Dr A Moorthy MB, MRCP(UK) Rheum,FRCP EdinCONSULTANT RHEUAMTOLOGIST

Have You got the - S Factor ?......

What is Arthritis?

Aches and painOld age diseaseWear and tearI am too young to get arthritis…

Inflammatory back pain

What is arthritis?

Auto immune conditionImmune system misbehave Debilitating , distressing , long term

condition

Arthritis…..Rheumatoid arthritisOsteo arthritisAnkylosing spondylitisPsoriatic arthritis

NAO July 2009580,000 Adults with diagnosis26,000 new cases every yearDelay in seeking help1/3 -1/2 3 months before see GPGP referral 4 visitsFirst three months crucial

NICE RA 1.5 men and 3.6 women developing RA per

10,000 people per year.

12,000 people developing RA per year in the UK.

RA is two to four times greater in women than men.

RA

1/3people stop work within 2 years of onset, and this prevalence increases thereafter.

Cost estimated at between £3.8 and £4.75 billion per year.

Clearly this disease is costly to the UK economy and to individuals.

Long term prognosis

• 29% at yr 1, 40% yr 5 have to give up work

• 80% disabled by yr 20• Joint replacement in 25% of patients

• Reduced life expectancy**- infections- malignancy?/ lymphoma- accelerated atherogenesis

**Vandenbroucke et al 1984

Burden to economyRA-Health economy

direct costs to the NHS and associated healthcare support services

indirect costs to the economy, including the effects of early mortality and lost productivity

the personal impact of RA and subsequent complications for people with RA and their families.

Management

Early referral

Early Inflammatory arthritis

Our mission is remission

A key element in successful patient care in RA is early recognition of the disease. Public awareness of the clinical presentation and potential consequences of a RA is still poor and many patients wait too long before presenting their symptoms to medical professionals (Westhovens et al., Belgian 2005 data, unpublished).

Management

Early referral

Early Inflammatory arthritis

Our mission is remission

Understanding of the disease

IntroductionIntroductionNational Audit Office (2009) Efficiency and effectiveness of services for people with

Rheumatoid Arthritis (RA) in England Patients with musculoskeletal symptoms delay seeking

medical attention from GPs Delays in referral to rheumatologists Lack of coordinated multidisciplinary services No consistent support or information regarding arthritis or

employment

NICE Rheumatoid Arthritis (2009) Emphasises early referral and the importance of patient

education and self-management plans.

RA -National Audit OfficeBetween ½- ¾ delay seeking helpPatient visit GP 4 times before refer to

specialistsAverage length of time from symptom

onset and treatment is 9 months

Patient Education & Awareness on Arthritis Patient Education & Awareness on Arthritis

Dr Sonia PanchalDr Sonia PanchalDr A MoorthyDr A MoorthyDr A SamantaDr A Samanta

GP VisitsGP Visits

(N=56)

GP VisitsGP Visits

With your symptoms, how many times did you visit your GP before a referral was made to Rheumatology?

(N=110)

Rheumatology ReferralRheumatology Referral

(N=110)

Prescription ExemptionPrescription Exemption

(N=56)

Inflammatory Arthritis? Have you got the ‘S’ Factor?Stiffness - Early morning joint stiffness lasting more than 30 minutes

Swelling - Persistent swelling of one joint or more, especially hand jointsSqueezing –

Squeezing the joints is painful in inflammatory

The message to the general public

‘If you have any symptoms highlighted in the poster which might possibly relate to either rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis, which are the three most common forms of inflammatory arthritis, then seek help from your GP, don’t delay’.

Referral for specialist treatmentRefer urgently if any of the following apply:

the small joints of the hands or feet are affected

more than one joint is affectedthere has been a delay of 3 months or

longer between onset of symptoms and seeking medical advice.

NICE guidelines 2009

EAC:

Symptoms present for at least 4 weeks but less than 1 year

Early morning stiffness of > 30 mins AND ANY ONE OF THE FOLLOWING: 3 or more swollen joints Tender/involved metacarpophalangeal

joints Tender/involved metatarsophalangeal

joints

First, aim at remission induction as soon as possible using intensive initial treatment strategies

secondly, once that objective is reached, treat to target based on disease monitoring and prompt treatment adaptation in the case of derailing

diagnosis

Early diagnosis Key for successful treatment Better outcome for treatment Less disability Increase productivity Increase gain to economy Productivity gain

Referral for specialist treatmentRefer urgently: small joints hand & feet, >1 joint,

>3/12Multidisciplinary Team

Access to named member of team to coordinate care

Diet & complimentary therapiesNo evidence – Mediterranean dietShort term benefit

Patient informationVerbal & written information

Self-management programmes

symptomPainStiffnessSwellingUnwell

DiagnosisSpecialist -- RheumatologyLong- term treatmentNew modalityBlood tests Scan the joints

Understanding of the disease

Management

Early referral

Early Inflammatory arthritis

Our mission is remission

Current Anti-TNF- agents

Adalimumab

HumanIgG1Human

Infliximab

Mouse

IgG1

Etanercept

Human p75

Human IgG1

Rheumatoid Arthritis treatment targets

B cell

T cell

Antigen-presenting

cells

Synoviocytes

Pannus

Articularcartilage

Chondrocytes

Macrophage

HLA -DRother cytokines

IFN- &

Production of collagenase and otherneutral proteases

Osteoclast

TNFIL-1

RheumatoidFactors, anti-CCP

Immune complexes

Bone

Complement

Neutrophil

Mast cell

Adapted from Arend WP, Dayer JM. Arthritis Rheum. 1990;33:305–15

Established Treatment Targets

Tight control ……

Smoke gets in your joints? RA a modern disease smoking a modern disease

RF more common in smokers* RA risk is ‘puffed up’ in smokers* RA erosions more severe in smokers, dose-dependent†

extra-articular features more common in smokers#

heavy smokers show abnormalities in circulating T lymphocytes, which may predispose to infection or malignancy

RA + smoking = CVS risk +++

D Sugiyama 2006*, KG Saag 1997†, BM Nyhall-Walin 2006#

TRAINING THE FUTURE RHEUMATOLOGY WORKFORCE

Accelerated atherosclerosisIncreased riskSmokingAnnual Review

Person-centred care

Treatment and care should take into account peoples’ needs and preferences.

People with RA should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals.

Back pain….Back painPain better with exerciseSkin, eye problems

Inflammatory back painAnkylosing spondylitisDelay in diagnosisEarly diagnosis Better out come

Inflammatory back pain

treatmentTraditional treatmentTarget therapyNew expensive drugsControl the symptom

Take home messages…..Auto immune diseases are commonBetter understandingTarget therapyEmerging new treatments

Message….See your doctor earlyEarly referral to specialistEarly treatment is key

Confused……

Thank you ……

NASS Meeting…….

Monday Nov 14th

clinical Education centre LGH

6- 9 PM