Hello, I’m Norman Swan. Welcome to this program on the clinical guideline for diagnosis and management of early rheumatoid arthritis. Rheumatoid arthritis is a chronic, debilitating disease which may last a lifetime. Early diagnosis and management can limit structural damage of the joints and improve quality and length of life as well as other health outcomes. This program is the second of four programs on the new musculoskeletal guidelines. The clinical guidelines for general practitioners and other primary healthcare professionals have been developed by the Royal Australian College of General Practitioners.
And approved by the National Health and Medical Research Council. This program will cover the diagnosis of rheumatoid arthritis and discuss the recommended interventions for early RA in the Australian primary healthcare setting. As always, you’ll find a useful number of resources on the Rural Health Education Foundation’s website I’ll introduce our panel to you. John Bennett is a GP at the University Health Service at the University of Queensland, and was a member of the College of GPs’ working group for the guideline. Welcome, John. Thank you. Lyn March is a rheumatologist at Royal North Shore Hospital.
In the University of Sydney. Welcome, Lyn. Thanks, Norman. Lyn was also a member of the guideline working group. Christine Retallack is a community health nurse in rheumatology working in the Albany Rheumatology Clinic in Western Australia. Welcome, Christine. Thank you. The community rheumatology nurse is a species unique to Western Australia It doesn’t happen anywhere else in Australia. Perhaps we’ll find out it should. Yes. Last but not least, Louise Sharpe, associate professor and director of Clinical Research in the School of Psychology at the University of Sydney. Welcome, Louise.
Early Rheumatoid Arthritis Clinical Guideline for Diagnosis and Management
Louise has a strong interest in rheumatoid arthritis and similar diseases. To start, let’s hear from four women from Western Australia, Liz, Anne, Terri and Jill, about their experiences of having early RA. 1983 was quite a stressful year for me. I felt that I was overweight, and I was doing an exercise program at home. Each morning I would wake up sore and stiff, and think, how unfit I am. So I would push myself harder until I was unable to sleep or unable to function very well at all.
I couldn’t get out of bed a lot of the time. Overwhelming fatigue. Just really felt like I had a bad flu all the time. My body felt like I had the worst flu you’ve ever had. It was getting worse and worse. I was finding it hard to get to the bus stop to get to work, to do those sorts of things. Yeah, definitely was depressed. Really didn’t want to do much. I just sort of wanted to hide away from everyone. I wasn’t really my normal self at all, no.
I was afraid and pretty unhappy. It was doing my head in. I was saying to my daughter, my friends, ‘I think I’m going nuts. I don’t know what’s wrong with me.’ I was shattered. I went out and bought some clothes that I didn’t want and didn’t need. Other people around often would think, oh, God, there’s Liz whinging again. She’s got the hypochondriac hat on. One of the problems with early rheumatoid arthritis is, the pain moves from joint to joint. One day it might be in a wrist, another day in an ankle,.
Another day in an elbow, then a shoulder. I began to feel a bit hypochondriac. Four stories of early rheumatoid arthritis from Western Australia. I’m not sure that we’ll find there’s levelone evidence for retail therapy, as one of our respondents there was telling us. John, how typical are those stories Very typical. It’s interesting how each one without fail had a strong psychological element. Suffering that went beyond the physical. We weren’t hearing much about joint problems, Lyn. Patients don’t tell you that their CRP is raised and their joints are swollen.
NORMAN How inconvenient. They tell you things that matter to them the fatigue and the overwhelming systemic effect. I think that’s the cytokines of inflammation. But they don’t tell you those words. How dominant is that psychological element, Louise Well, certainly when people develop rheumatoid arthritis, there’s good evidence that about one in five at any one time will be depressed of clinical magnitude. We found in some of our early research looking at early arthritis that that actually increases in the early phase of the illness. If you don’t help people to manage it,.
The symptoms are so allencompassing and systemic as well as the pain, which really does gets people down. As the stories themselves were saying, it starts to create a vicious cycle where they find it difficult to do the things they need to do to actually manage the illness better. Is treatment of depression the treatment of the illness or treatment of the depression If the depression is a response to the illness, if you help people to take control over their illness and manage it better, the symptoms of depression do actually lift.
You can use good strategies that have been used in the treatment of depression outside of ill health, but focus it towards the illness. Actually the outcomes can be very good. NORMAN Christine, we’ll talk about early detection and active management of somebody with early rheumatoid arthritis. For success, how important is it it sounds like a Dorothy Dixer. It’s easy to say, very important! to see the whole patient, how important is it It is extremely important to see the whole patient and not just the swollen joints.
If you can help people to do well with the emotional side of their condition as well as functional stuff, they do do so much better. What do people tell you bothers them the most They’ve been diagnosed with a chronic illness, quite a serious one. There’s probably two things they worry about. One is the overwhelming fatigue that they experience. The other one is the introduction of drugs that they have never seen the like of before. It’s really important to discuss the drugs with them so they do understand that they need to take them and how they work.
And that they do need to have followup blood tests and so on to monitor how they’re going. What’s the evidence, Lyn, that early diagnosis and intervention makes a difference There’s overwhelming evidence now that it’s the right thing to do. Ten years ago we thought it was the right thing to do. Now we really know, in terms of improving outcomes, quality of life, preventing the joint damage and even improving mortality lengthening life. Severe rheumatoid reduces life expectancy. NORMAN From coronary heart disease as much as anything. Yeah. Particularly in males, it lowers life expectancy by at least five years.
Treatment early helps improve that. I’ve heard, John, rheumatologists say that flail joints, ulnal deviation, horrible hands is a thing of the past you don’t see anymore apart from people who may be really elderly who have had rheumatoid for a long time. From modern treatment, you don’t see that anymore. Is that your experience I guess both are true. The newer drugs certainly offer much greater promise than we’ve seen before. Hopefully they will become more of a thing of the past. What figures are we seeing, Lyn My understanding is that it’s commoner than people think.
