Rheumatology
Dr Nicky Minaur
Consultant Rheumatologist
North Bristol NHS Trust
Talk Outline
• The local Rheumatology Service
• A tale of two patients – opportunities and
challenges
• Recording biologic treatments in primary
care
• CTD pathway
• Patients with chronic pain
• Discussion
Rheumatology in the Region
• NBT (8 Consultants), UHB (4 Consultants),
Weston (2 Consultants), Gloucester (5
Consultants)
• In-patient beds for all Bristol & Weston
patients on Trym Ward, Avon Orthopaedic
Centre, Southmead
• Number of beds is currently 9 reduced from
25 beds 10 years ago
New hospital?
Rheumatology Team at NBT
• Clinics held at Southmead, Frenchay and
Cossham Hospitals (Henshaw House)
• 8 Consultants, 3 SpRs, 1 ST1/2 ward doctor
• Specialist Nurses
• Specialist Rheumatology Physiotherapy,
Occupational Therapy, Psychologist
• Orthotics
Consultant Rheumatology Staff –
all see inflammatory arthritis
• Dr Peter Hollingworth
– SMD- medicolegal
• Dr Val Kyle
– FHY, CSSHM- PMR/GCA, vasculitis
• Dr Paul Creamer (Clinical Lead)
– SMD, FHY, CSSHM- clinical research, ankylosing
spondylitis, gout
• Dr Sam Patel (Rheumatology/General Medicine)
– FHY- MAU, Behçet’s syndrome, vasculitis
Consultant Rheumatology Staff
(contd)
• Dr Nicky Minaur
– SMD, CSSHM- modernisation, transition clinic for JIA
• Prof Jon Tobias (previously UHB)
– SMD- academic, osteoporosis, metabolic bone disease
• Dr Emma Clark (Senior Lecturer)
– SMD- academic, osteoporosis, hypermobility syndrome
• Dr Harsha Gunawardena
– SMD, CSSHM- connective tissue diseases, vasculitis
Specialised & Combined Clinics
• Specialised clinics for connective tissue
diseases, osteoporosis, transition patients
• Combined clinics with orthopaedics hands,
upper limbs, hips, knees and feet
• Combined clinics with dermatology,
respiratory, neurology
Request
• Please don’t allow patients with
inflammatory joint disease or connective
tissue diseases (eg scleroderma) to go to an
independent treatment centre for elective
orthopaedic sugery
• These patients need the specialised,
multidisciplinary care available at NBT
What’s new in Rheumatology?
A Tale of Two Patients
• Colin, now aged 71, developed RA 21 years
ago
• Stopped work age 50 due to RA
• IM Gold, D-Penicillamine, SSZ, steroids
• R TKR
Patient 1
•
•
•
•
Lost to follow-up in the 1990’s
Referred back 2005, on SSZ, active RA
MTX, escalated, switched to S/C
Assessed for anti-TNF, SOB++ on
Etanercept - pulmonary fibrosis
• Treated with Rituximab Feb/Mar 2009
Patient 2
• Jill developed RA aged 50 in 2010
• Off work with RA, also diagnosed with DM
• Had been started on Prednisolone 15mg by
GP before referral, CRP 92
• Seen first in June 09
• Started on MTX 15mg/wk, FA, Pred
weaned
• Referred Rheumatology PT, OT
Patient 2
• Reviewed 1 month later July 09
• August 09 - SSZ added to MTX, now off
steroids and diabetes resolved
• Sep 09 – DAS28 6.29 (active RA), SSZ
increased
• Oct 09 – RSN – DAS28 5.86 (still active
RA), MTX increased to 17.5mg/wk. Mood↓
Patient 2
• November 09 – DAS28 5.15, MTX
increased to 20mg/wk, SSZ reduced to 1g
bd
• Reviewed 8 weeks later, Feb 10 - DAS28
3.1
• Reviewed April 10 – DAS28 2.1
• In remission after 8 visits and 10 months
Differences
•
•
•
•
Colin
Never worked again
Very disabled
RA never really
controlled
• Comorbidities
• Has had 2 different
biologic agents
• Jillian
• RA under control
within a year
• Back at work
• No disability
• Diabetes gone
• Self-managing RA,
loosing weight
Costs: standard vs aggressive
3 or 4 monthly visits for
20 years is 60-80 visits
• Estimate 55 visits as
lost for 2 years
• Major joint surgery
• 2 biologic agents
• Benefits
• Poor quality of life
8 visits in first 10 months
• Estimate annual
review for next 20
years
• This is 28 visits
• Additional visits as
needed
• In work, no disability
Rheumatology in 1980
• NSAIDs were 1st line
• Wait for erosions
before starting
treatment with a
second-line drug
• Use of IM Gold and
D-Penicillamine still
common
Outcome of delayed, tentative
treatment
Rheumatology in 1990’s
• Start DMARD as soon as diagnosis made-don’t
wait for erosions- but there was often a 9 month
