Rheumatoid arthritis: the role of early intervention and self-management Diane Home and Maggie Carr Diane Home i: 4 Rhewmatlegy Nine Consultant, Wist Middlesex University Hospital and Mt Caneultant Nurse, Aa ind and S1 Pater Hospital hheumatois arthritis (RA) affects approsimately 10000 people im England and ie estimated that 26000 new cases are diagnosed each year (National Audi Office (NAO), 21486), The peak age of onset fe becween 40 and 60 years of age, with women bein times more likely to develop the condition (King’ Fund, 21418), A is an snlammnatory ateo-inmame disease sehich typically affects the small joins in the hands and feet. Te can ako affect any synovial joine ab well as having systemic ‘manifestations for example in the heat, hangs and skin es 2 chronic, progresve, potentially destructive dicate which ‘causes pain, stifness and fatigue as well as limiting mobility and joint function, RA. reduces life expectancy in severe cases by between 6-10 years (Pincus, 1993) ether through co-morbidity such as cardiovascular disease or teatment related adverse effects, Ie can affect al aspects of the persons life including their roles, retiomsbips and independence (Young etal 2000; Lempp et al. 2 A survey by the National Rheumatoid Arthritis Society (NRAS) found the IRA significantly curtailed an individual’ work life (NRAS, 2007), Studies show that after 5 years, 22 ‘of those in employment atthe time of their diagnosis were no longer working and this increased 10 40% at 10 years (Barret tal, 2000;Young et al, 2002)-Therefore, RA is cost- ly both to the indival and society: the National Fnstate snce (NICE) have estimated the total cost to the UK economy at between £3.8 and £473 billion per year (NICE, 2000), Health care cons alone tay reach [560 milion per annum with che majority spent in the acute sector (NAO, 2008), ABSTRACT 2009 has seen the publication ofa numberof key documents relating to the care of people with rheumatoid arthritis (RA). The Nationa Institute of Health and Cinical Excollonce issued guidance on the menagomont of RA in adults wile the King’s Fund and National Audit Office have reported on the services that are available for people with RA. This paper will provide ‘an overview ofthese reports and their implications for primary cere. The role of early identification, referral and diagnosis willbe explained as well, ‘as the treatment options available, The role of soltmanagement and how ‘community nurses can facilitate selt-management will be discussed, KEY WORDS Rheumatoid arthritis » NICE + Self-management » Early intervention foe Health and Clinical Excel 432 gle Can & a Rheumatol Recent guidance There have heen thse key pubcatinuria 2099 which hve provided guidance and information related co the care of people with RA Faary 2009: Penpons of patcs ind pes Find, Futives Group + February 2009: Rhewmalid arthritic The manage ibis cae. A Consultancy Report by the King the Rhesana theumloid aris in as (NICE, 2008) July 2009 Sonics for people with eeunatoid arthritis National Ant Office (NAO, 2009), Three messages emerged fom the King Fund report if there was an + Patients and protesionals perceived unacceptably wide variation in the level and quality of care available + The role of primary care clinicians could be enhanced to censane rapid refer for specialist sessment and support for ongoing; management and sreatmient of people with RA + Lo age Was perceived co be lacking. rm specialist care to enable patients to self man- Recommendations for action were identified that would improve care in ehree area: nical contact with the NHS, specialise intervention and ongoing eare (Tile 1).They also commented that more specialise and ongoing care should Severity of ymptons Unvelentingly destructive Relapsing and reiting q Te Figure 1. Possible trajectories for rheumatajd ayshritis (NAO, 2009) British Journal of Community Nursing, Vol 14, No 10Initial contact with NHS Improvementin knowiedge and competence of primary care teams in recognizing early sighs and symptoms of roumatoid arthritis Rapid referral to and availabilty of specialist care to support early diagnosis and initiation of treatment {Ineroased information forthe patient explaining the services availabe and treatment pathways to support se management Specialist intervention avoid a postcode loitery Variations in the quality and accessibility of spo ist care need tobe addressed to ‘Multciscipinary input should be available Improved communication about the pa secondary care Intoprating