2 to 3 of Australians in national health surveys think they have rheumatoid arthritis. Maybe it’s a bit less than that. At least 1 of the population has rheumatoid arthritis. In terms of new cases, even though the incidence is declining around the world, probably at least 1,000 new cases in Australia, based on our population, every year will have a range of severity of rheumatoid arthritis. But at least 1,000 new cases every year. NORMAN Most GPs will have a patient in their practice Most GPs will come across it, I guess not every day.
You were saying earlier that it’s commoner on an incidence basis than type1 diabetes Yes. It’s more common than that, and than multiple sclerosis and more common than other things that attract a lot more attention. Rheumatoid arthritis has been everyone gets it. We can’t do anything about it. Clearly that’s not the case. I’ve heard some say that the window of opportunity is six weeks. That’s what we’re recommending. The evidence is that the earlier you get on top of it, diagnose it, the earlier you treat it, the better the drugs work.
If you wait six months, you can still use the same drugs. You’re still highly likely to get a response, but it won’t be as good. You might have already had erosions by that time, and joint damage. That’s a pretty tight rope to put GPs on for diagnosis, John. It’s difficult. As we’re saying, it is an uncommon disorder, but hopefully there’s an opportunity to pick it up early and make a difference, to improve people’s lives. Christine, you’ve done work with colleagues on the incidence in Indigenous communities. This is a condition people say is genetic, related to HLA type.
How common is it in Indigenous communities The research showed that in 2001, there were only 15 cases of rheumatoid arthritis in the Indigenous population in far north Queensland. I’m talking to a colleague who visits the Kimberley as a rheumatologist. He has no cases of rheumatoid arthritis. Research showed that the majority of cases of rheumatoid arthritis in Indigenous populations was where parentage was mixed of Caucasian or other ethnic groups that carry RA. What do we know about causation, Lyn There’s definitely a genetic element. There’s no single gene that’s been identified,.
But there’s strong family history, strong in dizygotic and monozygotic twins. So, definitely underlying genetics, but something else triggers it. An environmental trigger, but often you don’t find the trigger. Smoking increases risk, probably through its ability to generate antibodies to citrullinated peptide, but smoking is a risk factor. Morbid obesity is a risk factor. NORMAN Vitamin D levels There’s some association in terms of inflammation. But it’s commoner in Tasmania than it is in Sydney. It hasn’t been as strongly linked as some of the other conditions like multiple sclerosis.
We’re looking into some treatments for that. The oral contraceptive pill might be protective. NORMAN Pregnancy Usually the symptoms of rheumatoid abate during pregnancy. Pregnancyrelated hormones have an antiinflammatory effect. There’s no evidence that pregnancy increases or decreases your risk. Blood transfusions might be a risk. Occasionally the immune system is triggered by immunisations. NORMAN There might be a viral aetiology Possibly. There’s never been a single infective agent found, though. You find it early. What’s your aim with treatment The aim of the rheumatologist or the clinician is to put the disease into remission.
NORMAN What’s that Remission is when the disease has gone away but you still need drugs. It’s very rare that we cure the disease. So when people talk about drugfree remission, those might not be people with rheumatoid arthritis A small percentage can go into drugfree remission, but our knowledge of the disease is that it always tends to come back, even when you’ve got people under very good control. Remission is ESR, CRP is zero, or a normal rate. NORMAN A CRP of less than 1. CRP less than 1, ESR less than 5,.
The count of swollen, tender joints, zero. If you’ve got some joint swelling, you’ve still got some rheumatoid disease. To the patient though, that means nothing. Well, it means something. It means their pain is gone. It also means usually that their fatigue is under control. So again, the patient is looking for improved quality of life, energy levels back, that sort of thing. As a doctor, we’re looking mainly to see no erosions, no joint damage. In order to get that, you have to have zero to very low joint count.
And normal inflammatory markers. There’s this debate about new biologicals people walk in the door saying, ‘Can I have my etanercept or my rituximab,’ or whatever is the latest one advertised in the United States. What is the role of these biological agents in treatment They’re very powerful and very useful agents. In Australia, we have them for people who still have very active disease after they’ve failed two or three other diseasemodifying agents and still have active disease. They have an important role, but they’re not without some potential for side effects.
They need to be used appropriately. John, we’ll come to some case studies in a moment, but give us a sense of what these new guidelines tell you to do in terms of diagnosis. We are asking the GP to make the diagnosis before referral Yes. As much as possible. What’s the algorithm It falls into basic clinical principles. One would take a history, look for features that would be suggestive of arthritis the classic of symmetrical smalljoint disease, fatigue, stiffness persists for an hour or more into the morning on awakening.
Then follow that up with blood tests ESR, CRP as a marker of inflammation, the timehonoured rheumatoid factor in the antiCCP. If you were suspecting rheumatoid, they would be the mix of tests you’d go for in a directed way. What’s this antiCCP, Lyn Before we get to that, we don’t necessarily need the GP to make the diagnosis. Sometimes if you wait until you’ve got a definite diagnosis of rheumatoid arthritis, it’s too late. You’ve already got the rheumatoid factor and you might already have erosions and joint damage.
The key message out of the guidelines on early referral, even if those tests are negative, if someone’s got persistent swelling or symptoms in their joints, refer on or seek additional advice. Joints should not persist in being swollen beyond six to eight weeks because there’s potential for joint damage. NORMAN Regardless of what the biochemistry shows Yes, try to work up the diagnosis. That saves time for the patient and for all the treating doctors. Don’t wait till you’re totally convinced it’s rheumatoid. It’s often too late. Christine, GPs watching from rural and regional Australia,.
And we’ll find out in a moment what proportion are those, they’d say, ‘It could take me a year to get someone to a rheumatologist.’ What do they do They refer. In our particular instance, I can triage the referral so that people who have a referral that’s indicating an inflammatory condition or where I’m suspicious, I can follow those people up, I can talk to their GP and make sure that they get in to be seen. NORMAN The GP knows there’s a clinic in town run by an expert nurse.
