Early Rheumatoid Arthritis: Clinical Guideline for Diagnosis and Management



hello I'm Norman Swan welcome to this program on the clinical guideline for diagnosis and management of early rheumatoid arthritis rheumatoid arthritis as you well know is a chronic debilitating disease which may last a lifetime barely 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 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 available in the rural health education foundation's website our atf dot-com today you know I'll introduce our panel to you john bennett is a general practitioner at the University Health Service the University of Queensland and was there a member of the College of GPs working group for the guideline welcome John Thank You Norman thank you in March is a Rheumatologist a role North Shore Hospital in the University of Sydney welcome Lyn Lyn was also a member of the guideline working group Christine rotala is a community health nurse in rheumatology working in the Albany Rheumatology clinic in Western Australia welcome Christine thank you and the pretty unique species the community Rheumatology nurse to Western Australia it doesn't happen anywhere else in Australia but perhaps we'll find out it should give its hope and last and certainly not least is Louise sharp who's associate professor and director of Clinical Research in the School of Psychology at the University of Sydney welcome Louise and Louise has a strong interest in rheumatoid arthritis and similar diseases well to start let's go and hear from four women from Western Australia Liz and Terri and Jill about their experiences of having early RA 1983 was quite a stressful year for me but I felt that I was a bit overweight and I was doing an exercise program at home and each morning I would wake up very sore and stiff and think or how unfit I am so I pushed myself until I was really unable to sleep unable to function very well at all I couldn't get out of bed a lot of the times I was overwhelmed I'm overwhelming fatigue just really felt like I had a bad flu all the time like my body felt like I had an extreme like the worst flu you've ever had it was getting worse and worse I was finding it hard to get down to the bus stop to get to work to do those sorts of things yeah definitely it was depressed I really didn't want to do much just sort of wanted to hide away from everyone I wasn't really my normal self at all no I was afraid and you know pretty unhappy it was doing my head in I was saying to my daughter to 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 lint whinging again she's got the hypochondriac hat on you know and the one of the problems with early rheumatoid arthritis is the pain moves from joint to joint so one day it might be an arrest another day in an ankle and another day in an elbow and a shoulder so I began to feel a bit hard to convey a key for stories of early rheumatoid arthritis from Western Australia I'm not sure that today we're going to find that there's level 1 evidence for retail therapy for rheumatoid arthritis as one of our is one of our respondents there was telling us but John how typical those stories very very typical it's interesting how each one of them I think of that file had a very strong psychological element of a suffering that went beyond the physical we weren't hearing much about joint problems all the patients don't tell you that their CRP is raised in their joints as well they tell you all the other things that matter to them the fatigue and the and just the the overwhelming systemic effect of the disease and I think that's the cytokines of inflammation but they don't tell you those words dominant is that psychological element louise well certainly when people develop rheumatoid arthritis there's good evidence that about one in five and in one time will be depressed of clinical magnitude and certainly we found in some of our early research looking at earlier arthritis that that actually increases in the early phase of the illness so that if you don't give people help and support and help to manage it that you know the symptoms are so all-encompassing and systemic as as well as the pain which really does get people down and then as the stories themselves were saying starts to create a vicious cycle where they then find it very difficult to to do the things that they need to do to actually manage the illness better and is the treatment of the depression the treatment of the illness or the treatment of the depression well if the depression in this instance is as a response to the illness then actually if you help people to learn to take some control over their illness and to manage it better what you find is that the symptoms of the depression do actually lift and you can use some very good strategies that have been used in the treatment of depression outside of ill health but focus it towards the illness and actually the outcomes can be very good so Christine we're going to be talking about your early detection and quite active management of somebody with early rheumatoid arthritis for success how important is it to actually I mean it sounds like a Dorothea Dix urban and you know it's easy to say well very important you see the whole patient but really how Borden is it it is extremely important to see the whole patient and not just the swollen joints if they if you can actually help people to do well with their emotional that the emotional side of their condition as well as functional staff then they do do so much better and what sort of what do people tell you with the retire that borrow that bothers them the most because they've been diagnosed with a chronic illness by a serious one it's probably two things that they worry about and one is fatigue they're overwhelming fatigue that they experience and the other one is the introduction of drugs that they have never had seen the like of before and it's really important to discuss the drugs with them so that they do understand they need to take them and how they work and that they do need to have follow-up blood tests and so on to monitor how they're going how important what's the evidence Lin the 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 it's the right thing to do in terms of improving outcomes improving quality of life preventing the joint damage and even improving mortality or lengthening life because severe rheumatoid reduces life expectancy and with the drug for heart disease as much as anything yes yes yeah and and particularly in males probably lowers life expectancy by at least five years so treatment early helps to improve that I've heard John rheumatologists say that the flail joints the owner deviation those horrible hands is a thing of the past you don't see that so much anymore apart from people who may be really older who've had rheumatoid for a long time but for modern treatment you don't see that anymore is that your experience well I guess by that true I mean it's a newer drug certainly offered much greater promise then we've have seen before so hopefully they will become much more a thing of the past what figures are we seeing here Lin I mean how common is I here I mean my understanding is it's common than people think yes yeah well 2 to 3 percent of Australians in national health surveys think they have ruined to arthritis maybe it's a bit less than that so at least 1% of the population that has rheumatoid arthritis and in terms of new cases even though the incidence is declining around the world probably at least a thousand new cases in Australia based on our population every year will have a range of severity of rheumatoid arthritis but at least a thousand new cases every year has have a patient in their practice yes most GPS will come across it I guess not every day as we've are you seeing now that it's common or on an instance basis than type 1 diabetes yes yes it's as more common than that and more common than multiple sclerosis more common than other things that attract a lot more attention at times