RHEUMATOID ARTHRITIS. Dr Bruce Kirkham Rheumatology Clinical Lead

Transcription

1 RHEUMATOID ARTHRITIS Dr Bruce Kirkham Rheumatology Clinical Lead

2 RHEUMATOID ARTHRITIS (RA) RA is a common disease: 0.8 per cent of the population RA more common in females: female to male ratio 3:1 RA is a serious disease: pain, disability, crippling social isolation, unable to look after family high divorce rate RA is a costly disease: total costs 1.3 billion per annum Severe, uncontrolled RA increases mortality

3 NORMAL RA Synovial membrane Cartilage Inflamed synovial membrane Pannus Major cell types: T lymphocytes macrophages Minor cell types: fibroblasts plasma cells dendritic cells mast cells Capsule Synovial fluid Major cell type: neutrophils

4 Blood vessel capsule The normal joint lining is very thin. it has a few blood vessels no white blood cells in it. White blood cells capsule The inflamed joint lining is very different: it is thickened it is crowded with white blood cells it has many new blood vessels

5 KNEE JOINT ARTHROSCOPY

6 MACROSCOPIC VIEW OF INFLAMED SYNOVIAL MEMBRANE IN RA

7 INFLAMED SYNOVIAL MEMBRANE Thickening of the synovial membrane Inflammatory infiltrate of immune cells Increased numbers of blood vessels Rosenberg A. In: Cotran RS, Kumar V, Collins T, eds. Robbins Pathologic Basis of Disease. 6th ed. Philadelphia, PA: WB Saunders; 1999:

8

9 WHAT ARE MY TREATMENT GOALS IN RHEUMATOLOGY? Improving patients lives - pain reduction and restored function are the top two goals of therapy for people with RA Treating to target is the strategy to maximise improvement Use measurable outcomes

10 WHAT ARE MY TREATMENT GOALS IN RHEUMATOLOGY? PREVENT PROGRESSIVE JOINT DAMAGE Uncontrolled RA causes joint damage Once joint damage has occurred it produces irreversible loss of function Remission results in much lower rates of joint damage

11 GOAL-DIRECTED THERAPY IN RA (Treat-to-Target, Goal-steered therapy) Aim to suppress the RA disease activity to a predetermined level i.e. goal of therapy Most common measure is DAS28 DAS28 - a composite score of 28 swollen joints, 28 tender joints, patient global score, ESR 11

12 TREATMENT GOAL: REMISSION DAS28 Scale Severe disease activity Disease activity Normal labs (ESR, CRP) DAS28 <2.6 DAS44 < Moderate disease activity Low disease activity Remission Quality of life Zero disability (HAQ <0.5) X-rays No radiographic progression (Change of TSS O) True remission: absence of symptoms, inflammation, and damage progression

13 MR AH - Electrician Onset of inflammatory arthritis 10/05 NSAID s little response difficult to get out of bed Rheumatologist Diagnosis RA Rx MTX Serious difficulty working Abnormal LFT ALP & GGT -? Liver Bx Seen by nurse SJC 3, ESR 104, CRP 80

14 Mr AH - Electrician Seen RA Centre 02/06 DAS score 7.1 SJC 15 about to stop job Rx Pred 30mg/d, increase MTX 04/06 DAS 4.3 Working well- Triple Rx 08/06 - DAS 2.3 In remission - feels normal, can do everything except running MTX/SASP/HCQ No prednisolone

15 RA: TREATMENT MAKES A DIFFERENCE Treatment: must begin early (within 6 months) must be effective Drugs and biologics: slow/halt joint damage improve quality of life Methotrexate and biologics reduce increased mortality

16 WHAT PRESSURES ARE ON ME TO ACHIEVE THEM? Meeting NICE requirements NICE guidelines recommend treat to target strategy for RA Trust targets A balance of NICE guidelines and payor requests (e.g. new to follow-up ratios) Patient awareness Varies, organisations such as NRAS and Arthritis Care promote good practice Managing complex patients as individuals the role of the rheumatologist is to balance payor requests, NICE guidance and the evidence base, to achieve an optimal outcome for each individual patient