Yes. How often does that happen anywhere else in Australia, Lyn Not any other States have that luxury. It is a problem for GPs at times to get access to rheumatology services. The Australian Rheumatology Association has a website. The public can see where rheumatologists are. GPs can look. Not every rheumatologist is on that, but if someone is in an area where they can’t get access to a rheumatologist, they should email or call the Australian Rheumatology Association secretariat, and we’ll get them in touch with someone. Those women who said they had fatigue.
And weren’t talking about their joints apart from the last lady, if the GP wasn’t to take this as fatigue but ask the next questions, because they might be thinking of gluten enteropathy or thyroid or a lot of things, but they do ask the questions about joints, in what proportion of cases when it is rheumatoid are they going to get a joint story A high percentage. The majority will have some joint symptoms. They might be coming and going, like that last lady said palindromic rheumatism, where it’s all sore and painful,.
And by the time they see the doctor, it’s gone. That’s a very common scenario when rheumatoid is first starting. The synovitis can be very subtle, particularly wrists and shoulders. You don’t even always see it. It’s based on that morning stiffness, looking for inflammatory markers, doing some blood tests to see if there’s an associated inflammation. You’ll occasionally see people who don’t have much in the way of joint swelling, have normal inflammatory markers, but go on to damage their joints. They are the minority. The majority will have joint symptoms.
And this antiCCP Antibodies to citrullinated peptide, which is part of the cell nucleus, one of the peptides. It’s probably just as sensitive as rheumatoid factor. If your rheumatoid factor is positive, the CCP doesn’t help you make an additional diagnosis if you’ve got the clinical picture, but it is more specific. Rheumatoid factor can be positive in other things chronic infection, part of an ageing phenomenon. Whereas CCP at this stage appears to be quite specific for rheumatoid. But it’s also a poorer prognostic marker, particularly if you have rheumatoidfactor positive.
And antiCCPpositive looking in earlyonset arthritis. Sometimes up to about 30, 40 of an early polyarthritis will be gone in 12 months. But if you’ve got both rheumatoidfactorpositive and CCPpositive, your chances of having erosive, damaging rheumatoid arthritis at two years are very high. It’s like a 90 predictive value that you will have an erosive disease. So they’re quite strong prognostic markers, very useful to help people realise, and part of that education, knowing, why do I have to take all these drugs If you can show them some of that prognosticmarker stuff,.
It means a bit more to them, that it is worth the tradeoff of the potential for side effects and the things they worry about with their drugs. It’s worth taking that tradeoff. John, what’s the role of the GP in all this We’ve alluded that we expect the GP to refer promptly, maybe do tests first. What else Because if you take type1 diabetes an an example, most GPs run for the hills. If you don’t run for the hills, the local children’s hospital takes the child away from you.
Yeah, they like doing that. Just again to consider the diagnosis, it’s uncommon, but if people, as Lyn has been saying, have persistent joint swelling and other symptoms, with or without the tests being positive or not, they need to consider that diagnosis. In the longer term, there’s that role for GPs as in so many chronic diseases, to help maintain the patient, help to coordinate care with professionals that would be involved. Lyn, some people would argue that remission is no more erosions in your joints. In addition to what you said, you stop the disease in the joints dead.
Is that what you aim for in your remission That’s the ideal, that you see no more damage in the joints. Xray is the crudest way to see erosions. As time progresses and maybe MRI becomes cheaper and Doppler ultras, at the moment they’re research techniques. There are a number of techniques to show very early changes in the joints. You’d want to see that those changes were switched off. That’s remission. People who appear to be in clinical remission with that scenario I suggested normal inflammatory markers and normallooking joints on examination can still have ongoing inflammation.
How early do you think somebody in rural Australia, where it’s not easy to get allied health professionals, how early in an ideal world would someone like you, Louise, be brought in Our research suggests that the earlier you intervene, the better. What’s important is, the time when people are least likely to do what’s best for their own management is early on, when they’re just adjusting to illness. They’re adjusting to the idea that they have an illness. If you don’t believe that you have an illness, you won’t do things that will manage that illness.
Part of needing to accept that you need to take medication, that you need to develop a balance between rest and exercise and listen to your body, that you need to have an optimistic but realistic attitude about the future is really helpful in terms of how you manage it. My own studies showed that if you can get in in the first two years of illness, you can affect longterm outcomes. Five years later you can show that people are needing to use fewer healthcare resources because they have managed their illness well enough in the shorter term.
That they actually become less disabled over time. That’s doing evidencebased therapy as a psychologist, cognitivebehavioural therapy or interpersonal psychotherapy Helping people to change what they do to respond to the illness so that they don’t become overactive on inflamed joints or at the same time don’t respond to the stiffness by inactivity, but foster that balance between rest and exercise and try and teach people skills to maintain that optimistic attitude that protects them against depression. Let’s try a case study. Let’s meet Lily, who comes in to see John.
She’s 32 years old. She comes into the surgery with stiffness of both her hands, wrists and shoulder joints. When John examines them, they’re slightly swollen, tender and painful. It’s developed over the last few months and tends to be worse in the morning. She’s a smoker, and she’s got two kids, both quite young. She’s pretty tired, especially in the afternoon, which she puts down to running around with her children. There’s lots of tired mums out there. There are. NORMAN It’s winter. There’s lots of people with sore, aching joints.
It’s part of that challenge, that soup you see in general practice, of trying to pick out the bits you should be considering. It’s a difficult problem. This one’s highly suggestive of it because of the features small joints are involved, more than three areas, there’s a symmetry to it, morning stiffness, fatigue lots of markers that you should at least be thinking that this woman has the potential for some severe forms of arthritis. Following the guideline, what do you do as the GP As has been said, examination confirmed.
There’s some joint swelling in those areas as listed. I think with that presentation, it would be reasonable to do the tests we’ve discussed an ESR, CRP, looking for evidence of inflammation and the timehonoured rheumatoid factor and an antiCCP. What are you going to do if they’re all negative I suppose it would be reasonable to institute some therapy. You’d be doing that in either sense, ’cause she’s clearly in pain, it’s influencing her ability to function. NORMAN She says she’s taken Panadol and it doesn’t make any difference.