pathways and guidelines into development of futur nts trestment botveen primary and Ongoing care Q Improvement be available out of the hospital setting, which isin line with the current government agenda for care closer to home Department of Health, 2006). However, while patients asserted that they wanted care more locally they did not ‘want to lowe ongoing access to specialist clinical knowledge and shils during the transition of developing services away fiom the acute hospital setting. In February 2009, NICE issued guidelines on the Management of Rheumatoid Anhrtis in Adults The key pri bites for implementation by: loca commisioners and providers are detailed in Table 2 (NICE, 2009), The most recent guidance to be published was presented in the NAO report, Series jor People with Rlcwnatid Arthris (NAO, 2008), Ie concluded that too. few people were presenting or being diagnosed or seated quickly enough, The report identiied that while initially. more expensive here cond be long-term cost savings t0 the NHS and wider economy if patients had earlice access to specials treatment and i services were better coordinated at a local level. For individuals there would be improve ments in their quality of life and for those of working age they would have more chance of remaining in work. Treatment for RA Evidence suggests chat adopting an aggresive approach 16 suppressing the disse process in RA is best practice in controlling the cisease (Luqmani et al, 2006; NICE, 2009). This involves the use of disease-modlfying anti- theumatic drugs (DMARDs), corticosteroids, biologic cleugs, non-steroidal ant-inflammatory drugs (NSAIDs) and analgesics, DMARDs Ie is recommended that treatment with DMARDS should ideally within 3 months of the onset of persistent symptoms of RA in order to con trol the diseise (NICE, 2009). Methotrexate taken once ‘weekly (oral or subcutaneous) is now the most widely used DMARD in the UK, followed by sulfazine and lef nnomide. Wo or more of these drugs should be combined ase suppresion ifthe be initiated a soon as possi tn order to bring about effective dis British Journal of Community Nursing Vol 14, No 10 Develop clear pathways for pationts experiencing a flare-up of disease activiy ‘quality of care and monitoring of co-morbidities disease remains active with one DMARD (Luguani t al 2006; NICE 048). All of these treatments require regular g oF blood tests (and for some drugs, monitoring ‘of blood pressure, urinalysis and weight) in onder to iden tify and manage any adverse effects or toxicity a an early stage (Chakravarty etal, 2008). Corticosteroids . Corticosteroids such as oral prednisolone and intramus- are used alongside DMARDs as they work quickly and can bridge the gap while waitin for DMARDs to take effect, IM depomedrone isa ae I rearment for managing fares of disease activity and cular (IM) depomedron intra-articular injections of corticosteroids are effective at suppressing inflammation in individual joints (Laggan et 12006) Ie is inyportane cha the risk: bene corticosteroids is comsides sd and that they are wsed as a short-term treatment. Supplementation seth calcium and vitamin D should be considered at an ealy st eto prevent the development of oseeopoross Biologic treatments NICE have approved four biologic medications for the trearment of RA (NICE, 20073; 2007b). Adalimumab, etanercept and infliximab block the action of tumour nnectosis fietor alpha (TNFa). TNFa is an important pro-inflammatory mesienger or cytokine which, when blocked, can prevent messages passing along the inflamma tory pathway. Adabimumab and etanercepe are subewtane fous and ean be self-administered while infliximab is given ingavenously, Ritwximab is also intravenous and works by depleting B cells. NICE have hid out eligibiliey criteria for these eatments which include the patient having active disease despite despite 0 conventional DMARDs at maxim tolerated doses, NSAIDs and analgesics These medications are used «0 provide control of pain and stiffnes. Examples of NSAIDs include naproxen, diclofenac and ibuprofen. Commonly sed analgesics include paracetamol, co-dydramol and tramadol 433Table 2. NICE Guidance on mi: Pee cr ee Referral for specialist treatment = Anyone with suspected persistont synovitis of undetermined cause * Urgent referral if any ofthe following present: “Tho small joints of the hands and feet are affected “> More than one joint is affected “There has bean 3 dolay of 3 months or longer between onset of symptoms and st Disease-moditying and