I think rheumatoid arthritis arthritis has been something well everyone gets that we can't do anything about it but clearly that's not the case with rheumatoid arthritis now I've heard some say that the window of opportunity here is six weeks that's what we're recommending and the evidence the earlier you get on top of it the earlier diagnosed that the early you treated 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 and you might have already had erosions by that time and joint damage it's a pretty tight rope to put GPS on for diagnosis John it's difficult and this we're saying they you know it is an uncommon disorder but hopefully is an opportunity to pick it up early and to make a difference to improve people's lives Kristen you've done some work and with colleagues on instance and indigenous communities because this is a condition that people say is genetic related to HLA type how common is it in indigenous communities uh when I was looking at the research the research actually showed that they were in 2001 I think it was there were only 15 cases of rheumatoid arthritis in and the indigenous population in Far North Queensland and I'm talking to a colleague who actually visits the Kimberley as a Rheumatologist he has no cases of rheumatoid arthritis and the research actually showed that the majority of cases of rheumatoid arthritis in the indigenous population where parent was where parentage was mixed so of Caucasian or another ethnic group that carries the exam so what do we know about the causation there's definitely a genetic element there's no single gene that's been identified but they're people they're strong family history strong in dizygotic and monozygotic twins so definitely underlying genetics but something else triggers at an environmental trigger but often you don't find the trigger smoking increases risk probably through its ability to generate some ad antibodies to sit related peptide but smoking is a risk factor morbid obesity is a risk factor vitamin D levels vitamin D levels some association in terms of inflammation there's some interesting research going common areas has many Oh than it is hasn't been as strongly linked as some of the other conditions like multiple sclerosis but there's some trick we're looking into some treatments for that oral contraceptive pill might be protective pregnancy pregnancy usually the symptoms of rheumatoid about during pregnancy so that the pregnancy related hormones have an anti-inflammatory effect no evidence of pregnancy sort of increases or decreases your risk though blood transfusions might be a risk occasionally the immune systems triggered by vaccinations and immunizations but so the money the viral etiology possibly never been seen never been an Engel infective agent found them so you find it early what's your aim with treatment well the the aim of the rheumatologist or the name of the clinician is to put the disease into remission what remission is when you've got the disease and it's gone away but you still need drugs it's very rare that we cure the disease people talk about drug-free remission those may not be people with rheumatoid arthritis well a small percentage can go into drug-free 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 so remission is ESR CRP is zero or normal one CRP less than one ESR less than five the joint count swollen tender joints zero so if you've got some joint swelling you've still got some rheumatoid disease and to the patient though that means nothing and well it means something but it means their pains gone but it also means usually that their fatigue is under control so again the patient's looking for improved quality of life and and and energy levels back and that sort of thing but as a doctor we're looking to mainly see no erosions no joint damage but in order to get that you really have to have zero to a very low joint count and and normally inflammatory markers and there's always debate about these new biologicals people walk in the door saying you know can have my tanner cept or my rituximab or whatever is the latest one being advertised in the United States what is the role of these biological agents in the in the treatment they're very powerful and very useful agents in Australia we can have them for people who still have very severely active disease after they've failed two or three other disease modifying agents and and still yet still have active disease in that but but they have an important role but they're not without some potential for side effects as well so they need to be used appropriately yeah so what are John what just give us a sense we'll come to some case studies in the morning but it was a sense of what this new guideline tells you to do in terms of diagnosis because we are asking the GP to make the diagnosis before a Farrell aren't we yes as much as possible yep so what's what's the algorithm if you like it it falls into basic technical principles that one would take a history look for features that would be suggestive of arthritis so the classical symmetrical small joint disease fatigue stiffness that persists for some hour or more into the into the morning on wakening and then follow that up with certain blood tests ESR CRP is a marker of inflammation the time-honoured rheumatoid factor and the ADC CP if you were highly if you were suspecting rheumatoid they would be the mix of tests you'd go for in a directed way what's this anti-ccp Lin before we get to that though I don't I think we don't necessarily need the GP to make the diagnosis and if they're sitting waiting sometimes if you wait until you've got a definite diagnosis of rheumatoid arthritis it's too late because you've already got the rheumatoid factor and you might already have erosions already have joint damage so I think the key message that comes out of the guidelines an early referral even if those tests are negative is someone still got persistent swelling or symptoms in their joints refer on or seek additional advice because the joints should not persist in being swollen beyond sort of six to eight weeks because there's potential for joint damage so regardless of what the biochemistry yes but yes try to work up the diagnosis it but and clearly that saves time for the patient and and and for all the treating doctors but don't wait till you're totally convinced it's rheumatoid because it's often too late but Christine GP is watching this from rural and regional Australia I'll find out in a moment just what proportion of our audience is that are those they'd say look it can take me a year to get somebody into a Rheumatologist what do they do they were fear and in our particular instance we I can actually triage the referral so that people who have a referral that's indicating an inflammatory condition or where I'm a bit suspicious I can follow those people up I can talk to their GP and and make sure that they get in to see it's getting to be so the GP knows that there's a clinic in town does that happen anywhere else it's true yeah not not many other states or any other states have that luxury and I guess that it is a problem for GPS at times to get access to Rheumatology services but certainly the Australian mortality Association has a website people the public can look and see where rheumatologists are GPS can look not every rheumatologist is on that but if someone's in an area where they feel they can't get access to a Rheumatologist they should email contact the the or call the Australian Rheumatology Association Secretariat and we'll get them in touch with someone so then those women who said you know they had fatigue and they weren't talking about the joints perhaps implants the last lady speaking when the GP word was – if the GP used to take a fool you know just take this as fatigue but to actually ask the next questions because they might be thinking of gluten Interop a–they or thyroid it all might be a whole lot of things or they might be thinking of and but they do ask the questions about