Effective management of arthritis. Gail Dolan Victoria ACH Liz McIvor Stobhill ACH

Size: px

Start display at page:

Download "Effective management of arthritis. Gail Dolan Victoria ACH Liz McIvor Stobhill ACH"

Stella Francis
5 years ago
Views:

1 Effective management of arthritis Gail Dolan Victoria ACH Liz McIvor Stobhill ACH

2 Role Types of arthritis Drugs Self Management

3 Role Of CNS Advanced level nurses offering specialist care in a specific field Education/ self management Support referrals to other MDT Clinical role e.g. Medication r/v, joint aspiration/injection, ultrasound Patient helpline management Research/Audit

4 Common Helpline Calls Medication advice Flare Vaccination advice Joint injection GP Advice Abnormal bloods Family planning Biologic advice Drug Administration Travel Advice Allergy advice PIP appeal support External support group (NRAS, arthritis UK) Appointments General disease advice Unrelated medical advice

5 Osteoarthritis - hands Bony swellings Heberdens Bouchards Non tender Not red X ray appearances

6 Monoarthritis Septic arthritis Gout Pseudogout Reactive arthritis

7 Rheumatoid Arthritis Progressive and disabling inflammatory disease Most patients sustain significant joint inflammation and erosions within first 2 years Visser. Best Pract & Research (1): % unable to do their job after 3 years of disease Bykerk Best Pract & Research (1):

9 Clinical presentations Symmetrical joint swelling (MCP s,pip s, feet) Pain Early morning joint stiffness Poor sleep/fatigue/ functional difficulties Weight loss / flu like symptoms Extra articular features (pulmonary involvement, sicca syndrome,anaemia)

11 Diagnosis History of symptoms Swollen joints (synovitis) Joint stiffness Inflammatory markers (ESR and CRP) RF (tried and tested since 1940 s, approx 30% of people with RA do not produce RF) Anti CCP antibodies (important

16 REAL EVERY DAY ISSUES PAIN STIFFNESS FATIGUE PSYCHOLOGICAL PROBLEMS WORK WORRIES FAMILY WORRIES TAKING DAILY DRUGS FOR EVER? WORRIES ABOUT THE FUTURE

17 RA Aggressive management- early referral, early DMARDs- Methotrexate monotherapy Triple therapymethotrexate sulphasalazine hydroxychloroquine If RA still active (DAS score): Biologic therapy (BSR guidelines) TNF key cytokine Infliximab, adalimumab Etanercept. Certolizumab, Golimumab Rituximab, Tocilizumab

18 Analgesic ladder Steroids NSAIDs Ibuprofen Treatments Diclofenac (Voltarol) Naprosyn (Naproxen) Etodolac (Lodine) Celcoxib (Celebrex)

19 NSAIDS Effective symptomatic relief. Reduce pain, stiffness and tenderness.

20 Risk of NSAID complications Age >65 increase directly with: History of peptic ulceration Co Morbidity eg. Cardiac disease Use of 2 Nsaids including asprin Concomitant Corticosteroid and Anticoagulant use Co-existing helicobacter pylori infection

21 Steroids Intra articular Intramuscular Oral Can cause rebound flare of psoriasis

22 Disease modifying drugs (DMARDS) Treat underlying disease - immunosuppressant Not a pain killer!! Often used in combination with anti inflammatory initially and IM / IA steroid injections Slow onset

23 When are they prescribed? Recommendations are to prescribe in early disease BSR, EULAR, ACR How are they prescribed? Mono, dual and triple therapy TICORA and TREAT to TARGET Monthly early RA clinic Rapid escalation of therapy dependant on regular measurement of disease activity

24 EXAMPLES Methotrexate also subcutaneous Sulphasalazine Hydroxychloroquine Leflunomide Gold Azathioprine Cyclosporin Steroids

25 Commonly used DMARDs Methotrexate -Taken once weekly (same day) Starting dose - varies severity of disease, co morbidities Dosing - 7.5mg 30mg option to switch to s/c preparation Side effects Rash, nausea ( can be severe), mouth ulcers, abnormal bloods, diarrhoea, headaches, PNEUMONITIS Requires folate replacement Blood monitoring fortnightly initially FBC, U&E,LFT, ESR

26 Commonly used DMARDs Sulphasalazine Taken daily Dosing - 40mg/kg 500mg tablets - start 1 daily and increase Side effects - similar to Methotrexate dizziness, abdominal pain (week 3-4), colour change of urine. Bloods fortnightly initially