Because she’s young, it would be worth trying antiinflammatories. Suggest ibuprofen if there weren’t any other reasons not to take that. See what that brought her in the short term. Even just while you’re waiting for the test, you could do the two things concurrently, see if you can bring relief while you’ve got further indications. But the clear message here is, you don’t hang around You bring her back soon, after two weeks or something I guess it would depend upon how she’s functioning. We’re talking about a sixweek window of opportunity.
You can’t wait for a month. No. The scenario says, a few months. You would need to get her back. It would depend what her ESR, CRP was as to how much demonstrable evidence there was of inflammation. If that was up, you’d want to get her to see someone much more rapidly. Are nonsteroidals liable to have an effect if it’s rheumatoid, Lyn They’ll help in early rheumatoid and mild disease, for early symptom control. They don’t have any impact on the actual disease control and slowing erosion, slowing the disease.
The alarm bells with Lily are you could quite easily dismiss her because it’s a few months and the new baby and tired, those sorts of things but the alarm bells here that she’s got joint swelling. It’s only slight, but it is always only slight in early rheumatoid. The fact that that’s persisted, you can’t put that down to tiredness. There might be some hormonal changes and all of that sort of thing. She might be still breastfeeding. You’d need to weigh that into your decisionmaking for her.
She might be thinking of more babies soon, so that also influences what you might do. Nonsteroidals could help her a little bit, but you wouldn’t want to be waiting around too long. Perhaps you’d start the nonsteroidals, start the tests and organise a referral. If she’s better by the time she’s seeing the rheumatologist, she can cancel the appointment. The other thing I’d try with her would be some highdose omega3 oil, either as fish oil or flaxseed oil. Although that takes a little while, that can be a good antiinflammatory.
And work almost as well as nonsteroidal prescribed drugs. When we talk about high dose, we’re talking 15mL It depends which oil you use. There’s a number of different brands now. 15mL, or there’s one you can take 5mL. There’s a number of different brands. Or about 10 to 12 capsules. The important thing is to look up the dosage of the DHA and EPA of the omega3. NORMAN What’s the equivalent dose you’re looking for You need probably 3g to 4g of actual DHA or EPA. NORMAN A day A day.
Which is quite a lot of omega3, but it does take three to four weeks at least to have its full antiinflammatory effect. But as a stopgap measure if you’re all negative. How often does a woman like this turn up with negative tests, and do they become positive over time Rheumatoid factor and CCP only have about an 80 sensitivity. Up to 20 of people who have classic rheumatoid arthritis, including damaging and eroding their joints, are never positive. It’s a very common scenario that they’re negative in the first instance.
In someone like Lily, it’s very common they would be negative. They would become positive over the next 12 months or so. Unusual for the CRP and ESR to be totally normal. Very unusual. You occasionally see very low levels, but people are still destroying their joints. It gets back again to, if you see joint swelling, no matter how slight, if it’s persisting, seek referral to confirm that. If a rheumatologist isn’t available I was talking to a rheumatologist from north Queensland who said he’s got a twoyear wait to be seen.
Yes, they might have a twoyear wait, but I think all rheumatologists, if the patient’s been worked up appropriately and they get the call from the GP, all rheumatologists will respond to that in some way. If you’ve got the luxury of the Western Australian situation, the community nurse will respond. Most rheumatologists would welcome the call from the GP that said, what tests will I do while they’re waiting to see you NORMAN John, what alternatives should you look for What’s the differential diagnosis that you should be eliminating A younger female, it would be reasonable if you’re ordering tests, do her ANA.
If that was positive, they’d do the more specific things looking for lupus. With that number of joints, you wouldn’t be thinking of things like gout. She’s in the wrong age and gender. NORMAN Does joint aspiration have any role, if she’s got a swollen knee Ah, yeah, you could certainly have a look. I’d have to depend upon ringing a rheumatologic colleague to see how to interpret the result, but it could certainly be of assistance. NORMAN Lyn If there’s a single, reasonably swollen joint, it’s always worth aspirating because it might be infected.
There might be crystals. There’s no definitive diagnosis. Sometimes you find the rheumatoid factor in the synovial fluid and you don’t find it in the blood yet. In early rheumatoid, that can be positive. The whitecell count gives you some clues. And it can be therapeutic at the same time. Sometimes the rheumatologist says, get going on some DMARDs. Take us through what the nonbiological, standard DMARDs are. They can be remarkably effective. They certainly can. The gold standard, and what all the biologic agents have been compared to, is methotrexate.
We really put that up as the gold standard. But not every patient wants to take methotrexate. NORMAN But it’s less toxic than a nonsteroidal. It is less toxic, but one does have to limit alcohol intake and you have to be monitored. Not everyone is in a position to be monitored or want to be monitored in terms of monitoring blood tests. Not everyone wants to maintain healthy alcohol intake or no alcohol intake. Some people want to become pregnant. There’s a number of people that you don’t prescribe methotrexate to.
You might just use methotrexate as a monotherapy, a single therapy, but there’s a reasonable body of evidence that if you have more aggressive disease, you’re better off with a combination of therapies that work in different ways. NORMAN Hydroxychloroquine, salazopyrin. Are the main three that you would use first up. There are other ones available too. I’m told, them used in the right dose, judiciously, gives you as good a result as adding a biological, in terms of getting remission. In terms of getting clinical remission and earlysymptom control, yes.
But if they aren’t working within three to six months, according to our guidelines, you could get onto a biologic. If you look at what’s happening at the joint level, synovial level, erosion level, the rate of remission is probably greater if you add in a biologic early as well. By and large, the majority of people get very good response to early and pretty aggressive therapy, like treating to a target, treating to get their CRP and ESR in the normal range, get their joint count right down low. We’ve all been brought up with first, do no harm.
