Arthritis and Rheumatology. Antoni Chan MBChB, FRCP, PhD Consultant Rheumatologist Royal Berkshire NHS Foundation Trust

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1 Antoni Chan MBChB, FRCP, PhD Consultant Rheumatologist Royal Berkshire NHS Foundation Trust

2 Rheumatology Investigation, Diagnosis, Treatment

3 The challenge 8 billion a year in cost 700,000 people suffering from rheumatoid arthritis in Britain 26,000 more cases identified every year in England alone. Average days off sick in RA is 40 compared to 6.5 days (Arthritis Research UK)

4 What is a Rheumatologist interested in? Bones Joints Muscles Soft tissues Connective tissue Internal organs Whole systems

5 Arthritis

6 What is arthritis?

7 Acute inflammation Calor, Rubor, Tumor, Dolor, Functio laesa (Hot, Red, Swollen, Pain, Loss of Function)

8 Autoimmune u disease Inflammation that lasts for a long time in arthritis leads to tissue damage Inflammation that lasts for a long time in arthritis leads to tissue damage through release of chemical called cytokines

9 Osteoarthritis Commonest form of arthritis, affects > 8 million people in UK Commoner in women, usually occurs with age > 40 years Exercise, diet and nutrition, complementary treatments, acupuncture, regular pain medication Reduce weight and loading on joints (back, hip, knees)

10 Rheumatoid arthritis Inflammatory arthritis affecting many joints Affects % of the population in the UK Can affect any age but usually starts at ages years Early treatment improves long term outcomes

11 Ankylosing spondylitis (AS) Inflammation of the spine Back pain that improves with exercise and worsens with rest Individual id bones of the spine may fuse resulting in stiffening i of the spine (ankylosis) if untreated Starts at age 20-30s

12 Why me? Genetics Infections Hormones Viruses Diet Trauma Accidents

13 Is it in the genes? HLA DR4 in Rheumatoid Arthritis HLA B27 in Ankylosing Spondylitis

14 What are the triggers? Causes increased risk of developing rheumatoid arthritis and cardiovascular disease

15 Chronic periodontal disease may increase the risk of developing rheumatoid arthritis Porphyromonas gingivalis area of research

16 Diet No special RA diet or diet "cure Mediterranean diet is protective Fish oils and omega-3 fatty acids

17 Keep moving Regular exercise is beneficial for joints Low impact movement swimming, tai chi, yoga

18 The revolution in Rheumatology Rapidly expanding field in Early diagnosis of arthritis Targeted personalised therapies Keep patients active and in work

19 Anti-TNF alpha treatment t t (biologic i therapy) Newer agents that block other chemical signals (cytokines) Must be monitored with regular blood tests and clinic review Stop if having infection or on antibiotics

20 Rheumatology Clinics `Care Closer to Home Wallingford Townlands (Henley) Royal Berkshire Hospital (Reading) Newbury (WBCH) Woosehill (Wokingham)

21 Multidisciplinary Infusion Unit Approach Metabolic Bone Research & Development Drug Monitoring: Enabling Shared Care with GP s to Enhance n Patient Safety Rheumatology Service Peripheral Clinics: Outpatient clinics in the community, providing care closer to home Biologics: Education, Therapies & Screening RBH: Inpatient Care Mobile Ultrasound Examination Flare Clinic Local Patient Groups Rheumatology Advice Line

22 Ultrasound of joints Early diagnosis and Assessment Safe, no radiation Treatment to Target Tight Control of Rheumatoid Arthritis

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24 Thank you Department of Rheumatology Royal Berkshire NHS Foundation Trust Secretary: Lindsey Smith Tel:

25 Connective Tissue Diseases Dr Gordon MacDonald BSc MBBChir MRCP Consultant Rheumatologist Arthritis and Rheumatology Seminar Thursday 9 th April 2015

26 Plan The immune system When the immune system goes wrong Symptoms of connective tissue disease Lupus (SLE) Tests/ Treatment Interactive!!! 26

27 What does the immune system do?

28 What does the immune system do? Fights infections

29 Immune response it s complicated!

30 Self vs. Non-self hypothesis Nobel Prize for Medicine Transplant Immunology Self vs. Non-self Peter Medawar

31 The Danger Model Polly Matzinger

32 When the immune system goes wrong Autoimmunity immune system attacks body s own tissues Inflammation and damage Friendly fire

33 When the immune system goes wrong

34 Rheumatologists t like a good mystery!

35 What is this condition called?

36 How common is Raynaud s disease? A. 1 in 1000 B. 1 in 100 C. 1 in 10 D. 1 in 3

37 Pi Primary versus secondary Raynaud s

38 Symptoms of connective tissue disease Joint pain Skin rashes Sensitivity to light Mouth ulcers Hair loss Raynaud s Digital ulcers Skin thickening Dry eyes and mouth Swallowing problems Muscle weakness Fatigue Weight loss Recurrent miscarriages Blood clots in legs/lungs g Headache Seizure Mental health problems Chest pain

39 What is this rash called?

40 Butterfly rash of Lupus (SLE)

41 Lupus (SLE) 9 times more common in women Joint pain, skin rashes, extreme tiredness Mouth ulcers, hair loss Internal organs less common (heart, brain, kidney) 1/3 may have additional autoimmune condition (e.g underactive y ( g thyroid, Sjogren s syndrome)

42 Is it Lupus?

43 What causes Lupus? Autoantibodies attack body s own tissues Environmental Genetic Hormonal

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45 Spectrum of connective tissue disease SLE Undifferentiated CTD Systemic sclerosis Sjogren s Dermatomyositis/ polymyositis

46 Autoantibody tib testst Anti-Ro Anti-Jo-1 Anti-La ANA 1:640 Anti-DNA Anti-Centromere Anti-RNP Anti-Sm Speckled pattern C3/C4 Nucleolar l pattern

47 Treatment t Non-steroidal seoda anti-inflammatoriesa a Steroids DMARDs (Hydroxychloroquine, Azathioprine, Methotrexate) Biologics i (Rituximab, i Belimumab) Stem cells (Adult stem cells)

48 Summary Connective tissue disease cause wide range of symptoms Minority can have serious complications (heart, brain, kidney, lung) Expanding range of new treatments

49 Thank you Any questions?