joints how 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 the last lady said it's sort of that palindromic rheumatism where it's all sore and painful and by the time they get to see the doctor it's actually gone that's a very common so now when when rheumatoid is first starting and the synovitis can be very subtle it might just be and particularly wrists and shoulders you don't even always see it but so it's sort of based on that morning stiffness and looking at for inflammatory markers doing some blood tests to sort of see if there's an Associated inflammation and yes of course you'll you'll occasionally see people who don't have much in the way of joint swelling have normally inflammatory markers but sort of go on to sort of damage their joints but they are the minority the majority will have some joint symptoms so just this anti-ccp is just so it's antibodies to certain elated peptide which is part of the cell nucleus one of the peptides it's probably just as sensitive as rheumatoid factor so if your rheumatoid factor is positive the CCP doesn't really help you make an additional diagnosis if you've got the clinical picture but it is more specific so rheumatoid factor can be positive in other things chronic infection just part of an aging phenomenon whereas CCP at this stage appears to be quite specific for rheumatoid but it's also a poor prognostic marker and particularly if you actually have rheumatoid factor positive end anti-ccp positive looking in early onset arthritis sometimes up to about 30-40 percent of an early polyarthritis will be gone in 12 months but if you've got both rheumatoid factor positive and CCP positive your chances of having erosive damaging rheumatoid arthritis at two years are very high it's sort of like a 90% predictive value that you will have a an erosive disease so they're quite strong prognostic markers very useful to help people realize in part of that education you know sort of knowing what why do I have to take all these drugs if you can show them some of that prognostic marker stuff then it means a little bit more to them that it's it is worth the trade-off it's of the potential for side effects and the things that they do worry about with their drugs it's worth taking that trade-off John what's the role the GP in all this we've alluded to this that we're expecting the GP to you know refer promptly maybe do some tests first so they're sure what else because if you take type 1 diabetes example most gp's run for the hills I go run for the hills local Children's Hospital takes the child away from you they like doing that I look I think it would fall into just again to consider the diagnosis it's uncommon but a people as Lin's been saying have some sort of persistent joint swelling and other symptoms that go with that with or without the test being positive or not you need to consider that diagnosis in the sort of longer term I guess then there's that role for GPS as they as they're doing so many chronic diseases just to help maintain the patient's through that help to coordinate key with the various health professionals who'd be involved Lin some people would argue that remission is no more erosions on your joint in your joints so it's in addition to what you've just said you stopped the disease in the joints dead is that what you're in for in your remission yeah that's the ideal that you see no no more damage in the joints x-ray yeah I guess is the crudest way to see erosions I think as time progresses and we and maybe MRI becomes cheaper and Doppler ultrasound there are a number of different that but at a moment really at the moment there research techniques but there are a number of different techniques to show very early changes in the joints and also you'd want to see that those changes were switched off yes and that that's remission because people who appear to be in clinical remission with that scenario I suggested with normal inflammatory markers and normal-looking joints on examination actually can still have ongoing inflammation how early do you think somebody I mean we're talking about rural Australia here where you know it's not easy to get allied health professionals but how early in an ideal world would someone like you Louise be brought in well certainly I mean our research suggests that the earlier that you intervene the better for people because I think what's really important is the time when people are least likely to do what's best for their own management is actually early on when they're just adjusting to illness and they're just adjusting to the idea that they have an illness and if you believe that you have an illness then you're not actually going to do the things that will actually help you to manage that illness and so part of needing to accept that you need to take medication that you need to actually develop a balance between rest and exercise and listen to your body that you need to have a domestic but realistic attitude about the future is really helpful in terms of how you manage it and in in my own studies one of the things that was shown is if you can get in certainly we we found in the first two years of illness that you can actually affect long-term outcomes so five years later you can actually show that people are are needing to use fewer healthcare resources because they have managed their illness well enough in the shorter term if you like that they actually become this disabled over time and that's just doing evidence-based therapy as a psychologist call intervene or therapy or interpreting and helping helping people to really try to change what they do to to respond to the illness if you like so that they don't become overactive on inflamed joints or at the same time don't sort of respond to the stiffness by inactivity but keep that foster that balance between rest and exercise and try and teach people skills to maintain that kind of optimistic attitude that protects them against depression let's try this though 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 and when John examines them they're slightly swollen tender and painful has developed over the last few months and tends to be worse in the morning and she's a smoker and she's got two kids both quite young and she's pretty tired especially in the afternoon which she puts down to all the running around with her children there's lots of tired moms out there there aren t it's winter there's a lot of people out there with sore aching joints yeah I I guess it's part of that challenge of that soup you see in general practice of trying to pick out the sort of bits that you should really be you know considering it's a it's a difficult difficult problem this one's you know sort of partly 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 there that you'd at least should be thinking that this woman has you know the potential for some more severe forms of arthritis so if you're following the guideline what do you what do you do is the GP well as has been said out there we've assumed with examiner we've confirmed that there's some joint swelling and in those areas as as listed a matter I think with that presentation of that time it would be reasonable to do the tests that we discussed before it would be a ESR CRP looking for evidence of inflammation and at the time wanted rheumatoid factor and an anti CCP what are you going to do if it's negative they're all negative I suppose it would be reasonable to institute some therapy I mean I suppose you'd be doing that in either sense because she's clearly clearly in pain it's clearly influencing her ability to function as she tells you that she's been to keep an eye on doesn't make any difference okay you could then I mean because she's she's younger to be certainly worth trying some anti-inflammatories see if that would help you know suggest some ibuprofen if there weren't any other reasons for her not to not to take that and see what that brought her in the short term but again that would be you know even just while