Of course all these drugs have some side effects. There’s no side effectfree drug. There’s that tradeoff as well, getting that right. The patients don’t always want the side effects of the drugs too because they see it as arthritis and not something that’s going to kill them. The message with rheumatoid arthritis is, it’s about getting in early. John, in terms of what might kill you, it’s like diabetes. It’s a heart attack that’s going to kill you, or stroke, from the inflammation. At what point do the guidelines tell you.
To institute aggressive coronary riskfactor reduction My take on that is, you’d see them in a highrisk group. You might, in an equivalent sense, treat them like they had diabetes. You could be quite aggressive. Would a 32yearold woman with two children fit that Hopefully not. Hopefully she doesn’t have other factors. She is a smoker. You’d obviously be strongly into her about, this is very good time to give up, for a range of reasons. NORMAN Does that help the symptoms Is there evidence for that I’m not sure. I think.
I don’t think there’s any evidence that it helps symptoms, but people with rheumatoid arthritis get bad lung disease, bronchiectasis. If they smoke as well as have rheumatoid arthritis, they are at high risk. She should stop smoking for lots of reasons, but cardiovascular riskfactor monitoring is critically important. All the traditional risk factors are important, but maintaining a normal CRP is important for the cardiovascular risk longterm. Christine, how important is multidisciplinary care, particular in a country town, for somebody with rheumatoid arthritis Extremely important. Cardiovascular disease and the like are all slightly higher percentage.
In country and rural areas. If we’ve got rheumatoid arthritis added to that picture, people are at higher risk. Between when we get a referral, seeing the patient and they see the rheumatologist, if they’re a smoker or overweight, we can do something about that, or start to do something. They may need occupational therapy to help them with daily activities. NORMAN Psychologically, Louise, what would you do for Lily The first thing you’d want to talk to her about is what the longterm prognosis is, to help her, not to be concerned inappropriately about the future,.
But to take the illness seriously enough that she’s motivated to try to get that balance between rest and exercise, even at a demanding time where she has so much going on. The need to prioritise her health in these early stages is really crucial for these patients. If she’s breastfeeding, how does that affect therapy LYN It can affect it significantly. All the diseasemodifying agents can get into the breast milk. She would probably want to delay that. Wait a little while, or even consider stopping breastfeeding if her disease is active enough.
Antiinflammatories, steroids, some will get into the breast milk. It’s a matter of timing it using the shortestacting antiinflammatory and timing when you breastfeed. Listening to rheumatologists talking about rheumatoid arthritis, they say prednisone is out. The occasional intraarticular injection, but it’s a matter of pride that they have an almost zero prescribing of prednisone. They might all say that. And almost zero nonsteroidals as well. It’s certainly our aim to have people’s disease controlled on diseasemodifying agents alone. But if you look at most longstanding rheumatoid patients, a vast majority 40, 50 will be on some prednisone.
Because it works so well. Early regimens that treat to target with combination therapies all have some component of the corticosteroid, either as intraarticular, multiple intraarticular, intramuscular or orally or intravenously. Steroids work very, very, well. They probably are also diseasemodifying agents in terms of reducing erosions. NORMAN But you get hooked on them. Yes. It’s hard to get back off it. They’re very effective for controlling symptoms, and if there is some sort of delay, even though most rheumatologists do not like the steroids to be started before they’ve seen the patient, sometimes you just have to.
If you do start steroids, you need to have a withdrawal plan to see if it’s gone yet or what’s happening. They can be lifeshortening. They can. If you look at longevity now, that’s the tradeoff. You might get disease modification early, but the tradeoff is, you get atherosclerosis and coronary heart disease and risk factors longerterm. The surprise is that something like methotrexate isn’t as toxic as you think That’s right. It’s got its potential for side effects and needs to be monitored, but it’s safer than nonsteroidals.
Somebody told me that a reduced whitecell count is good news it shows it’s working. That’s right. If your lymphocyte count is down a bit, it means it’s having some modification of the immune system. Let’s go to our third case study. This is a 65yearold woman called Jean. She presents to you, John, complaining of recurrent painful attacks in both knee joints. It goes away for a few weeks, then comes back. She’s borderline obese, with a waist circumference of 90cm. She says she’s tired, has trouble sleeping and has felt low.
For the last couple of months. She’s taking ibuprofen and paracetamol and it’s not seeming to have much effect. What are you going to do about Jean She’s just got arthritis of the knee, hasn’t he Send her home. You’d think of that first. That would be a reasonable diagnosis. Female, age she is. That’s her current BMI. She may have been heavier. There’s certainly risk factors there for the more common disorder, which is always a good concept to go with first. Does she have depression That’s the thing that may explain it.
It’s a difficult one, but that’s what general practice is all about often. It’s not always clearcut, is it It’s easy just to send her home, but there are other clues here as well. Sure. What questions should you be asking in your sixminute consultation to get beyond the obvious Are there other joints involved Maybe the ones that are most involved, and she’s focusing on those. Bring those to attention first. People often have gnarled, painful hand joints. That’s probably going to be more fingers, than the base of the wrists.
NORMAN Distal IP joint rather than her metacarpophalangeal joint Yep. Thinking of the classic gnarlidge you see in an elderly aunt or something. If she had other joints involved, that would make you think more strongly rheumatoid, and maybe test for that at the initial consultation, particularly if she hasn’t felt she’d had adequate response from taking paracetamol and antiinflammatories. This is bilateral, whereas osteoarthritis is usually one side worse than the other. Usually one side worse than the other in terms of presentation. An obese female is more at risk of getting bilateral knee OA.
She’s had these recurrent attacks, she’s got the joint swelling. She probably does have osteoarthritis and a bit of depression, but she seems to have a superimposed inflammation on that. A small percentage of osteoarthritis will be inflammatory. There could be gout crystals there, pseudogout, pyraphosphate crystals. Persistent inflammation, you’d be thinking other inflammatory. You’d look for psoriasis, a psoriatic arthritis. There’s other differentials there. It’s a slightly atypical presentation for rheumatoid. You’d look for family history. NORMAN She’s got an aunt with rheumatoid. OK, so there’s that family connection.