17 WHAT ARE MY TREATMENT GOALS IN RHEUMATOLOGY? Treating to target in routine practice Does this improve patients lives? RA Centre at Guy s Established in 2004 Goal of therapy DAS28 remission for all patients if possible

18 FUNCTION IMPROVES WITH BETTER CONTROL GULLICK ET AL (IN PREPARATION )

19 TREAT-TO TARGET IMPROVES OUTCOMES OVERTIME

20 CONCLUSION Treat-to-Target strategy is highly effective Optimises individual patient needs to achieve important patient-related outcomes Multiple therapy options are necessary Achievable within normal NHS resource

21 THE ROLE OF NURSES IN THE RHEUMATOLOGY DEPARTMENT Laura Blackler Clinical Nurse Specialist

22 IMPACT OF INFLAMMATORY Life-long condition Can affect relationships ARTHRITIS Lifestyle - smoking, alcohol intake Work sometimes have difficulties in remaining in work if employer not able/want to make any changes to job or environment Hospital & GP appointments, regular blood tests

23 RHEUMATOLOGY NURSING TEAM Clinical Nurse Specialist Clinics Telephone Advice line Providing information and advice to patients and GPs Audit Staff nurses Providing support for patients attending clinics Organising and administering infusions Providing education and support to patients about their condition and medication Organising prescriptions for patients self-administering drugs at home Healthcare Assistants Providing phlebotomy service Supporting the nurses

24 CLINICAL NURSE SPECIALIST CLINICS Newly diagnosed patients Providing support and education about their disease and treatment Providing advice about managing the symptoms Dealing with side effects related to the medication Dose escalation Patients on high cost drugs Education Assessment Pregnancy advice clinic Osteoporosis

25 TELEPHONE ADVICE LINE Enables patients to contact the department for nonemergency queries Medication Management of flare-ups Questions about disease Queries from GPs

26 IMPACT OF THE ROLE OF THE CLINICAL NURSE SPECIALIST Aim of treatment for patients with Rheumatoid Arthritis is remission Study was done to look at whether we were treating to target and if not, why The results of the study were compared with previous studies

27 COMPARISONS OF STUDIES Reasons Number of patients Declined 8% 35% 34% Pain score> inflammation 30% 20% 5% Contra-indications 8% 17% 22% Flare up only 4% 10% 15% Waiting for previous treatment to take effect 28% 6% 12% Other reasons 22% 12% 12%

28 The aim of treatment is to reduce arthritis activity and joint damage so that the patient can continue with their normal activities

29 OTHER TYPES OF ARTHRITIS & THEIR MANAGEMENT

30 THE HEALTHCARE TEAM APPROACH TO THE MANAGEMENT OF SPONDYLOARTHRITIS Melanie Martin Extended Scope/Clinical Specialist Physiotherapist in Rheumatology

31 WHAT IS SPONDYLOARTHRITIS? Spondyloarthritis is a type of inflammatory arthritis. The main symptom is Inflammatory Back Pain. When symptoms affect the spine, the condition is called Axial Spondyloarthritis. Other types of Spondyloarthritis may affect peripheral joints such as the hands, knees and feet, known as Peripheral Spondyloarthritis. Ankylosing Spondylitis is a form of Spondyloarthritis and is as common as Rheumatoid Arthritis.

32

33 THE SPONDYLOARTHRITIS HEALTHCARE TEAM Rheumatologist Physiotherapist Patient GP Occupational Therapy Podiatry

34 MANAGEMENT OF SPONDYLOARTHRITIS Drug Management Non-Drug Management Non-steroidal Anti-Inflammatory Drugs Disease-Modifying Anti-Rheumatic Drugs Steroids Biologic Therapy Physiotherapy Exercise Self-Management Education Hydrotherapy

35 PATIENT-FOCUSED MANAGEMENT CHOICES Axial Spondyloarthritis Know-How Self-Management Intervention Annual Review in Rheumatology Rheumatology Help-line Patient Inflammatory Back Pain Hydrotherapy Class 1:1 Physiotherapy Treatment

36 To provide the right treatment to the right patient at the right dose at the right time for their condition PATIENT-CENTRED APPROACH

37 Discussions, Questions and answers