you're waiting for the test you could do the two things concurrently see if he could bring us some relief while you got some further indications but the clear message here is you don't hang around no I bring her back soon after two weeks or something I guess it would depend upon her she was functioning safe she's so you can't wait for a month oh no there are several scenarios a few months are things they say ya know you would you would need to get her back it would depend what areas are CRP was for me in that sense sister how much sort of demonstrable evidence there was of inflammation if that was up you'd certainly want to get her to see somebody much more rapidly or nice tierod was liable to have an effect if it's rheumatoid then they'll help in early rheumatoid Ann and mild disease in for the early symptom control they don't have any the impact on the actual disease control and slowing erosion and slowing the disease but I think the alarm bells here with Lilia that you could quite easily dismiss her because it's a few months and the new baby and tired and and those sorts of things but their loan bills here that she's got joint swelling and it's my only slight but it is only always slight in early rheumatoid so I think the fact that that's persisted you can't really put that down to tiredness yes 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 that your decision making for her she might be thinking of you know more babies soon so that also influences what you might do but for that but nonsteroidals could help her a little bit but again you wouldn't really want to be waiting around too long perhaps you'd start the nonsteroidal start the tests and refer get organized the referral and sure if she's better by the time she's saying the Rheumatology she can cancel the appointment but the other thing I'd try with her would be some high dose omega-3 oil as well either as fish oil or flax seed oil because although that takes a little while that can be a good natural anti-inflammatory work almost as well as as the non-steroidal as we were talking about high doors we're talking about 15 mils of the oil depending on which oil that you use there's a number of different brands now there's a either 15 mils there's a one that you can take five mils so it's number of different brands or about sort of ten to twelve capsules but I think the important thing is to sort of to look up the actual dosage of the DHA and ndpa of the you need to you need probably three to four grams of actual DHA or epa OD a day which is quite a lot of omega-3 but and does take I guess three to four weeks at least to have its full anti-inflammatory effect there's a stopgap measure if you're all negative so how often does a woman like this turn up with negative tests and do they become positive over time well Rema type factor and CCP only have about an eighty sensitivity so there are up to 20 percent of people who have classic rheumatoid arthritis including damaging and eroding their joints who are never positive but it's very common scenario that they're negative in the first instance so in someone like Lily very common that they would be negative they would become positive over the over the the next 12 months or so unusual for the CRP and ESR to be totally normal very unusual but you occasionally see just very low levels but people still destroying their joint so I think it gets back again to the if you see some joint swelling no matter how slight if it's persisting then you know seek referral to to confirm that and if one is a Rheumatologist isn't available I mean I was talking to some rheumatologists the other day and in a Rheumatologist North Queensland said he's got a two-year wait to be seen I think all yes they might have two-year wait but I think all rheumatologists would if the patient's been worked up appropriately they get the call from the GP or rheumatologists will respond to that in some way or 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 you know what tests will I do what will I do while they're waiting to see you I've got this package on what alternatives should you be looking for as well what's the differential diagnosis here that you should be eliminating I suppose it would be right I mean a younger female again it would be reasonable if you're going to be ordering a set of chesty or ini and if that was positive they did the more specific things looking for lupus I guess with that number of joints I mean you wouldn't be thinking of things like gout and she's in the sort of wrong age and gender you know you'd be restoring aspiration have any rule she's got a swollen knee yeah you could you certainly have a look I would have to sort of depend upon ringing a sort of remand illogical colleague to see how to interpret the result but it could certainly be the be of assistance sure it is if there's a swollen joints Ingle sort of reasonably swollen joint it's always worth aspirating because it might be infected might there might be crystals there's no definitive diagnosis but sometimes you actually find the rheumatoid factor in the synovial fluid and you don't find it in the blood yet so early rheumatoid that can be positive the white cell count gives you some clues and it can be therapeutic at the same time you rheumatologist sort of just say get going on some DMARDs and just take us through what the non-biological the standard DMARDs are because they can be remarkably effective coming on they certainly can they certainly can the the I guess the gold standard and in fact what all the biologic agents have been compared to is methotrexate so we really put that up there as a gold standard but not every patient wants to take methotrexate in terms less toxic than a non-steroidal it is less toxic but one does have to limit alcohol intake and you have to be monitored and not everyone is in a position to be monitored or want to be monitored in terms of their monitoring blood tests not everyone wants to maintain healthy alcohol intake or no alcohol intake so there are some people want to become pregnant so there's something not a wait there's a number of people that you don't give me a prescribed methotrexate to and there's but and also now you've might just use mr. X aiders and mono therapies a single therapy but but there's a reasonable body of evidence that if you have more aggressive disease that you're better off with a combination of therapies that work in difficulty Laura's a Pyron yeah the the main three that you would use first up there are other ones available too and then used in the right doors judiciously gives you as good a result as adding a biological remission in terms of getting clinical remission and getting an early symptom control yes that's correct but if they aren't working within a sort of three to six months according to our guidelines then you could get on to a biologic and if you look very closely at what's happening at the joint level in the synovial level erosion level the rate of remission is probably greater if you can add in a biologic early as well but but by and large the majority of people get very good response too early and pretty aggressive therapy like treating to a target like really treating to get their CRP and ESR in the normal range get their joint count right down low and we've all sort of been brought up with the you know first do no harm and of course all these drugs have some side effects there's no such thing as a side effect free drug so there's that that trade-off as well that getting that right and but and the patients don't always want to what the side effects of the drugs to because they see it as arthritis and perhaps something that's not going to kill them but I think you know the the message with rheumatoid arthritis is that it's it's about getting in early and John the in terms of what might kill you it's like diabetes it's a heart attack is going to kill you or a stroke from the inflammation at what point the guidelines tell you to institute quite aggressive coronary