There is this second peak of onset of rheumatoid, where you see it a bit later late 60s, early 70s. Males are often equally affected as females. They often have a polymyalgic onset, so looking a bit like polymyalgia rheumatica. It can trick you sometimes. She’s already tried the antiinflammatories. The mild inflammation of OA would usually respond to the antiinflammatories, and she’s still got inflammation. She’s still got the systemic things, the fatigue. Christine, this is the sort of person that gets missed It is, the sort of person that, when we’re doing the triage,.
We need to follow up closer, go back and ask more questions. They might not have indicated something to the GP, thinking it’s unimportant. In spending a little more time, we find out something else that triggers them being referred earlier. NORMAN Which could save considerable disability later in life. I’ll ask another poll question now We’d be interested to know what your answers to that are. Let’s go through some questions coming in. From Anne, a nurse in Queensland ‘Can having a blood transfusion trigger rheumatoid’ There’s epidemiological evidence.
That people who develop rheumatoid have an increased chance of having had a blood transfusion in the past, so, yes is the answer to that. In terms of of absolute risk of everyone having rheumatoid after a transfusion, I’m not sure about the exact level. You’d need a genetic tendency as well. A question from a physiotherapist in NSW ‘How often should patients with RA be reviewed by the general practitioner’ I’ll quote back to the guidelines you’d think at least three or four times a year would be reasonable.
It would depend on their clinical state and what other things were happening for them. A question from a GP in South Australia ‘Should a GP be prescribing combination therapy’ I would be a bit reluctant unless the GP was very knowledgeable and had other patients with rheumatoid arthritis. There really isn’t an exact number of joints or an exact level of ESR, CRP that I would always prescribe combination therapy. I would be reluctant to recommend that a GP did that. I would prefer that was done in consultation with a rheumatologist.
Is adjusting that therapy tricky It can be. They each have their own side effects. Combinations of methotrexates, salazopyrin have a little more effect on the liver. It is a juggle in terms of which one you ramp up or down and which ones to bring in at different times. Christine, people often tell you things they won’t tell the doctor. A GP in Nowra in NSW asks, ‘Many patients are reluctant to take medications such as methotrexate early in RA. How would you convince them it’s a good thing’ What do you say when they tell you, ‘I don’t want to take this cancer drug’.
Probably the most common thing that happens when people hear they’re going to take methotrexate is that they listen to everybody around them who says, it’s toxic, don’t take it. The way I use education is to put it alongside doses that might be used in oncology the huge amounts and the toxicity there, and show them that the amounts you take in rheumatoid arthritis are very tiny and the toxicity is less. Also, educate them about the side effects. It would convince me if you told me it was less toxic than ibuprofen.
That’s a pretty dramatic statistic. Yeah. NORMAN That would be settling for me. In my experience, most of the time when patients don’t adhere well to medication it’s because they have misunderstandings about the medications. It can be effective to ask the patient their concerns about taking them. Nine times out of ten you’ll find their concerns are based on misinformation or something they’ve been told. But you need a healthy respect for the drug. You want them to have some concern but not too much. You want them to have enough concern to monitor it and take it properly,.
But not so much that they miss out on effective therapy. Particularly in that early phase. They’re often confused and overwhelmed. That’s when they can’t make the decision. It’s the same balance you need them to have about the disease. You need them to have a respect for it but not a fear of it. A question from Janet at the Greater Western Area Health Service, which I assume is in New South Wales ‘What’s the earliest diagnosed age for rheumatoid arthritis’ Lyn You had the program for juvenile idiopathic arthritis.
In that spectrum of juvenile arthritis, there is a small subset who get a rheumatoidlike illness even as babies. NORMAN Rash and things like that. Yes, a different spectrum. You see some teenage girls, in particular, who have classic rheumatoid arthritis, but that’s a very small percentage of juvenile. But it can occur at any age. It can start at any age later in life as well. It’s unusual to see it starting over 70 or 80, but it does happen. A question from Elizabeth in NSW ‘What dose of fish oil, please specifically DHA or 24G.
The combination of the DHA and EPA combined, at least 3g. You really need to look at the individual preparations to see how much. They all say they’re 1,000mg of fish oil, but you need to work out. NORMAN How much omega3 is in there. It’s cheaper to do it by oil than capsules LYN Cheaper to do it by liquid oil. Elizabeth also asks, ‘Is there a role for paracetamol at any stage’ Yes. We say for any chronicpain management, paracetamol should be firstline. It’s a very good adjunct in that first setting.
With paracetamol and perhaps some nonsteroidals. At any time people have a flare, sometimes just a little additional analgesia is all that’s needed to get back a little control. Yes, it does have a role. What do the guidelines say about when to refer to a rheumatologist, John, particularly in someone like Jean’s case She’s had symptoms for some time, so you’d probably be doing tests and treat and refer within a tight time frame, a week or two depending on the results of initial tests. NORMAN Do you agree Yes, I agree. Jean would be one that you’d want to drain the knee,.
Take that fluid off, maybe put corticosteroid in. Unfortunately, the item number is gone, so she’ll have to pay for that. There’s no Medicare item for that. That would be therapeutic for her. She’d almost certainly get symptom relief from putting some corticosteroid in early. That might mean you’d need to refer to the rheumatologist to do that. Christine, what’s the role of exercise, weight loss, lifestyle interventions The role really comes after treatment has been instituted. If people are suffering, they’re in a lot of pain, they feel fatigued, then exercise is probably fairly difficult.
You can talk to them about it. Nutrition is important. They need good nutrition when they’re unwell. Well, all of the time, but particularly when they’re unwell. But even in the setting of inflamed joints, a lot of people think it’s getting back to your point of the right balance a lot of people think they shouldn’t move the swollen, painful joint. But some movement is how you get rid of the toxins, how it actually improves mobility. NORMAN Can you damage the joint with exercise Very hard to damage the joint with exercise.