wait from GP referral to Rheumatology
appointment
• Increasing use of Methotrexate and doses creeping
up to 15mg/week or higher
• Combination treatment eg MTX and SSZ shown
to be effective in trials, not used much in practice
Rheumatology in 2000’s
• Methotrexate became thought of as the
‘anchor drug’
• S/C Methotrexate use increased, and doses
increased- commence at 15mg/wk, max 2530mg/wk
• Leflunomide introduced 2000
• Increasing use of combination Rx- MTX,
SSZ, HCQ, Prednisolone
Rheumatology in the 2000’s
• Services changed with the NHS plan
• Waiting times came down dramatically
• Musculoskeletal interface services
developed
• Case-mix in rheumatology has changed as
non-inflammatory conditions are not
reviewed, and ‘simple’ conditions not seen
Rheumatology in 2000’s
• First RCT of anti-TNF therapy in RA was
published in 1999 Infliximab (Maini & Feldman)
• Many others followed
• NICE has approved use of
–
–
–
–
Infliximab, Etanercept (2002)
Adalimumab (2007)
Certolizumab (2010)
Rituximab (2007)
• In pipeline Tocilizumab and Golimumab…….
ATTRACT Study 2004
MTX did not halt new
erosions, especially in
early RA (< 2years), but
may slow their
development compared
to no treatment
Infliximab does halt
new erosions, even in
early RA
Anti-TNF is more effective in
combination with MTX
In clinical
practice, 70% of
patients are still
on Rx with antiTNF and MTX
after 1 year
MTX is the
comparator drug
in all biologic
trials now
Standard care in 2010
• Patient may delay more than 3 months to see GP
• GP may try NSAID or 2, occasionally start
steroids, arrange x-rays hands and feet, do bloods
(FBC, CRP, PV, RF)
• GP then refers, using Choose and Book
• Seen in rheumatology 6-9 weeks later, diagnosis
made
• Starts MTX, review 3 months
Standard care in 2010
• 3 monthly reviews and MTX gradually
increased, then SSZ added and/ or MTX
changed to S/C injections, as necessary
• After approx 2 years, if still active RA
• Assessed for anti-TNF
Timing needs to change
How can we apply these tools in
good time?
NICE Clinical Guideline 79
• Rheumatoid Arthritis: the management of
rheumatoid arthritis in adults
• Issued February 2009
• Guidance is aspirational and will require a
major shift in the way services are delivered
Window of opportunity
‘Remission’ may be low disease activity, or drug-free
remission. NB RA does not ‘burn out’.
Referral for specialist treatment
(NICE CG79)
• Refer for specialist opinion any person with suspected
persistent synovitis of undetermined cause.
• Refer urgently if any of the following apply:
− the small joints of the hands or feet are affected (squeeze
MCPJs and MTPJs, should not hurt)
− more than one joint is affected
− there has been a delay of 3 months or longer between
onset of symptoms and seeking medical advice.
• Do not put off referring a patient with
persistent synovitis to a specialist if the
bloods and x-rays are normal- these tests
can be normal in early RA
• If symptoms have been present already for
more than 3 months, reactive arthritis is
unlikely and further delay affects outcome,
so refer immediately
Single joint pain – not NICE
guidance
• Should be referred to Rheumatology if
inflammatory
– Early morning stiffness > 30 minutes, or
– Boggy swelling suggesting synovitis, or
– Raised inflammatory markers eg PV/CRP
• Any of these features is significant
• Psoriatic arthritis often presents with a
mono-arthritis- personal or FH of Psoriasis?
Disease modifying agents
(NICE CG79)
• Offer a combination of disease-modifying antirheumatic drugs (DMARDs) in people with newly
diagnosed active RA, (including methotrexate and
at least one other DMARD, plus short-term
glucocorticoids) as soon as possible, ideally within
3 months of the onset of persistent symptoms.
• Start DMARD monotherapy in people with
newly diagnosed RA for whom combination
DMARD therapy is not appropriate.
Disease modifying agents
(NICE CG79)
• Cautiously reduce drug doses to levels that
maintain disease control in people with recentonset RA receiving combination DMARD therapy
in whom disease has been controlled ie those who
have gone into remissison.