risk factor reduction I mean I you would I mean my take on that is you'd actually see them in a high-risk group and you might you know you know in an equivalent sense I suppose treat them like they had diabetes you could be quite aggressive wanting to get there don't lift Lisa 32 year old woman with two children she fit that well hopefully not hopefully she doesn't have other factors except she's a smoke and you'd obviously be strongly into her about you know this is a very good time time to give up for a whole range of reason and does that help the symptoms not sure they I think don't think there's any evidence that it helps the symptoms but I mean people with rheumatoid arthritis get bad lung disease get bronchiectasis if they smoke as well as have their remember toward arthritis they are at higher risk so she should stop smoking for lots of reasons but the cardiovascular risk factor monitoring is critically important all the traditional respects are important but maintaining a normal CRP is probably important for the cardiovascular risk long-term as well so Christine how important is multidisciplinary care particularly a country tone for somebody with rheumatoid arthritis really extremely important ko vascular disease and the like are all slightly higher percentage in country and all areas and so if we if we've got rheumatoid arthritis added to that picture as well people then are at higher risk and so even in between when we get a referral of seeing the patient and they see the rheumatologist if they're a smoker or they're overweight we can actually do something about that we'll start to do something about that they may need some occupational therapy to help them with living daily living activities and psychologically Louise what would you be doing for Lisa well I mean I think the first thing that you'd be wanting to really talk to her about is about what the long-term prognosis is to try and help her to to not again be concerned inappropriately about the future but to take their illness seriously enough that she's motivated really to be trying to get that balance between rest and exercise that we talked about even at such a demanding time in her life where you know she perhaps has so much going on that the need to prioritize her health in these early stages is really really crucial I think for these patients she's breastfeeding how does that affect the try therapy well it can affect it quite civilly because all the the disease modifying agents you can get into the breast milk and so she would probably want to delay that or Thor trade-off again wait a little while or or or or even consider stopping breastfeeding if her disease is active enough the anti-inflammatories and steroids we'll all some will get into the breast milk so it's a matter of timing it for using the shortest acting anti-inflammatory and timing in terms of when you breastfeed I mean listening to Roberto just talking about rheumatoid arthritis they say prednisone is out you know the occasional intra-articular injection but they don't want people you know the ticket as a matter of pride that they don't have patients almost zero prescribing of prednisone and almost zero non-steroidals as well yeah it's it's certainly our aim to have people's disease controlled on disease-modifying agents alone that if you look at most rheumatoid patients long-standing patients a vast majority 40 50 % will be on some pregnant because it works so well and early regimens that treat to target with the combination therapies all have some component of the corticosteroid either as intra-articular multiple interarticularis killer or orally or intravenously so steroids work very very well they probably are also disease-modifying agents in terms of reducing erosion that's on but they yes it's very hard to get back off it so if they're very effective for controlling symptoms and if there is some sort of delay even though most rheumatologists do not like the stewards to be started before they've seen the patient sometimes you just have to but if you do start steroids you really need to have a withdrawal plan as well to see well is it gone yet or what's happening because there could be like shortening the wrong they certainly can and if you look at longevity now that's the trade-off so you might get disease modification early but the trade-off is that you get atherosclerosis and coronary heart disease and risk factors longer term so the surprises that's something about me that Trixie isn't as toxic as you think that's right I mean it's also got a potential for side effects and needs to be monitored but it's my cell count and somebody told me that a reduced white cell count is actually good news it shows it's working that's right if your luffa site counts down a bit then it means it's having some modification on the immune system yeah let's go to our third case study this is a 65 year old woman he's called gene presents to you John complaining of recurrent painful attacks in both knee joints it goes away for a few weeks and then comes back she's just borderline obese with the waist circumference of 90 centimeters she says she's tired has trouble sleeping at night she's been feeling a bit low for the last couple of months she's already taking ibuprofen and paracetamol from the chemist and it's not seeming to have much effect weren't we gonna do about gene yeah just close your eyes then he hasn't she said send her home you'd certainly think of that first wouldn't you that would be a very reasonable diagnosis female you know age she is I mean that's the current BMI she may have been heavier you know there's certainly respect as there for the for for the more common this which is a always a good sort of concept to go with first but she's been you know she's she's I mean does she have our I end depression I guess that's the you know the thing that might explain it it's a difficult one but that's what general practice is that often it's not a you know always quite clear card isn't it so it's easy just to send her home there for there are other clues here as well I don't know sure so so what questions should you be asking in your six minute consultation just to get beyond the obvious well I guess other other joints involved I mean they'd be maybe the ones that are most involved and she's focusing on those and obviously you know bring those to your attention first if they were people go away often have narrow painful hand joints I mean that's probably going to be more in a dive fingers rather than sight the base of her fingers or wrist so she you know evolved this little IP joint rather joint yeah yeah I thinking of the sorts of classic nodes we you see then you in your elderly aunt or something but yeah I mean certainly she had other other joints involved that would certainly make you think more strongly rheumatoid and maybe test for that at the initial consultation particularly she's had no response or at least she hasn't felt he's had adequate response from taking standard medications like paracetamol enantiomer cou here Linda's there's bilateral whereas osteoarthritis is usually one side worse than the other usually one side worse than the other in terms of its presentation but certainly if you're obese if no beast female is more at risk of getting bilateral neoui but she's had this sort of recurrent attacks she's got the joint swelling and yes 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 that could be pseudogout pyrophosphate crystals but you know persistent inflammation you'd be thinking other inflammatory you'd look for psoriasis is at a psoriatic arthritis so there's other differentials there but in in it's a slightly atypical presentation from rheumatoid you'd look for family history so she's got an aunt with okay so that there's that that family connection there so but 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 so and they often have a polymyalgia concept so looking a bit like polymyalgia rheumatica so a kid can trick you sometimes but