RHEUMATOLOGY IN THE
21st CENTURY
Rheumatoid Arthritis: Modern
Management of an Ancient Disease
Dr Chandini Rao
Consultant Rheumatologist
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 LandréBeauvais (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?
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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
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Geography
Hormones
Infection
Smoking
Diet
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Symptoms
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Joint pain
Joint swelling
Morning stiffness
Fatigue
Weight loss
Flu-like symptoms
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What else does RA do?
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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
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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)
Biologic drugs
•Methotrexate
•Sulfasalazine
•Leflunomide
•Hydroxychloroquine
•Azathioprine
•Ciclosporin
•Gold
•Penicillamine
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Anti-TNF therapy:
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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!
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RHEUMATOLOGY IN THE
21st CENTURY
The role of the Rheumatology Nurse
Practitioner.
Janice Booth
ABOUT ME
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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
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Consultants x 3 + 1 (SPR & SHO)
Rheumatology Nurse practitioner
Biologics Nurse practitioner
Osteoporosis CNS
Occupational Therapist
Physiotherapist
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CONDITIONS SEEN
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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.”
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