before I start asking. And they learn to look for
the symptoms of possible side effects.
1.
Contact to someone with tuberculosis
Most
patients answer the first time with: "How should I know?", or:
"Not to my knowledge." I tell them, that they will know, as public
health officials will contact them, if they had been in contact. Lately I had
two patients: one working as an emergency assistant and another working as an
interpreter.
2.
Infections
I look for
any hint of an infection, also if these are past. We talk about the therapies
and sometimes I can educate, if things haven't run smoothly, like antibiotics without
making sure that it's a bacterial infection. Or not stopping the biologic in a
relatively severe infection.
3. Loss
of Weight
Most people
will answer that they gained weight. I've seen more patients under traditional
DMARDs with wasting due to the drug. Wasting - that is what we should look for.
4. Night
Sweats
There are
some patients, who have night sweats now and then, or where I have to ask if
they also sweat during daytime. Together with loss of weight you might get the
alarm ringing for more diagnosis and postponing the biologic.
5. Neurological
disorders
Some
patients think I ask for depression or nervousness. The question is more to
know if dysaesthesia and other neurological disorders are developing.
6. Diarrhoea
Quite
people think going three times per day to the toilet is diarrhoea. So you
should give a definition. And I like to quote Hippocrates, who though four
times soft stool per day is normal; people obviously ate more fibre in these
days.
7.
Stomach Problems
I added
this question (also No. 6) because of the side medications and tocilizumab.
Some people take NSAIDs without PPIs, so you might have to add a PPI to the
regular medication.
8. Loss
of Hair
Not every
loss of hair is due to medication! It is the unexpected loss of hair that I'm
interested in. Some patients have to count how many hairs from the head they
loose in 24 hours. You might say that isn't an issue with biologics, but think
of all you patients, who take concomitantly methotrexate, leflunomide, and
others.
The Magic
Eight Questions won't solve all your problems, but make your life as a
rheumatologist easier and help to identify safety issues with your patients.
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