she's already tried the anti-inflammatories and and the mild inflammation of oay would usually respond to the anti-inflammatories and she's not responding and she's still got inflammation he's got these systemic things that fatigue that the the patient's has this is the sort of person who gets missed isn't it it is and they're the sort of person I guess that when we're doing the triage we just need to follow up a bit closer go back and ask more questions and they might have not have indicated something to the GP thinking it's unimportant but in spending a little more time you find out something else that triggers them being referred a little earlier it could save quite considerable disability of in your own life I'm just going to ask another poor question now before we come back to this discussion what access do you have to a Rheumatologist do you have a resident room at a local rheumatologist you're visiting rheumatologist do a telehealth clinic you get foreign support or no support at all be really interested to know what your answers to that are let's just go through some questions that are coming in one from an Anderson Queensland can having a blood transfusion or trigger rheumatoid there's certainly epidemiological evidence that people who develop rheumatoid have an increased chance of having had a blood transfusion in in the past so yes is the answer to that but in terms of absolute risk of everyone having a rheumatoid having rheumatoid after and transfusion I'm not sure about the exact level I think you'd need a genetic tendency as well John how often a question for a physiotherapist in New South Wales how often should patients with RA be refused by the general practitioner again well quite back to the guidelines that have been produced you'd think at least three or four times a year would be reasonable but it would depend on their clinical state and what other things were happening for a question where a GP in South Australia shoot a GP be prescribing combination therapy I would be a bit reluctant unless the GP was very knowledgeable and had other patients so with rheumatoid arthritis for a GP to start there because there really isn't an exact number of joints or an exact a level of ESR CRP that I would always prescribe combination therapy so I would be reluctant to recommend that a GP did that I would I would you know prefer that that was done in consultation with the rheumatologist and was adjusting that therapy tricky it can be they each have their own different side effects combinations of the methotrexate and size of power and have a little bit more effect on the liver so there it is a juggle in terms of which one are you ramp up or down and and which ones to sort of bring in at different times but yeah Christine people often tell you things they won't tell the doctor GP and neuro New South Wales asks many patients are reluctant to take medications such as methotrexate earlier in our early inari how would you convince them that's a good thing what do you say to them when they tell you I really don't want to take this cancer drug probably the most common thing that happens when people hear they're going to take methotrexate methotrexate is that they listen to everybody around them who says it's toxic don't take it so the way I use education is to actually put it alongside the doses that might be used in in oncology and 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 but also educate them about the side effects and the importance of having it would convince me if you told me it was less toxic than ibuprofen that's a pretty dramatic statistic very setting for me in my experience most of the time when patients don't adhere well to their medications it's because they have real misunderstandings and other medications that they're taking and so I think it can be very effective just to ask the patient what their concerns about taking them and nine times out of ten you'll find that their concerns perhaps are based on misinformation or something as you say that they've been told by somebody else but you need a healthy respect for the drug so you want them to have some concern you want them have enough concern to monitor it and take it properly but not too much concerns that then they miss out on effective therapies because they do and particularly in that early phase if you said their arms confused overwhelmed by everything else it's happening and that's right when they can't make the decision and it's the same balance that you need them to have about the disease you know you need them to have a healthy respect for it but you have a fear of it yeah what question from Janet in the greater area greater Western Area Health Service which I see South Wales what's the earliest diagnosed stage for rheumatoid arthritis well I think you've had the program on the juvenile idiopathic arthritis that in that spectrum of juvenile arthritis they're a small subset who get a rheumatoid like illness even as babies and but the mother's rash it's been a different spectrum and I guess then you see some teenage girls in particular who have classic rheumatoid arthritis but that's a very small percentage of juvenile but but it can occur at any age and it can start at any age later in life as well it's unusual to see it over sort of 70 or 80 is starting but it does happen question from Elizabeth who's in New South Wales what doors of fish oil please specifically DHA or two for gene the the combination of actually the DHA and EPA combined at least three grams yeah so you really need to look at the individual preparations to see how much they all say there are thousand milligrams of Omega of fish oil but you need to look in that and sort of work out and it's cheaper to do it by oil then it's liquid oil yes and Elizabeth also asks is there a raw power suitable at any stage yes we we say for any pain management rate for any chronic pain management paracetamol should be first-line it's a very good adjunct to in that sort of first setting with a paracetamol and perhaps some nonsteroidals and at any time people have a bit of a flair sometimes in fact just a little bit of additional analgesia is all that's needed to get a little bit better back at control so yes it does have a wrong so when to refer what does the guidelines they were when to refer to a Rheumatologist John different some like James case James case well she's had symptoms now for some time so as we sort of discussed there you'd be probably doing tests and treat and refer probably in a very tight tight timeframe say within a week or two depending upon the results of those initial tests and that's agreed yes I agree and Jean would be one that you would want to drain the knee take that fluid off maybe even put corticosteroid in unfortunately the item numbers gone now so she will have to pay for that there's no Medicare item for that but that would be therapeutic for her she'd almost certainly get symptom relief from putting some corticosteroid in and doing that earlier and then that might in fact mean you need to refer to the dermatologist to do that for you so Christine was there all of exercise weight loss those sorts of lifestyle interventions the role really comes probably after after treatments being instituted if people are suffering they're in a lot of pain they feel very fatigued then exercise is probably fairly difficult you can talk to them about it for sure nutrition is important and a good nutrition when they're unwell what all of the time but particularly when they're unwell but even in the setting of the inflamed joints a lot of people think and it's getting back to your point of the right balance a lot of people think they shouldn't move the swollen painful joint they in fact some movement is how you get rid of the toxins and you know how it actually improves mobility and very hard to damage the joint with exercise very hard yeah so if you actually want to push it a little bit you're not going to do yourself any might really do any harm it