RHEUMATOLOGY IN THE 21 st CENTURY

1. RHEUMATOLOGY IN THE 21st CENTURY Rheumatoid Arthritis: Modern Management of an Ancient Disease Dr Chandini Rao Consultant Rheumatologist

2. 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.

3. What is it? • Chronic, progressive, autoimmune disease • Causes inflammation in joints (especially hands, wrists, feet) • Systemic condition

4. 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

8. 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

9. What causes RA? • Genetics • Environment

10. Genetics • 1st degree relative: 2-7 fold risk • Identical twin: 16% chance of RA • Need an environmental trigger as well

11. Environment • Geography • Hormones • Infection • Smoking • Diet

13. Symptoms • Joint pain • Joint swelling • Morning stiffness • Fatigue • Weight loss • Flu-like symptoms

14. 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

15. How is RA treated? General Principles: • Patient education/self-management • Multi-professional team care • Medication • Surgery

16. Symptomatic Treatments • Education/support • Rest/relaxation • Joint protection • Physiotherapy • Painkillers • Anti-inflammatory drugs • Steroids • Joint injections • Pain Management Clinics

17. 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 Reduction of Joint Damage

18. Goals of Therapy • To relieve pain, stiffness, swelling, fatigue • To prevent joint damage/disability • To improve quality of life • ? To achieve disease remission

19. Principles of Treatment • Early diagnosis • Early initiation of treatment • Regular assessment (Disease Activity Scores) • “Treat to Target” • Annual review

21. 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

22. Pierre-Auguste Renior (1841-1919) • French, impressionist • 1892 RA – 51 yrs

27. Thank You!

28. RHEUMATOLOGY IN THE 21st CENTURY The role of the Rheumatology Nurse Practitioner. Janice Booth

29. 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.

30. THE MULTI DISCIPLINARY TEAM • Consultants x 3 + 1 (SPR & SHO) • Rheumatology Nurse practitioner • Biologics Nurse practitioner • Osteoporosis CNS • Occupational Therapist • Physiotherapist

31. CONDITIONS SEEN • Rheumatoid Arthritis • Psoriatic Arthritis • Ankylosing Spondylitis • Lupus • Polymyalgia Rheumatica

32. RHEUMATOLOGY NURSING • Moved from the bedside to the clinic • From Nurses as carers • To autonomous practitioners. • Higher education – extended roles and skills.

33. WHY???? • Face of Rheumatology has dramatically changed. • Focus on prevention of disease progression. • Maintaining function.

34. WHY? • From more conservative approach, To proactive management – treat to target. • Standards and Guidelines - direct practice. • Drug development, evidence based practice.

35. TREATMENT • Pharmacological. • Physical – Occupational Therapy / Physiotherapy. • Psychological.

36. DISEASE MANAGEMENT • Early intervention • Aggressive • Combination therapy (NICE, 2009. BSR,2006. 2009.)

37. Early RA

38. ADVANCED RA.

39. Psoriatic Arthritis

40. Role of Rheumatology Nurse • Educate. • Assess. • Monitor. Concordance with treatment improves outcomes.

41. REFERRALS • Members of the MDT • Primary care – GP, Practice Nurses, Community Matron • Patients – helpline or monitoring clinic

42. 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

43. Nurse Practitioner Assessment • Review medication / concordance. • Monitoring. • Disease Activity. • Education / counselling. • Treatment plan / Recommendations / Interventions / referral.

44. SERVICE • Nurse Led Clinics – Clifton and Fleetwood • MDT Clinic – Clifton (2 x month) • Rheumatology Monitoring Clinic – BVH weekly with OPD

45. 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

46. 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).

47. SERVICE DEVELOPMENT • Implementation of NICE – 79 • Early arthritis clinics • Annual review clinics • I/A injection (nurse led) • S/C Methotrexate - Community

48. THANK YOU Any Questions?

49. 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.”