dr moorthy arthritis awareness clash ppt 2011 2
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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patients wait too long before presenting their symptoms to medical professionals (Westhovens et al., Belgian 2005 data, unpublished).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