might flare up a bit and be a bit more painful but some some range even in acute inflammation some gentle range of movements maintenance with isometric exercises of course muscles around an inflamed joint waste very quickly and someone like Jean sort of being older and maybe God the poor quad strength already she doesn't do any walking doesn't do anything then she puts it herself at risk of lots of other things yeah John what are the guidelines they have a complementary medicines well it depends again we've been talking about then I basically fish oil source or therapy some people maybe that is the instruments randomized control trial well yeah 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 actually greatly helpful at any harm yes and I knew you'd ask me that and you're much better on the name than that what's was it was a trip to probably finish down no I mean I guess the key point about this is that some things is that so the the particular one is a Chinese herb the key thing for a GP is to know all the things that their patients are taking because they're all taking something and and some of them well they're not harmful but they're not particularly useful either so they're spending their money person probably doesn't have any role in rheumatoid arthritis it's really the omega-3 which is fish oil flaxseed oil and the ones that have been have been proven and will help you depression at the same time yes yeah let's go to our next case study which centers on a self-management and education program run by arthritis Western Australia in Perth the course is the 6-week program that covers a range of topics of interest to people with inflammatory rheumatoid arthritis their partners and support people we develop the rheumatoid arthritis education program because we had been running generic arthritis programs and also the Stanford chronic diseases server management program and it was apparent that we weren't meeting the needs of the people with inflammatory arthritis we did a needs assessment and asked people what they wanted and we developed a program around that what we do is we run a six-week program because it's been documented that you need at least six weeks to try to change people's behavior we teach them exercises that they can do and encourage them to do so we talked about depression and the emotional loss that comes with having a chronic disease we talked about medications we spend a whole session on medications at different times of medications and how in which sequence they they given and we talked about blood tests what they mean and why they have them done we talk about relaxation we teach them different relaxation techniques because it's important that they know learned some relaxation and learn some stress management we talked about osteoporosis briefly because they're much more it was again in osteoporosis and we also encourage them to bring along partners and significant others because one of the issues they seem to have these problems you know telling people about this disease and how they cope with it often you don't talk openly when you're amongst friends or family or anybody about the illness because they're sick and tired of hearing about it and you don't want to bore them but when you are in a group like that with like-minded people and sharing the experience you realize I'm very lucky and there are others and far worse off than I am and you know it's just a support for each other within that group framework which is I felt 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 specialists they have got to be diagnosed with either rheumatoid arthritis or one of the inflammatory arthritis sprints and sciatic arthritis or Ciera negative arthritis we do try to be absolutely sure that we get in the right sort of people that we can't she help people about she got to learn to manage their disease otherwise it will manage them I've been going along just doing as I was told like yes so no sir three bags full sir and 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 and suddenly I feel tremendous because I'm learning so much I've got a great sense of empowerment and it was to do with I am the best person to know about my disease although I need to work within a team so a team of health providers but I am the leader because it is my illness I own it and I must manage it and I become the expert and that was such a liberating thought for me now release program in some of the rural areas who understand Arcanine we run ten car ghuli a management where we've got Rheumatology nurses and we train in other half professionals at the moment 200 in the eastern states it's going to be run in Victoria and Queensland and New South Wales because I'm so alone with it I didn't know anybody with rheumatoid arthritis and I felt that I was the only person walking around or limping around the only person that took takes two hours to do the dishes the only person had to give up their job just so many things I can't do cross the road camel across the road and have a cup of coffee no I can't I wanted to know that the rather people going through that with me that was a primarily 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 then I had learned in the previous 28 years of my illness getting people back to some of the elderly ones to play in balls and and just you know let 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 is over you know I thought oh you're probably gonna be in a wheelchair you know you're gonna be you're not gonna be able to do anything someone's gonna have to look after you you know but it doesn't have to be like that and I think they teach you that in the course that you know it's not you can be your own power of your own destiny with the disease and hopefully it doesn't have to be that difficult you know I've taken up exercise programs such as the touchy I do a lot more swimming than I used to to try and keep my fitness levels and everything going but it 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 and for many years I did suffer quite severely with depression and I was actually on medication for it but since doing the course and understanding the illness I have found other ways of overcoming the depression and I no longer need to take medication for the depression so it's when I say empowerment I really do mean empowerment that 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 self-management in education program in Western Australia is it widely applicable people have criticized these programs Christine we're saying we it's fantastic for middle-class well-educated people who've got time to spend six weeks but in fact it's not and they're expensive and there's not broadly applicable to the general community I think a lot of the generic programs are a bit like that but certainly in in my experience with this particular program patients are actually really interested in learning more about their condition and what your thing is that it's really got to be highly specific to the problem yes I think so and this particular program which is all from Western Australia is disease specific people learn about their condition they learn about all the things that go with their condition so their drugs their blood tests they learn about communication with how to work with their health and healthcare team and who is that sense of control can be an antidepressant in its own right yeah absolutely and I mean I think you know it's it's very important that you can see how people get into a vicious cycle when they've got an illness they feel like they can't move and they become less active and they become more depressed and then it's harder to motivate themselves to do anything and when they have to start off don't have to take such small steps that they feel it's almost not even worthwhile and I think programs like this I think the real key to the success of programs is when they get people to actually change what they're doing because if you can get people to change what they're