iological drugs (DMARDs) ing medical advice * Offer combination DMARDs plus corticosteroids as first-line treatment in newly diagnosed rheumatoid arthritis (RA), ideally within 3 months of onset of persistent symptoms * If combination is not appropriate rapid esc ion ofa single DMARD to clinically effective dose + Once satisfactory disease control has been achieved, cautiously reduce the drug dose toa level that maintains disease control ‘Monitoring disease + Monthly montoring of aspects of disease actvty in people with recent-onset active RA, eg C-rectve protein (CRP or a composite score of disease activity, 0. DASZ8 ‘The multidisciplinary team (MOT) * People with RA should have access to a named member of the MDT who is responsible for coordinating their care, Implications for primary care ‘Alef tis publican Stench wed Gober nce rallaad fnterendons this appsich'Ss-noprthe- corneas of tmgement of RAL Evitence’chows tht the eatir teratnent is initiated the betes. Convene tity Wh ateactacneg intr sie ihe join damage (Finckh etal, 2006; rich, 2008) which leas to poorer outcomes and inreseddisbliy: However, aloes) ery esi seep ila die Vatepisech bly AONE people ere rool wtnrtnoliie cbs of syonpona onset as recamamended by NICE (NAO, 2008; NICE, 2008), Delays in sarting. teatmenit ae wo-fole tien niaynot vac cecil evn poeta depen tut of tarpttt til ey Se bearable hnave been identified, in some eases a long as 3 years (Kumar 1007: King’s Fund, 2009). Between 50-75% of people delay seeking medical help for over 3 months and 20% delay for a year oF more (NAO, 2009). On average a person wists the GP four times prior t refertal and 18% vist more than ight times (NAO, 2009)."There are therefore issues relating to both general public and professional awareness about RA, its carly manifestations and the need not to delay in scck- spt. Ie is imperative that clini cians in the front line have the opportunity to update © knowledge and competences in relation to RA identifica tion, diagnosis and management (King Fund, 2009), The NAO report acknowledges that diagnosis can be dificult ing medical and specialise and most GPs will see a new presentation less than once per year (NAO, 2000). The NICE guideline defines those patients who should be referred for specialist opinion; these are outlined in Tile 2 (NICE, 2009) In addition to their role in the carly identification of RA, primary care health professionals may become more wolved in the ongoing, care of people with RA as changes to the way services are commissioned and delivered are ‘made (DH, 2006; 2009), However the NAO report identi fied that currently there is a lack of integration beeween primary and secondary care with lide impetus to change the way services are configured. They recommend thae the number of people in a population with RA, current service provision and finding arringements need to he identified in onder to commission care ¢o meet local need (NAO, 2009), ‘The DH¥ 18 week commissioning pathway for RA (DH, 2009h) takes account af recent mecommencdarions (Kini Fund, 2009) and will proside a vital resource for commis= sioners of rheumatology services 38 well a clinicians under= taking service redesign ‘The NICE guideline on RA suggests that few appoint- iments should be ata frequency and location suitable to the individuals need (NICE, 2009).(The guidelines also recom- ‘mend the adoption of an annual review in RA, aspects of which may be undertaken in primary care, eg checking, for co-morbidities such as depression, hypertension and ischaemic heart disease This is particulaely important as RA isan independent risk fictor for developing. cardiovascular 200; Lugmani etal, 2006). Health promotion such as advice on dict, weight reduction, and stopping smoking is essential. Smoking is a risk factor for the development of RA (Symmons et al, 1997). Theee is ako evidence to suggest that thote patients who continue to disease (Goodson, et al, smoke after diagnoss are more likely to develop severe joine disease and extra-articular manifestations sich as vasculitis and nodules (Saag et al, 1997), Self-management cerncteyaane elisa Saeed ae The individual's ability (© manage the symptoms, 4 cal contesuences and lifestyle changes inherent in living with a long term (Barlow, 2002). nent, physical and psycho RA is unpredictable in its nature and course self ms ment skills are vital in helping: people to cope wi Impact of their condition and to be able to make informed choices about treatment options. The NAO audit explored