1. Rheumatoid Arthritis Dr Chandini Rao Consultant Rheumatologist

2. Overview  What is RA?  What causes it?  How does it present?  How is it treated?  Current concepts  Future plans

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  NHS costs: £560 million/year  Economy: £3.8-4.75 billion/year

9. What causes RA?  Genetics  Environment

10. Genetics  1st degree relative: 2-7 fold risk  Identical twin: 15% chance of RA  Need an environmental trigger as well

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

13. How does it present?  Joint pain  Joint swelling  Morning stiffness  Fatigue  Weight loss  Flu-like symptoms

14. How is RA diagnosed?  History  Examination  Blood tests - anaemia - raised inflammatory markers - rheumatoid factor/anti-CCP antibody  X-rays  Ultrasound scan Blood tests and X-rays may be normal in early RA

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. Reduction of Joint Damage Disease-modifying drugs (DMARDS)  Methotrexate  Sulfasalazine  Leflunomide  Hydroxychloroquine  Azathioprine  Ciclosporin  Gold  Penicillamine Biologic drugs  Anti-TNF therapy (Infliximab, Etanercept, Adalimumab, Certolizumab)  Rituximab  Abatacept  Tocilizumab  Golimumab

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. “Window of Opportunity”  Starting disease-modifying therapy within 12 weeks of symptom onset significantly reduces future joint damage  Challenges!

21. Early Arthritis Clinics  Fast-track service to see people with suspected inflammatory arthritis within 4 weeks of referral  Strict referral criteria  Investigations done at or before clinic visit  Aim to confirm diagnosis and start treatment at first visit  Monthly follow up to assess disease activity and adjust treatment accordingly (“Treat to Target”)

22. Annual Review Clinics  Assess disease activity/damage  Assess functional ability  Check for associated conditions (heart disease, osteoporosis, depression)  Assess for complications (vasculitis, eye problems etc)  Referral to other members of MDT  Assess the impact on quality of life

23. Achievements of people with RA

33. Thank You!