Rheumatology GP update. Dr Mark Quinn (York) Dr Anna Moverley (SNEY) Dr Toby Wallace (Malton) November 2017

Transcription

1 Rheumatology GP update Dr Mark Quinn (York) Dr Anna Moverley (SNEY) Dr Toby Wallace (Malton) November 2017

2 Aims and ambitions Rheumatology update: selected topics Service developments Local developments Fluid and interactive please Ask lots, learn lots..

3 Conflicts of interest Trained as a GP Married to a GP Clinical Director of Specialist Medicine No commercial affiliations Competitive Cyclist and former fell runner

4 Agenda 2pm 220pm 250pm 315pm 330pm 355pm - Welcome and Intro- MQ - Changes in rheumatology- Referral management: lessons and sound bites - Intermediate care in rheumatology- TW - Update- Gout guidelines - Fibromyalgia + Hypermobility - AM - Break - Inflammatory arthritis- MQ - Osteoporosis AM

5 Rheumatology- update Dr M Quinn 14 th Nov 2017

6 Rheumatology Service York Staff Dr M Green Dr M Quinn Dr A Brown Dr B Saleem Dr E Ferguson Dr M Rogers Sr Julie Green Sr Anne Gill Sr Veronica Cryle Sr Helen Bickerdike SpR/ CT SNEY Staff Dr Z Al-Saffar Dr S Westlake Dr A Moverley Sr Sally Kingscott Sr Ruth Newton Sr Diane Tyas No Ward base Disintegrating extended MDT

7 The Hospital picture Increasing referrals Long new patient waits Large follow up back log More complex patients (less discharges) More complex therapies (red and amber drugs) Changes in doctors training Expensive biological drugs Financially challenged commissioners & providers Need for change

8 Previous Internal changes Staff recruited-consultants & nurses Alternative contact types - / telephone advice lines - Telephone clinics Increasing self management strategies Front loading efforts/ BPT More discharges to meet New:FU targets set FU backlog review Overall only marginal impact

9 What are we doing now?

10 Current approach Limit what we see to the most appropriate patients or whom we can do most for Triage access - RSS - E-vetting new referrals - Advice and guidance through CPD- new & FUs Ease follow up burden - Intermediate care pilot (Scarb + Ryedale CCG)

11 Triage Referral data New Referrals new referrals first 6mths 2017 RSS data - Approx 10% returned - Approx 10% upgraded - Returns most advice, some further information requests Easier access or stemming the tide A+G Utilisation SNEY 39 (9.6%) York 223 (23.4%) A+G New Total Total

12 Utilisation of Intermediate care Suitable patients identified- Stable RA/ IA on conventional DMARDs Non-complex Crystal disease (non-red drugs) Osteoporosis on oral agents if FU required OA needing injections FM? IA not requiring DMARDs etc

13 Derwent practice data List size 20,000 patients 96 patients (0.5%) 23 unsuitable 7 biologic patients 12 unstable + 2 cancer Rx 2 CTD 12 No rheum records 10 Discharged 51 suitable Almost all stable IA on DMARDs Equal split York/ Malton, v few SNEY

14 Sherburn practice data List size patients (1%) 14 unsuitable biologic patients 11 unstable 3 CTD 11 No rheum records 3 Discharged 25 suitable Almost all stable IA on DMARDs

15 Where next? GP and patient education Improve, expand and refine triage Improve A+G/ communication Condition identification e.g. hypermobility, FM etc Different ways of working for all Discharge a priority in secondary care Scarborough intermediate care model expansion?

16 Triage Referral-Lessons to date Mostly appropriate Generally good quality RSS ensures attachments are there? Condition guidance helpful (next slide) Grey areas Some themes: - Osteoporosis - Crystal disease - Fibromyalgia - Osteoarthritis

17 Rheumatology guidelines on RSS Osteoporosis Gout Inflammatory arthritis Spondyloarthropathy Hypermobility Further suggestions welcome

18 Grey areas Patient requests rheumatology referral Specialist recommends rheumatology referral Re-referrals and 2 nd or 3 rd opinions Tests Osteoarthritis Managing expectations Unsure, but would you have a look

19 Osteoporosis Letter detail is key - How and when diagnosed - Treatment start date +/- compliance - DXA scan results- if done - Calcium and vitamin D replacement - Fracture history - Additional risk factors e.g. steroids, etc - You can still fracture and be having a good treatment response!

20 Gout Failed allopurinol = caused flares No attempt at urate lowering therapy X-ray shows erosion typical of gout- rheumatology referral advised Continued symptoms despite treatment, without escalation of treatment Target serum urate not set or achieved

21 Fibromyalgia Referrals & awareness increasing Risk of over diagnosis vs missing disease Exclude mimics All about patient self management & empowerment The drugs don t work Alternative plans required

22 Your experiences? Feedback - Appropriate and helpful? - Inappropriate? Suggestions for improvement What do you want given limited resource?

