arthritis and rheumatology - royal berkshire · pdf filearthritis and rheumatology ......

Arthritis and Rheumatology

Antoni Chan MBChB, FRCP, PhD

Consultant Rheumatologist

Royal Berkshire NHS Foundation Trust


RheumatologyRheumatology

Investigation, Diagnosis, Treatment


The challenge £8 billion a year in cost

700,000 people suffering from rheumatoid arthritis in Britain

26,000 more cases identified every year in England alone.year in England alone.

Average days off sick in RA is 40Average days off sick in RA is 40 compared to 6.5 days

(Arthritis Research UK)


What is a Rheumatologist interested in ?

Bones

Joints

Muscles

Soft tissues

Connective tissue

Internal organs

Whole systems


A th itiArthritis


Wh t i th iti ?What is arthritis?


Acute inflammationAcute inflammation

CCalor, Rubor, Tumor, Dolor, Functio laesa

(Hot, Red, Swollen, Pain, Loss of Function)


Autoimmune disease u o u e d sease

Inflammation that lasts for a long time in arthritis leads to tissue damageInflammation that lasts for a long time in arthritis leads to tissue damage through release of chemical called cytokines


Osteoarthritis

Commonest form of arthritis, affects > 8 million people in UK

Commoner in women, usually occurs with age > 40 years

Exercise diet and nutrition complementary treatmentsExercise, diet and nutrition, complementary treatments, acupuncture, regular pain medication

Reduce weight and loading on joints (back hip knees)Reduce weight and loading on joints (back, hip, knees)


Rheumatoid arthritisRheumatoid arthritis

Inflammatory arthritis affecting many joints

Affects 0 8-1 0% of the population in the UKAffects 0.8 1.0% of the population in the UK

Can affect any age but usually starts at ages 40-60 years

Early treatment improves long term outcomes


A k l i d liti (AS)Ankylosing spondylitis (AS)

Inflammation of the spine p

Back pain that improves with exercise and worsens with rest

I di id l b f th i f lti i tiff iIndividual bones of the spine may fuse resulting in stiffening of the spine (ankylosis) if untreated

Starts at age 20-30s


Why me?y

Genetics

Infections

HHormones

Viruses

Diet

TraumaTrauma

Accidents


‘Is it in the genes ?’

HLA – DR4 in Rheumatoid ArthritisHLA B27 in Ankylosing SpondylitisHLA – B27 in Ankylosing Spondylitis


What are the triggers?

Causes increased risk of developing rheumatoid arthritisd di l diand cardiovascular disease


Chronic periodontal disease may increase the risk of developing rheumatoid arthritisof developing rheumatoid arthritisPorphyromonas gingivalis – area of research


Diet

No special RA diet or diet "cure”No special RA diet or diet cure Mediterranean diet is protectiveFish oils and omega-3 fatty acidsFish oils and omega 3 fatty acids


K iKeep moving

Regular exercise is beneficial for jointsg jLow impact movement – swimming, tai chi, yoga


The revolution in Rheumatology

Rapidly expanding field in

−Early diagnosis of arthritisarthritis

−Targeted personalised therapies

−Keep patients active and in workactive and in work


A ti TNF l h t t t (bi l i th )Anti-TNF alpha treatment (biologic therapy)

•Newer agents that block other chemical signals (cytokines)•Must be monitored with regular blood tests and clinic review•Stop if having infection or on antibiotics•Stop if having infection or on antibiotics


Rheumatology Clinics`Care Closer to Home’

Wallingford Townlands (Henley)

Royal Berkshire Hospital(Reading)

Newbury (WBCH) Woosehill (Wokingham)


Multi-disciplinary Approach Peripheral Clinics: Peripheral Clinics:

Outpatient clinics in the community, providing care closer to home

Drug Monitoring:Enabling Shared Care

ith GP’s t Enh n

Rheumatology

with GP s to Enhance Patient Safety

Biologics: Education,

Metabolic Bone

RheumatologyService

Biologics Education, Therapies & Screening

Infusion Unit

Mobile

Unit

RBH: Inpatient CareResearch & Development Mobile

Ultrasound Examination

p

Local Patient Groups

Flare Clinic

Rheumatology Advice Line


Ultrasound of joints

• Early diagnosis and Assessment• Safe, no radiationSafe, no radiation• Treatment to Target – Tight Control of Rheumatoid Arthritis


