rheumatoid arthritis: modern management of an ancient disease dr chandini rao consultant...
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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.”