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

2. 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. 3 What is it? Chronic, progressive, autoimmune disease Causes inflammation in joints (especially hands, wrists, feet) Systemic condition

4. 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

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8. 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. 9 What causes RA? Genetics Environment

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

11. 11 Environment Geography Hormones Infection Smoking Diet

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

14. 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. 15 How is RA treated? General Principles: Patient education/self-management Multi-professional team care Medication Surgery

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

17. 17 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

18. 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. 19 Principles of Treatment Early diagnosis Early initiation of treatment Regular assessment (Disease Activity Scores) “Treat to Target” Annual review

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21. 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. 22 Pierre-Auguste Renior (1841-1919) French, impressionist 1892 RA – 51 yrs

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27. 27 Thank You!

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

29. 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. 30 THE MULTI DISCIPLINARY TEAM Consultants x 3 + 1 (SPR & SHO) Rheumatology Nurse practitioner Biologics Nurse practitioner Osteoporosis CNS Occupational Therapist Physiotherapist

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

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

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

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

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

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

37. 37 Early RA

38. 38 ADVANCED RA.

39. 39 Psoriatic Arthritis

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

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

42. 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. 43 Nurse Practitioner Assessment Review medication / concordance. Monitoring. Disease Activity. Education / counselling. Treatment plan / Recommendations / Interventions / referral.

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

45. 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 http://www.badrag.org.uk/index.html

46. 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. 47 SERVICE DEVELOPMENT Implementation of NICE – 79 Early arthritis clinics Annual review clinics I/A injection (nurse led) S/C Methotrexate - Community

48. 48 THANK YOU Any Questions?

49. 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.”