Thank youThank you

Department of RheumatologyRoyal Berkshire NHS Foundation TrustRoyal Berkshire NHS Foundation Trust

Secretary: Lindsey SmithTel: 0118 3225308

Connective Tissue Diseases

Dr Gordon MacDonald BSc MBBChir MRCPConsultant Rheumatologist

Arthritis and Rheumatology Seminar

Th rsda 9th April 2015Thursday 9th April 2015


Pl− The immune system

Plan

− When the immune system goes wrong…

− Symptoms of connective tissue disease

− Lupus (SLE)

− Tests/ Treatment

− Interactive!!!26

− Interactive!!!


Wh t d th i t d ?What does the immune system do?


Wh t d th i t d ?What does the immune system do?

Fights infections


I it’ li t d!Immune response – it’s complicated!


S lf N lf h th iSelf vs. Non-self hypothesis

− Nobel Prize for Medicine

− Transplant Immunology

− Self vs. Non-self

Peter Medawar


Th D M d lThe Danger Model

Polly Matzinger


Wh th i tWhen the immune system goes wrong…

− “Autoimmunity” – immune system attacks body’s own tissues

− Inflammation and damage

− “Friendly fire”


Wh th i tWhen the immune system goes wrong…


Rh t l i t lik d t !Rheumatologists like a good mystery!


Wh t i thi diti ll d?What is this condition called?


H i R d’ di ?How common is Raynaud’s disease?

A. 1 in 1000

B. 1 in 100

C. 1 in 10

D. 1 in 3


P i d R d’Primary versus secondary Raynaud’s


S t f ti ti diSymptoms of connective tissue disease

− Joint pain − Swallowing problemsp

− Skin rashes

− Sensitivity to light

− Muscle weakness− Fatigue

W i ht l− Mouth ulcers

− Hair loss

− Weight loss− Recurrent miscarriages− Blood clots in legs/lungs

− Raynaud’s

− Digital ulcers

g g− Headache− Seizure

− Skin thickening

− Dry eyes and mouth

− Mental health problems− Chest pain


Wh t i thi h ll d?What is this rash called?


B tt fl h f L (SLE)Butterfly rash of Lupus (SLE)


L (SLE)Lupus (SLE)− 9 times more common in women

− Joint pain, skin rashes, extreme tirednessp

− Mouth ulcers, hair loss

− Internal organs less common (heart, brain, kidney)g ( y)

− 1/3 may have additional autoimmune condition (e.g underactive y ( gthyroid, Sjogren’s syndrome)


I it L ?Is it Lupus?


Wh t L ?What causes Lupus?

− Autoantibodies attack body’s own tissues

− Environmental

− Genetic

− Hormonal


S t f ti ti diSpectrum of connective tissue disease

UndifferentiatedSLESystemic sclerosis

CTD

Sjogren’sDermatomyositis/

polymyositis


A t tib d t tAutoantibody tests

Anti-RoAnti-La

Anti-Jo-1 ANA 1:640

Anti-DNAAnti-Centromere

Anti-RNP

ANA 1:640

A ti SC3/C4

Anti-Centromere

N l l tt

Speckled patternAnti-Sm Nucleolar pattern


T t tTreatment

− Non-steroidal anti-inflammatorieso s e o da a a a o es

− SteroidsSteroids

DMARDs (Hydroxychloroquine Azathioprine Methotrexate)− DMARDs (Hydroxychloroquine, Azathioprine, Methotrexate)

Bi l i (Rit i b B li b)− Biologics (Rituximab, Belimumab)

− Stem cells (Adult stem cells)


SSummary

− Connective tissue disease cause wide range of symptoms

− Minority can have serious complications (heart, brain, kidney, lung)

− Expanding range of new treatments

Thank you

Any questions?

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