Monitoring disease (NICE CG79)
– In people with recent-onset active RA
measure:
- C-reactive protein (CRP)
- key components of disease activity
– Do this monthly until disease controlled to
level agreed with the person with RA
• This implies treating to a target Disease Activity
Score (DAS28)- composite outcome measure of
tender joints, swollen joints, patient’s global
assesment of their condition, and CRP
• Please measure CRP rather than PV with
monitoring bloods
• Target should be agreed with the patient at the
start of treatment by the rheumatologist
• People’s expectations are low and they are often
grateful for any reduction in symptoms
DAS28
• Greater than 5.1 – high disease activity,
threashold currently for biologic therapy,
but may come down to 3.2
• Less than 3.2 – low disease activity
• Less than 2.1 - remission
The multidisciplinary team
(NICE CG79)
People with RA should have
access to a named member of the
multidisciplinary team who is
responsible for coordinating their
care.
Person-centred care
(NICE CG79)
– Explain the risks and benefits of treatment
options.
– Offer the chance to discuss and agree care,
respecting decisions made.
– Offer verbal and written information to improve
understanding and counter misconceptions.
– Offer opportunities to take part in existing
educational activities, including self-management
programmes, to people who are interested.
Dilemma
• NICE - see early RA
monthly until in
remission, perhaps 912 visits over first 2
years
• This should translate
into 70% patients in
remission rather than
30%- fewer for TNF
• We all have clinics
full of existing
patients, many
diagnosed and treated
pre-biologic eracomplicated patients!
• We are being asked to
see all chronic disease
patients less often
Can we abandon all the longstanding pre-biologic patients?
• No, we have a duty of care
to these patients too
• However, in established
RA (> 2 yrs), usual review
should be annual
• Advice and sooner review
available- telephone
advice line (on handout)
• Patient reps’ group view
Recording biologic treatments in
primary care
• A recent audit at NBT found patients given
Rituximab did not have it recorded in the
GP medication lists, as hospital prescribed
• Anti-TNF side effects – risk of severe
infection, reactivation of TB & Hep B,
worsening cardiac failure, multiple
sclerosis, SLE-syndrome, if previous solid
tumour increased risk of malignancy
Rituximab- anti-B cell
• 2 infusions given a month apart, and then
re-treatment if needed- mean 9 months later
• Effect on immune system long-lasting
• Side effects- severe infections, reactivation
of TB and Hep B, rare neurological side
effects progressive multifocal
leucoencephalopathy, migraine, urticaria
Aid to ensure these medications
are recorded in primary care
• We propose to add a phrase to letters from the
specialist nurses when patients start treatment with
anti-TNF and Rituximab
• Please add this treatment to the patient’s
medication list, marked hospital-prescription only
• Then if another GP or speciality sees the patient,
they are aware of the biologic treatment
• ? Likely to happen
Directorate of Musculoskeletal Services
Department of Rheumatology
Symptoms of fever, weight loss, malaise, rash, arthritis,
renal insufficiency, chronic sinusitis, unilateral headache,
cough and/or SOB
Constitutional symptoms, rash, photosensitivity,
arthralgia/arthritis, Raynaud’s, alopecia, serositis, muscle
weakness, skin tightening, SOB
Clinically stable?
History of recurrent miscarriages or unexplained
thromboses
Yes
Consider infection or malignancy
Negative ANA /ANCA
Pre-clinic investigations:
FBC, UE, LFT, PV, CK, ANA,
urine dipstick, CXR, consider
ANCA
NO
No other cause identified – still
consider CTD / vasculitis
Rheumatology SpR Southmead via Southmead switchboard
or
CTD Consultant Dr. Harsha Gunawardena
0117 3232175 (secretary) & 0117 323 5289 (fax)
0117 9505050 ext: 2615 (office)
Mobile via NBT switchboard
Email: harsha.gunawardena@nbt.nhs.uk
(Positive ANA /ANCA)
Clinically stable?
Yes
NO
Refer to Dr. Harsha Gunawardena - CTD clinic (Southmead / Cossham) via Choose and Book
Osteoporosis
• Open access DXA if amber risk on www.sheffield.ac.uk/FRAX
• Refer complex or severe OP to Prof Tobias’
osteoporosis clinic
• Rachel Lewis (rheum physio) can do
lunchtime meetings for interested practices
talking about the physiotherapy service for
osteoporosis and hypermobility syndrome
Patients with widespread chronic
pain- ? fibromyalgia
• Handout suggesting some blood tests and
conditions to consider
• Coeliac disease
• Hypermobility syndrome
Benign joint hypermobility
syndrome
Rheumatology physio
can help with postural
and core stability, or,
refer rheumatology
(Dr Emma Clark).
• Thanks for listening
• Any Questions or Comments?
• nicola.minaur@nbt.nhs.uk