doing then often you can have a much greater effect on behavior some of the old education programs didn't translate the knowledge which is absolutely essential but probably not sufficient to affect behaviour change we want is the Royal self management then because I mean it's actually very difficult to prove sort of using conventional outcome measures that it makes a difference very difficult to prove that like how to improve someone feeling more empowered I mean how do you measure empowerment how do you measure the change how do you prove that those people take their medications better in fact maybe they don't always take the munication as better they just feel better about managing their disease themselves so by traditional outcome measures it's hard to show that that's beneficial and that's why they they get criticised but clearly it's such an important part of any crime disease and there's certain generic elements to all chronic disease management but I think it is quite important that it's also tailored and specific to the particular disease and the particular drugs and and and knowledge does help compliance and adherence with therapy just some quick questions because we're nearly out of time any role in physiotherapy for heat in rheumatoid arthritis yes yes yes I think in an inflamed joint it's certainly that early morning stiffness a warm shower the the the bad hands in a warm basin of water good old-fashioned therapy of wax therapy so heat helps inflamed joints as does ice in some circumstances so that's a difficult one it's an individual patient thing that an acutely swollen joint not so much hands but an acutely swollen knee or ankle or it can respond to ice as well so question from Veronica and Castlemaine and Victoria for patients who've avoided medications such as methotrexate for say 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 because remote as you mentioned at the beginning it can be a lifelong in fact it mostly is a lifelong disease and people can still have quite severe exacerbations and inflammation when they appear to have sort of so-called burnt out or damaged joints so yes people with chronic damage are still getting a benefit from the biologics if they have ongoing inflammation Daniel from the University of Wollongong I think we've got this round the wrong way you mentioned the methotrexate was more harmful than NSAIDs in fact what we said was it was less harmful than NSAIDs I was wondering if you could elaborate on that it's Daniels question let's assume that you've got it wrong we're talking about less harmful than NSAIDs yes this data comes from epidemiological studies because there hasn't been a randomized control trial that compares the two and clearly they're working in different ways nonsteroidals hadn't offered no benefit for disease modification whereas methotrexate will help put people in remission and and control their disease but in terms of the long term effects of the GI risk and the cardiovascular risk from nonsteroidals as people get older those risks are higher than the risk of method seit and the really the the long-term risk of methotrexate is liver fibrosis but that risk appears to be quite a bit lower than we used to worry about the people on methotrexate for many years as long as that's monitored as long as they keep their alcohol to the reasonable controlled level let two or less drinks and two alcohol-free nights a week following the guidelines the long-term risk of mr. X though is very low may be an increased risk of skin cancer in Australia but we have to be alert for that anyway question two questions from Keith from the Victorian physio that from Victorians physiotherapy services can the parvovirus trigger RA the Snipe Machine syndrome you can get a very classic polyarthritis following a parvovirus infection you can also get transient rheumatoid factor positivity but mostly the polyarthritis will be gone within sort of four four months occasionally you see people where it persists as a chronic rheumatoid arthritis after that and Keith also asks how often or when should an actually be taken of affected joints once the diagnosis of rheumatoid made the baseline soon at the time of commencing the DMARDs it's useful to have a baseline x-ray of your hands and feet to identify whether you have erosions or not it's not really worth repeating that under sort of one to two years and you would at a time perhaps when you were thinking things were in remission after a couple of years just so to make sure with you with your x-ray question from Roy from in-service therapy service a new south wales what's the role of referral to occupational therapists and hand therapists they're important part of the multidisciplinary team that not every patient needs to see every member of the multidisciplinary team you're targeted to the individuals so people with a lot of hand in inflammation spenting can help hand exercises can help so an occupational therapists very important for helping with activities of daily living joint protection strategies it's all part of the that's where you start to have problems with access though in terms of the access to services for a lot of the multidisciplinary although we say they should have it not everyone has access that and of course totally tangentially one shouldn't forget the feet and rheumatoid know the feeder in fact sometimes to the patient's the most important part of them and that's also part of what the occupational therapists or forest or podiatrists can't can help with we've already covered this adores of flaxseed oil and type of preparation we're just talking here about any omega-3 preparation that gives you three grams okay yes that's really what you are the doors of Omega of DHA and EPA yes and we've already talked about hand rehab which was a question also from a m– in New South Wales the extent to which we should worry about the kidneys in are a very unusual for the kidneys to be involved in the rheumatoid process but it does happen that you can get a glimmer Linda fries but that's unusual that you're thinking more of SQLite us or lupus with that some of the drugs can affect the kidneys but that was really more the old-fashioned ones the gold and the penicillamine the ones that we were small now and the nonsteroidals the ones that we use more now don't have that much impact on the kidneys it's been a very informative program thank you all very much what are your takeaway messages Louise well I think it's important just to remember that you know patients do need to really understand about their illness and really try and get that balance between rest and exercise and try and I guess develop that healthy respect for the illness whereby they take it sufficiently seriously but not to the degree to which they're frightened of us or worried about the long term Christine really diagnosis is important and that we have people referred in quickly and we're talking about weeks not months yes exactly then I'd support that getting on to this disease modifying agents early is important and linking in with your rheumatologist is early it as early as possible na RI is uncommon but it's important to pick it up again as early as one can get a hold of the guideline and don't use it as a doorstop that would be another message and I hope you've enjoyed their program this is program on the new clinical guideline on diagnosis and management of early rheumatoid arthritis our thanks to the Department of Health and Ageing for making the program possible but thanks also to you in such large numbers for taking the time to attend and ask us all those questions if you're interested in obtaining more information about the issues raised there are a number of resources available including links to the guideline on the rural health education foundation's website our HAF comdataís you don't forget to complete and send in your evaluation forms to register for CPD points I'm Norman Swan goodnight

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