27 Commonly used DMARDs Hydroxychloroquine Taken daily Dosing - >62kg = 400mg daily >46kg <62kg = 200mg/400mg alternate days <46kg >31kg = 200mg daily Well tolerated, main side effect is a rash and headache No blood monitoring required Yearly eye tests at opticians as can cause retinal toxicity

28 RA - Disease Activity Score (DAS) 28 Measure of overall disease activity Composite score derived from 4 measures Number of swollen joints (out of 28) Number of tender joints (out of 28) Measure ESR/CRP Measure global assessment of health Health Assessment Questionnaire (HAQ)- used to assess function

30 Symptoms of PsA Pain Swelling EMS Gelling Difficulty with grip Stiff back/neck Swollen digit Heel pain

31 Patterns of disease Monoarthritis - one joint involved Asymmetrical oligoarthritis <5 joints Polyarthritis- >5 joints Spondyloarthropathy - back and neck Arthritis mutilans DIP disease Enthesitis Dactylitis

32 Psoriatic disease - not just skin Comorbidities Metabolic syndrome Obesity- waist circumference Dyslipidaemia - high triglycerides, low HDL Hypertension NIDDM NASH Smoking and alcohol and joints

33 Association with psoriasis Simultaneous onset 15% 60% psoriasis prior to PsA 25% arthritis prior to skin - PsA sine psoriasis

34 PsA in UK 1-3% population with psoriasis 30% co existing arthropathy

35 PsA - hands

39 Pathophysiology Genetic HLA subtypes Environmental Infection eg streptococcal Trauma- Koebner Immunological T cell medicated (Th1 Th17)

40 Second line drugs Skin and joints Methotrexate Cyclosporin Leflunomide Joints alone Sulphasalazine Azathioprine

41 Assessment tools-the core domains Skin Enthesis Dactylitis Articular disease activity Spine QOL and function

42 Psoriasis Area and Severity Index PASI

48 Cervical flexion Question mark posture? Thoracic kyphosis Loss of lumbar lordosis Flexion hips

49 Ankylosing Spondylitis Disease Assessment tools BASDAI Bath Ankylosing Spondylitis Disease Activity Index BASFI Bath Ankylosing Spondylitis Functional Index BASMI Bath Ankylosing Spondylitis Metrology Index

50 Criteria for biologic agents RA - DAS-28 > or more tender joint and 3 or more swollen joints Failed trials of two DMARDs, including MTX (unless contraindicated). PsA - 3 or more tender joint and 3 or more swollen joints Failed trials of two DMARDs, including MTX (unless contraindicated) ( CASPAR guidelines) AkSpa Failed two NSAIDs 2 consecutive BASDAI > 4 taken 4 weeks apart

51 Biological Screening Checklist Comments Risk Factors Malignancy(year/site) MS Septic Arthritis (year) Bloods HIV HEP B screen HEP C (sag, cab) Varicella Zoster AB s(if no chickenpox) FBC U&E, LFT, ESR/CRP Immunoglobulins lymphocyte subsets ( Rituximab) Lipids (tocilizimab) Biologics Checklist Patient name Diagnosis Previous DMARDS Baseline DAS28/BASDAI/BASFI Height/ Weight BP TB Screening Ethnicity Country of birth Previous TB/exposure Any Recent foreign travel Chest Xray (within 6 months) Tspot/ Quantiferon Gold Advice what to do if surgery planned What to do if infection Vaccinations Risk of severe infection including TB Pregnancy Food BSRBR/NHS GGC audit (consent) Sun protection Alert card

52 Surgery Infection Other Considerations Pregnancy and pre pregnancy Chickenpox Vaccines Flu jab Skin care Alcohol

53 Biological Therapies Etanercept Adalimumab Certolizumab Golimumab Rituximab RA PsA AkSpa Tocilizumab Secukinumab Ustekinumab Infliximab

54 Biosimilars a biological medicine which is highly similar to another biological medicine already licensed for use a biological medicine which has been shown not to have any clinical meaningful differences from the originator biological medicine in terms of quality, safety and efficacy Biosimilar medicines have the potential to provide the NHS with considerable cost savings

55 SELF MANAGEMENT Weight management Smoking Alcohol Exercise Drug compliance

56 Questions?

BSR Biologics Register Rheumatoid Arthritis Clinical Baseline Form

BSR Biologics Register Rheumatoid Arthritis Clinical Baseline Form Please complete the following PATIENT information ID For office use only Gender: Male Female Date of birth: D D M M Y Y Y Y Hospital Reg.