Shared Care Panel Discussion Caring for your Patient with Arthritis

Panelists Moderator: Dr. Julia Alleyne Dr. Diane Lacaille Dr. Ken Hughes Ms. Linda Li Dr. George Watson Dr. Patrick Chan

Format Provide the panel with a rolling case Direct questions to panel Ask the panel to limit answers to 2 minutes Ask audience for questions and comments Closing pearls of practice

Maggie’s Voice Maggie is 51 years old and was diagnosed with Rheumatoid arthritis 7 years ago. She has been managed with medications (Plaquenil) for inflammation but is still complaining of pain and swelling. Maggie – other health problems include mild skin irritation diagnosed as eczema, long term. She has had a peptic ulcer 5 years ago and responded well to H. Pylori treatment regime. Medications include: Oral hydroxychloroquine(Plaquenil) 200 mg Twice daily and Acetominophen, 2000 mg/day Pain occurs at Rest and her swelling is noted in her hands, wrist and feet.

Panelists Where would you start in assessing Maggie’s symptoms and effectiveness of medication? What is your approach to patient education regarding symptom management? Diane –Q1 Lead off with key messages for medications management. Dosage and monitoring - Targeting assessment of inflammation and joint damage - Dealing with Side effects Patrick Q2 Patient education on Medication use, compliance, family support How often will you see a patient who you are trying to stabilize on meds

Maggie Maggie works in a sedentary job and lives alone. She is experiencing prolonged morning stiffness, night time pain and increased foot joint swelling.

Panelists Would rehabilitation help Maggie cope better with work or home activities? What has been your experience with community resources for patients like Maggie? Linda Q 3 Role of rehabilitation, role of self-management, ergonomic assessments or not? Patient tolerance for activity, how do you assess readiness ? George Q4 Describe some of the community resources that you are familiar with for RA but also for OA and perhaps some feedback that patients have given you. Linda, Q4, add in some additional resources once George has explained his experience.

Maggie 2 weeks ago, Maggie started a walking program on the treadmill as she read that it exercise might help her. She started to run one day but felt a sudden pop in her knee and it has been swollen ever since.

Panelist How do you assess knee pain which may be mechanical or osteoarthritic in the patient with inflammatory symptoms? What is your criteria for surgical intervention in a patient with rheumatoid arthritis? Ken Q.5 Need to approach Knee pain NYD and how to do that ? Do you use imaging more frequently in this population? Are you more conservative with activity recommendations. Implications of surgical intervention in this patient. Ken, Q6 Surgical criteria, always a question, your opportunity to be really clear with referral criteria and stage.

Cortisone Injections What’s the scoop? Who When Why How Many This is an issues that is always of interest, I think that probably Diane, Ken and Patrick can all add something. Here are some teaching notes from the Rheumatologist: Important to minimize dose and duration of CS because of risk of side-effects, especially increased risk of cardiovascular disease with long term use.     Oral steroids do have a role in RA, when used in small doses (ie less than 10 mg daily) over short periods, such as for bridging therapy (when waiting for DMARDs to take effect), early on at time of RA onset, or to control a flare-up. Intramuscular dose of steroid (e.g. 40 mg of depomedrol im) is a useful alternative to oral steroids in this context. - Avoid using steroids prior to referral to a rheumatologist for diagnosis of new onset inflammatory arthritis, because it masks the signs and prevents a clear diagnosis. Refer urgently instead. -          Steroids alone are not enough to treat RA. If steroids are needed to control the disease, then DMARDs need to be added or adjusted -          Intraarticular injections of steroids are very effective at controlling inflammation and a good alternative to oral steroids

Maggie Maggie is divorced and has one sister who lives 3 hours away. Her work is as a receptionist for a car dealer and her hours are scattered over days, evenings and weekends. She has had a past history of panic attacks and recently experienced some palpitations. “My biggest concern is that I won’t be able to support myself and I don’t know how to change things around this time. Being sick costs money! Life’s demands don’t stop just because you have arthritis.”

Panelist How do you monitor and manage co-morbidities within a scheduled office visit? Q. 7 Perhaps Diane taking a crack at this and then George to provide the primary care aspect Diane Know what to expect, look for it, attempt to prevent George How to ask the psychosocial questions tactfully and yet directly.

Panelist If we were in your office for a day, what is the one pearl that you would like us to take home regarding the care of a patient with arthritis?

Thank you