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Fatigue is caused by a wide variety of conditions.  While rheumatic conditions can cause fatigue, they are not the only conditions that do so.  Reviewing with your family doctor if you have any other symptoms can help narrow down the cause of the fatigue to ensure you manage it appropriately.  If your family doctor finds other symptoms that could be related to rheumatic diseases, then it would be appropriate to see a rheumatologist to determine if this is the case.

Rheumatologists do treat Connective Tissue Diseases (CTDs), such as lupus, Sjogren’s, myositis, scleroderma and more.  More and more, we have renamed this group of conditions as systemic autoimmune rheumatic diseases (SARDs).  Sometimes there is confusion about another group of CTDs which cause hypermobile joints or genetic conditions such as Ehlers Danlos syndrome.  While rheumatologists occasionally will see these latter conditions, it is not within their scope of practice.  Rheumatologists will diagnose DISH (Diffuse Idiopathic Skeletal Hyperostosis), which is a form of osteoarthritis of the back.  Ultimately, DISH is managed similar to mechanical back pain and osteoarthritis, with a focus on decreasing pain and improving function.

While most rheumatologists provide excellent care, we recognize not everyones’ personalities are a perfect fit, and that sometimes can affect care.  We always encourage individuals to give your rheumatologist a fair try to ensure there truly is a mismatch.  It really takes 6-12 months to determine this, which would be 3-4 visits typically.  If you still think you want to consider different care, discussing this with your rheumatologist is a good idea.  An honest respectful conversation may help the relationship, but most rheumatologists also respect the need for a second opinion and can help facilitate this.  Your family doctor can also do this if you are not comfortable.  If you are seeking a third opinion or more, that becomes more challenging to arrange.  The wait times to see a rheumatologist are too long, and there needs to be a balance between optimizing the care relationship and ensuring everyone gets access to a rheumatologist.

While biologics can be very effective at treating rheumatoid arthritis, they typically are not considered the first choice.  In most cases, methotrexate remains the gold standard treatment.  This is not just because it costs less, but in fact, when studied head to head, methotrexate works just as well as biologics do.  When combined together, methotrexate and biologics are more effective.  Overall, methotrexate is likely a safer option compared to biologics; and, well over 50% of individuals will go into remission on traditional DMARDs like methotrexate without needing biologic medications.

While rheumatoid arthritis can potentially affect nearly every joint in your body, the one area that is uncommon to be affected is the lower back.  If someone has lower back pain and rheumatoid arthritis, the lower back pain is more often mechanical in nature, or “normal” back pain.  That said, other forms of inflammatory arthritis – like psoriatic arthritis, ankylosing spondylitis and others – can involve the lower back.  Sometimes, it is difficult to know what type of arthritis someone has.  Inflammatory back involvement can be an important clue to help.

Rheumatologists diagnose and manage over 100 different forms of arthritis.  However, what treatment looks like is different depending on the form of arthritis.  Currently, management of osteoarthritis is focused on optimizing pain and function, with no long term disease modifying medications yet available.  Because of this, while rheumatologists often will see individuals to diagnose osteoarthritis, they do not typically follow these individuals long term as there is often no further recommendations that can be provided beyond the initial assessment.  Family doctors are typically excellent at providing care for osteoarthritis, but it usually needs an entire team – physiotherapists, occupational therapists and sometimes orthopedic surgeons all have a role to play.  Learn more about management options for osteoarthritis here.

An internal medicine specialist is a doctor for adults who can diagnose and manage a wide variety of complex and multi-system diseases.  As part of their training, they will complete rotations in many different areas of medicine, often including some time in rheumatology.  To become a rheumatologist in Canada, a doctor first completes core internal medicine training before receiving at least 2 years of further subspecialty training exclusively in rheumatology.  While having a rheumatologist manage a rheumatic condition is ideal, there are certainly situations where having an internist involved may be a good choice in care.  Any type of doctor – including internist and family doctors – can refer individuals to a rheumatologist for care.

When it comes to inflammatory arthritis, like rheumatoid arthritis, psoriatic arthritis and others, the goal of treat is remission – no pain, no stiffness, no swelling, doing all the things in life that you want and prevent damage.  We try to do this using DMARDs – both conventional ones like methotrexate or hydroxychloroquine, or any of our newer biologics.  It is relatively common to try some of these in combination to get better effects.  It is also common that we need to keep trying different DMARDs – including different biologics – in different combinations until we get it right and you feel better.  While we typically only use one biologic at a time, trying more than biologic is very reasonable if the first one does not work.  This of course assumes no other side effects or safety concerns because of other health problems one may have.

These tests are often associated with lupus, but it can get confusing.  An ANA test is not diagnostic of lupus; a negative test essentially rules it out, while a positive test often means nothing on its own (1/200 individuals who are positive have lupus).  On the other hand, we usually say that dsDNA test is a very good test for lupus.  In other words, if you test positive for dsDNA, it usually means you have lupus.  Unfortunately, the way the test is run by many labs these days is not as accurate as it was in the past, resulting in false positive results.  When a positive result returns, some labs will double check the test with the traditional crithidia method, which is more trustworthy.  In someone who is ANA negative and crithidia dsDNA negative, it is reassuring that lupus is an unlikely diagnosis.

Point of care ultrasound (versus ultrasound done at a radiology centre) is becoming more commonly seen in rheumatology offices.  It is still not considered standard of practice for rheumatologists, as those rheumatologists who offer ultrasound should have undertaken extra training to ensure they are competent and able to accurately interpret the images.  Ultrasound is not necessarily needed for all patients.  For most individuals, a good physical exam provides the needed information to make a good plan for managing your arthritis.  In some cases, it can be helpful, which is when a rheumatologist who does not do ultrasound themselves will either ask their colleague to perform the test, or have the patient assessed at a radiology centre.