Rheumatoid Arthritis: Modern Management of an Ancient Disease

Dr Chandini RaoConsultant Rheumatologist

RHEUMATOLOGY IN THE 21st CENTURY

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History of Rheumatoid Arthritis (RA)

• 123 AD first text describes symptoms very similar to RA

• 1800 first recognised description of RA by French physician Dr A J Landré-Beauvais (1772-1840)

• 1859 name “rheumatoid arthritis" itself was coined by British Dr A B Garrod.

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What is it?

• Chronic, progressive, autoimmune disease

• Causes inflammation in joints (especially hands, wrists, feet)

• Systemic condition

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What is inflammation?

• Normal body defence mechanism

• Increased blood flow

• Blood cells produce chemical messengers to continue the process

• Heat, swelling, redness, pain, loss of function

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Who does it affect?

• 0.8% of UK population• 3x more common in women• Onset usually between ages 40 - 60• Approx 580,000 patients in UK• 12,000 under age 16• 26,000 new diagnoses/year• NHS costs: £560 million/year • Economy: £1.8 billion/year

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What causes RA?

• Genetics

• Environment

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Genetics

• 1st degree relative: 2-7 fold risk

• Identical twin: 16% chance of RA

• Need an environmental trigger as well

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Environment

• Geography

• Hormones

• Infection

• Smoking

• Diet

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Symptoms

• Joint pain

• Joint swelling

• Morning stiffness

• Fatigue

• Weight loss

• Flu-like symptoms

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What else does RA do?

• Eyes: dryness, inflammation

• Lungs: fluid, inflammation, nodules

• Skin: nodules, ulcers

• Heart: fluid, inflammation, ischaemic heart disease

• Blood: anaemia, low counts

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How is RA treated?

General Principles:

• Patient education/self-management

• Multi-professional team care

• Medication

• Surgery

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Symptomatic Treatments

• Education/support• Rest/relaxation• Joint protection• Physiotherapy• Painkillers• Anti-inflammatory drugs• Steroids• Joint injections• Pain Management Clinics

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Reduction of Joint Damage

Disease-modifying Anti-Rheumatic Drugs (DMARDS)

•Methotrexate•Sulfasalazine•Leflunomide•Hydroxychloroquine•Azathioprine•Ciclosporin•Gold•Penicillamine

Biologic drugs

• Anti-TNF therapy: Infliximab Etanercept Adalimumab Certolizumab Golimumab

• Rituximab

• Abatacept

• Tocilizumab

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Goals of Therapy

• To relieve pain, stiffness, swelling, fatigue

• To prevent joint damage/disability

• To improve quality of life

• ? To achieve disease remission

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Principles of Treatment

• Early diagnosis

• Early initiation of treatment

• Regular assessment (Disease Activity Scores)

• “Treat to Target”

• Annual review

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Famous people with RA• Dorothy Hodgkin: Nobel prize winning scientist,

developed severe RA at age 28. Developed X-ray crystallography, discovered the structure of insulin and enabled discovery of the genetic code.

• Christiaan Barnard: performed first heart transplant in 1967, 11 years after developing RA. Wrote a book on living with arthritis

• Kathleen Turner: Hollywood actress

• Bob Mortimer: British comedian

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Pierre-Auguste Renior (1841-1919)

• French, impressionist

• 1892 RA – 51 yrs

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Thank You!

The role of the Rheumatology Nurse Practitioner.

Janice Booth

RHEUMATOLOGY IN THE 21st CENTURY

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ABOUT ME

• RGN (SRN) 1981• Rheumatology 1984 / Research / CNS• BA Hons, Health and Psychology 2001• Nurse Practitioner, 2007• Non Medical Prescriber, 2009

Blackpool since December 2002.

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THE MULTI DISCIPLINARY TEAM

• Consultants x 3 + 1 (SPR & SHO)

• Rheumatology Nurse practitioner

• Biologics Nurse practitioner

• Osteoporosis CNS

• Occupational Therapist

• Physiotherapist

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CONDITIONS SEEN

• Rheumatoid Arthritis

• Psoriatic Arthritis

• Ankylosing Spondylitis

• Lupus

• Polymyalgia Rheumatica

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RHEUMATOLOGY NURSING

• Moved from the bedside to the clinic

• From Nurses as carers

• To autonomous practitioners.

• Higher education – extended roles and skills.

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WHY????

• Face of Rheumatology has dramatically changed.

• Focus on prevention of disease progression.

• Maintaining function.

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WHY?

• From more conservative approach, To proactive management – treat to target.

• Standards and Guidelines - direct practice.

• Drug development, evidence based practice.

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TREATMENT

• Pharmacological.

• Physical – Occupational Therapy / Physiotherapy.

• Psychological.

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DISEASE MANAGEMENT

• Early intervention

• Aggressive

• Combination therapy

(NICE, 2009. BSR,2006. 2009.)

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Early RA

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ADVANCED RA.

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Psoriatic Arthritis

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Role of Rheumatology Nurse

• Educate.

• Assess.

• Monitor.

Concordance with treatment improves outcomes.

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REFERRALS

• Members of the MDT

• Primary care – GP, Practice Nurses, Community Matron

• Patients – helpline or monitoring clinic

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Reasons for referral

• New Diagnosis• New treatment / DMARD• Treatment efficacy – titration /

escalation• Biologic therapies• Interim follow ups• S.O.S – urgent clinic• Rheumatology Monitoring Clinic

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Nurse Practitioner Assessment

• Review medication / concordance.

• Monitoring.

• Disease Activity.

• Education / counselling.

• Treatment plan / Recommendations / Interventions / referral.

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SERVICE

• Nurse Led Clinics – Clifton and Fleetwood

• MDT Clinic – Clifton (2 x month)

• Rheumatology Monitoring Clinic – BVH weekly with OPD

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Service Cont.

• S.O.S clinic – Clifton (2 x month)

• Helpline

• Education – Pt Groups, Staff, Students

• NRAS group (BADRAG) http://www.badrag.org.uk/index.html

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ACTIVITY

• Nurse Led Clinics - Mon, Tues and Weds approx 25 appointment slots per week. Activity for 2010 = >1000 (1100 apps face to face contacts. (Data 2004 = 722)

• Helpline – 988 calls.

• Monitoring Clinic – 43 slots (28 injection+ 15 bloods).

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SERVICE DEVELOPMENT

• Implementation of NICE – 79

• Early arthritis clinics

• Annual review clinics

• I/A injection (nurse led)

• S/C Methotrexate - Community

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THANK YOU

Any Questions?

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The next Members health seminar will take place on:-

Thursday, September 22nd 2011

12 -1 pm in the Lecture Theatre,

Education Centre, BVH

The topic is:

“Bereavement across Lancashire and South Cumbria.”