If you actually push it a little bit, you won’t do any harm You won’t do any harm. It might flare up and be a bit more painful. Even in acute inflammation, some gentle range of movement, some maintenance with isometric exercises. Muscles around an inflamed joint waste very quickly. Someone like Jean, being older and got poor quad strength already, if she doesn’t do any walking or anything, she puts herself at risk of lots of other things. John, what do the guidelines say about complementary medicines We’ve been talking about fish oils as a therapy.
That’s pretty mainstream. There’s randomised controltrial evidence. OK, then. If we take the other side around complementary medicines, outside of those, there’s not really a lot that you’d say would be greatly helpful. NORMAN Are any harmful Yes. I knew you’d ask me that. You’re much better on the name of that. How do you pronounce it Triptergium or something. LYN Tripterygium wilfordii. Well done. She’s practised that one. That’s good, that’s good. Go on, Lyn, you can probably finish that off. I guess the key point about this is that some things,.
That particular one is a Chinese herb, the key thing for a GP is to know all the things their patients are taking, because they’re all taking something. Some of them, they’re not harmful, but they’re not particularly useful either. Does glucosamine have any influence on RA Glucosamine doesn’t have any role in rheumatoid arthritis. It’s really the omega3, fish oil, flaxseed oil, are the ones that have been proven. And will help your depression. Maybe. The magic treatment. Let’s go to our next case study, which centres on a selfmanagement and education program.
Run by Arthritis Western Australia in Perth. The course is a sixweek program that covers a range of topics of interest to people with inflammatory or rheumatoid arthritis, their partners and support people. We developed the rheumatoid arthritiseducation program because we had been running generic arthritis programs and also the Stanford Chronic Diseases Management program, and it was apparent that we weren’t meeting the needs of people with inflammatory arthritis We did a needs assessment and asked people what they wanted, and we developed a program around that. We run a sixweek program, because it’s been documented.
That you need at least six weeks to try to change people’s behaviour. We teach them exercises they can do, and encourage them to do so. We talk about depression and the emotional loss that comes with having a chronic disease. We spend a whole session on the different types of medications and in which sequence they’re given. We talk about blood tests, what they mean, why they have them done. We talk about relaxation, we teach them relaxation techniques. It’s important that they learn relaxation and stress management. We talk about osteoporosis briefly.
Because they’re much more at risk of getting osteoporosis. We also encourage them to bring along partners and significant others. One of the issues they have is telling people about this disease and how they cope with it. Often, you don’t talk openly amongst friends or family or anybody about the illness because they’re sick of hearing about it and you don’t want to bore them. But when you are in a group like that with likeminded people sharing the experience, you realise, I’m very lucky. There are others far worse off than I am.
It’s a support for each other within that group framework that I found to be very valuable. For people to get into this program, they have to have a referral from their GP or from their rheumatologist or other specialist. They have got to be diagnosed with either rheumatoid arthritis or one of the inflammatory arthritises, for instance, psoriatic arthritis or seronegative arthritis. We do try to be absolutely sure that we’re getting the right sort of people that we can help. People have got to learn to manage their disease, otherwise it will manage them.
I’ve been going along, just doing as I was told ‘Yes, sir. No, sir. Three bags full, sir.’ This course has told me that either the disease can be in control or the doctor can be in control or I can be in control. Suddenly, I feel tremendous because I’m learning so much. I got a great sense of empowerment. It was to do with, I am the best person to know about my disease although I need to work within a team a team of health providers, but I am the leader.
It is my illness, I own it and I must manage it. I become the expert. That was such a liberating thought for me. We now run this program in some of the rural areas. We run it in Albany, we run it in Kalgoorlie and manage it where we’ve got rheumatology nurses. We’re training health professionals to run it in the eastern States. It’s going to be run in Victoria and Queensland and New South Wales. I’m so alone with it. I didn’t know anybody with rheumatoid arthritis. I felt I was the only person walking around or limping around.
The only person that takes two hours to do the dishes. The only person that had to give up their job. Just so many things I can’t do cross the road. Can I cross the road and have a cup of coffee No, I can’t. I wanted to know that there are other people going through that with me. That was primarily the thing that I wanted. But now I’m here, the information is invaluable to me, it really is. I learned more in that six weeks’ course than I had learned in the previous 28 years of my illness.
Getting people, perhaps the elderly ones, back to playing bowls, and just letting them know that they can play sport within their limits, and that they can have a life with rheumatoid arthritis. A lot of them seem to think that their life was over. I thought, you’re probably going to be in a wheelchair. You won’t be able to do anything. Someone will have to look after you. But it doesn’t have to be like that. They teach you that on the course. You can be the power of your own destiny with the disease.
Hopefully it doesn’t have to be that difficult. I’ve taken up exercise programs such as tai chi. I do a lot more swimming than I used to to try and keep my fitness levels and everything going while listening to my body and getting to know my body so that I don’t do too much. But it has empowered me to take up a lot of the things that previously I had thought were beyond me. One of the symptoms is depression. For many years, I did suffer quite severely with depression.
I was actually on medication for it. Since doing the course and understanding the illness, I have found other ways of overcoming depression. I no longer need to take medication for depression. When I say empowerment, I really do mean empowerment. I feel a lot stronger, a lot more capable and a lot more what’s the word assertive in my own self, having the knowledge that the course brought me. The selfmanagement and education program in Western Australia. Is it widely applicable People have criticised these programs, Christine, saying it’s fantastic for middleclass, welleducated people.
Who have got time to spend six weeks, and they’re expensive and not broadly applicable to the general community. A lot of the generic programs are a bit like that. Certainly in my experience with this particular program, patients are really interested in learning more about their condition. You’re saying it’s got to be highly specific to the problem Yes, I think so. This program from Western Australia is diseasespecific. People learn about their condition, about all the things that go with their condition drugs, blood tests. They learn about communication, how to work with their healthcare team.