23 Inflammatory Arthritis Important because - Early diagnosis and successful treatment: 1. Prevents Joint damage 2. Prevents Functional impairment 3. Improves QoL 4. Maintains productivity

24 Consign this to History

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27 Inflammatory arthritis- key features Onset Symptom duration/ timing and evolution Site and number of joints Age Specific history Associations Family history Tests

28 Onset and evolution Fast Crystal (hrs) Infection (24-48hrs) Reactive (Days to wks) RA/ Psoriatic (Months) Slow OA (Years)

29 Site Discriminatory Disease suggestive not specific - Weight bearing joints commonly OA - Back pain usually mechanical - MCPs, wrists and MTPs suggest RA - Great toes = OA or Gout - Ankles = oedema or sarcoid (Lofgren s syndrome) - Think outside the joint! Entheses e.g. plantar fascia, epicondyles

30 Site- RA vs OA presentation

31 RA or Benign Self Limiting Disease?

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33 RA

34 Walking on pebbles and plantar stress distribution in RA

35 Too late

36 Number of joints Monoarthritis- OA/ crystal/ sepsis/ ReA/ PsA Oligoarthitis- PsA/ ReA Polyarthritis- RA/ OA, rarely gout

37 Age Average age onset RA = 56yrs in UK BUT, younger patients more likely to have IA - RA, ReA, PsA, IBD related arthropathy etc Inflammatory back disease (AS) late 2 nd / early 3 rd decade- women milder and later Older age groups - OA = universal - Crystal disease increasingly common - RA still likely Menopause/ post pregnancy

38 Specific Rarely generalised e.g. don t feel right Localising e.g. joint or joint area Timing e.g. early morning stiffness Beware poor sleep and low mood

39 Associations Remember Psoriasis Inflammatory bowel disease Inflammatory eye disease Drugs e.g. diuretics, statins, antibiotics, roaccutane, oestrogen antagonists etc Previous gout

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41 Family history Limited association RA= 5 fold increase over background - 1:250 to 1:50 Gout in young male patients, strong association Connective tissue diseases= data poor, but similar to RA where data available

42 Early on- The tests don t help in RA!! Bloods including CRP: normal in 80% of RA Antibodies: 60% RF positive at diagnosis 30-65% Anti-CCP/ CPA positive in UK XRs- erosive in only 20% at diagnosis BUT Long history- radiographs may be diagnostic Positive tests e.g. high CRP, positive antibodies etc are prognostic and can be specific in some cases

43 Spanner in the works- OA DIP joint

44 RA Remains a clinical diagnosis Affects approx. 0.4% of UK population Mean age of onset 56 yrs in UK cohorts Women > men 3:1 Genetic and environmental risk factors 95% will be chronic and progressive

45 Diagnosis Symptoms: Pain/ morning stiffness Indolent onset Joint distribution- MCPs/ MTPs & wrists Joint swelling Signs: Joint swelling/ tenderness MCP/ MTP squeeze test positive Extra-articular findings v rare Emphasis on early diagnosis and intervention

46 Antibodies precede disease onset Percentage of positive patients CCP+ RF+/CCP+ RF+ CRP Years pre symptoms (yrs) Nielen MMJ et al, A+R 2004

47 Why is early disease important? Similarities to cancer Treatment more effective Damage can be prevented Disability reduced

48 Prognosis Female sex Acute phase response Positive antibodies: RF/ CCP Damage: erosions on XR/ imaging Large joint involvement Extent of functional impairment Early Job loss Treatment intolerance/ acceptance Extra-articular disease now rare

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51 Treatment NSAIDs:? Role Corticosteroids: im/ IA/ oral DMARDs Biologic therapies Physiotherapy Occupational therapy

52 Treatment (2) DMARDs: mono vs combination therapy Methotrexate +/- Sulfasalazine Hydroxychloroquine Leflunomide Gold/ D-penicillamine/ Azathioprine/ Cyclosporin - rarely used or special circumstances

53 Treatment (3) Biologics: designer drugs Anti-TNFα e.g. etanercept/ adalimumab etc B-cell depletion e.g. rituximab Anti IL-6 e.g. tocilizumab/ sarilumab Second signal blockade e.g. abatacept Anti IL-23/ IL-12 e.g. Ustekinumab Anti IL-17 e.g. secukinumab Jak inhibitors e.g. Oral baricitinib/ tofacitinib Biosimilar etanercept & rituximab available = half price

54 Treatment aims Early intervention key Escalation of therapy according to response: Treat to target Close monitoring of disease Objective measures of outcome e.g. DAS, Health Assessment Questionnaire, XRs Remission for all (achieve 50%)

55 Treatment targets DAS28- mostly Swollen joint count Tender joint count Patient global health VAS CRP or ESR Other measures HAQ/ SDAI/ RAQoL Many tools lack sensitivity, specificity or accuracy for modern treatments

56 Any questions