That sense of control can be an antidepressant in its own right. Absolutely. You can see how people get into a vicious cycle when they’ve got an illness. They feel like they can’t move, they become less active, they become more depressed. Then it’s harder to motivate themselves to do anything. Then they have to take such small steps, they feel it’s not even worthwhile. The key to the success of programs like this is when they get people to actually change what they’re doing. If you can get people to change what they’re doing,.
Often you have a greater effect on behaviour. Some of the old education programs didn’t translate the knowledge, which is essential, but not sufficient to affect behaviour change. What is the role of selfmanagement It’s very difficult to prove, using conventional outcome measures, that it makes a difference. How do we prove someone feeling more empowered How do you measure empowerment, measure the change How do you prove that those people take their medications better In fact, maybe they don’t. Maybe they just feel better about managing their disease themselves. By traditional outcome measures, it’s hard to show that’s beneficial.
That’s why they get criticised. But clearly it’s such an important part of any chronic disease. There’s certain generic elements to all chronicdisease management. It’s quite important that it’s also tailored and specific to the disease and the particular drugs. Knowledge does help compliance and adherence with therapy. Just some quick questions, ’cause we’re nearly out of time. Any role in physiotherapy for heat in rheumatoid arthritis Ah, yes. In an inflamed joint, certainly that earlymorning stiffness, a warm shower, the bad hands in a warm basin of water. Good oldfashioned wax therapy.
Heat helps inflamed joints, as does ice in some circumstances. That’s a difficult one. It’s an individualpatient thing. An acutely swollen joint not so much hands but an acutely swollen knee or ankle can respond to ice as well. A question from Veronica in Castlemaine in Victoria ‘For patients who have avoided medications such as methotrexate for 10 or 20 years and have significant disability, how much difference can biological therapies make to those people at this stage of their disease’ We’ve been surprised, actually. As you mentioned at the beginning, it mostly is a lifelong disease.
People can still have quite severe exacerbations and inflammation when they appear to have socalled burnedout or damaged joints. So, yes, people with chronic damage are still getting benefit from biologics if they have ongoing inflammation. Daniel from the University of Wollongong I think you’ve got this the wrong way. ‘You mentioned methotrexate was more harmful than NSAIDs.’ We said it was less harmful than NSAIDs. Could you elaborate on Daniel’s question Let’s assume we’re talking about less harmful than NSAIDs. This data comes from epidemiological studies. There hasn’t been a randomisedcontrol trial that compares the two.
They’re working in different ways. Nonsteroidals often have no benefit for disease modification, whereas methotrexate will help put people in remission and control their disease. In terms of of the longterm effects of the GI risk and cardiovascular risk from nonsteroidals as people get older, those risks are higher than the risk of methotrexate. The longterm risk of methotrexate is liver fibrosis, but that risk appears to be quite a bit lower than we used to worry about. People on methotrexate for many years, as long as that’s monitored, they keep their alcohol to the reasonable controlled level.
Two or less drinks and two alcoholfree nights a week, following the guidelines, the longterm risk of methotrexate is very low. There may be an increased risk of skin cancer in Australia, but we have to be alert for that anyway. Two questions from Keith from Victorian Physiotherapy services ‘Can the parvovirus trigger RA the slapped cheek syndrome’ You can get a very classic polyarthritis following a parvovirus infection. You can also get transient rheumatoidfactor positivity. But mostly the polyarthritis will be gone within four months. Occasionally you see people.
Where it persists as chronic rheumatoid arthritis. Keith also asks, ‘How often or when should an Xray be taken of affected joints once a diagnosis of rheumatoid is made’ Soon after commencing the DMARDs, it’s useful to have a baseline Xray of your hands and feet to identify whether you have erosions. It’s not really worth repeating that under one to two years. You would at a time perhaps when you’re thinking things are in remission after a couple of years, to make sure. A question from Roy from a therapy service in New South Wales.
‘What’s the role of referral to occupational therapists and hand therapists’ They’re an important part of the multidisciplinary team. Not every patient needs to see every member of the multidisciplinary team. You target it to individuals. People with a lot of hand inflammation, splinting can help, hand exercises can help. An occupational therapist is very important for helping with activities of daily living and jointprotection strategies. That’s where you start to have problems with access to services for a lot of the multidisciplinary. Although we say they should have it, not everyone has access to that.
Totally tangentially, one shouldn’t forget the feet in rheumatoid. The feet are sometimes to patients the most important part of them. That’s part of what an occupational therapist or podiatrist can help with. We’ve covered flaxseed oil and preparation. We’re talking here about any omega3 preparation that gives you 3g a day. LYN Yes. You’re looking for the dose of DHA and EPA. LYN Yes. We talked about hand rehab, which was a question also from New South Wales. The extent to which we should worry about the kidneys in RA.
Very unusual for the kidneys to be involved in the rheumatoid process. But it does happen that you can get glomerulonephritis. But that’s unusual. You’re thinking more of vasculitis or lupus with that. Some of the drugs can affect the kidneys, but that was more the oldfashioned ones gold and penicillamine. NORMAN And the nonsteroidals. And nonsteroidals. The ones we use now don’t have that much impact on the kidneys. It’s been a very informative program. What are your takeaway messages, Louise It’s important to remember that patients need to understand about their illness.
Try and get that balance between rest and exercise and try and develop that healthy respect for the illness whereby they take it sufficiently seriously but not to the degree to which they’re frightened or worried about longterm. NORMAN Christine Early diagnosis is important, that we have people referred in quickly. NORMAN Weeks, not months Yes, exactly. I’d support that. Getting onto diseasemodifying agents early is important, and linking in with your rheumatologist as early as possible. RA is uncommon, but it’s important to pick it up as early as one can.
Get a hold of the guideline, and don’t use it as a doorstop. I hope you’ve enjoyed this program on the new clinical guideline on diagnosis and management of early rheumatoid arthritis. Thanks to the Department of Health and Ageing for making the program possible. Thanks to you in such large numbers for attending and asking questions. If you’re interested in obtaining more information, there are a number of resources available, including links to the guideline, on the Rural Health Education Foundation’s website Don’t forget to complete and send in your evaluation forms.