Key learning points:
– Inflammatory arthritis is characterised by pain, stiffness and swelling in the affected joints
– Early recognition and aggressive treatment is key to effectively manage inflammatory arthritis and prevent joint damage and disability
– Rheumatology specialist nurses play a key role in the management of a patient with chronic inflammatory arthritis
Arthritis is a commonly used term that means inflammation within the joints. It is a common condition, and it is estimated that about 10 million people in the UK have arthritis and that it is the biggest cause of pain and physical disability in this population. (1)
When health care professionals see someone with joint pain, also termed arthralgia, it is important to differentiate between inflammatory and non-inflammatory arthritis. In general, inflammatory arthritis is characterised by pain, stiffness and swelling in the affected joints, which is worst at the start of the day and on inactivity. In contrast, non-inflammatory arthritis characteristically causes pain in the affected joints and is often worse with activity and at the end of the day.
The most common chronic inflammatory arthritis is rheumatoid arthritis (RA). RA affects about 400,000 people in the UK (2) and is characterised by a symmetrical arthritis typically affecting the small joints of the hands and feet, although any synovial joint and many other organs can also be affected. The overall occurrence of RA is two-to-four times greater in women than
in men. (2) It can affect anyone at any age. Other causes of chronic inflammatory arthritis include psoriatic arthritis (PsA), ankylosing spondylitis (AS) and juvenile idiopathic arthritis (JIA).
The most common non-inflammatory arthritis is osteoarthritis (OA). It is felt that OA is largely a degenerative condition and is more common in older people. However, OA is one of the leading causes of pain and disability worldwide.
The general management of arthritis
The treatment of arthritis depends of the type of arthritis and is largely dependant on whether the arthritis is felt to be non-inflammatory or inflammatory in nature. The treatment of any arthritis should be based around pain management and assessment of physical function but, if the arthritis is inflammatory in nature, immunomodulatory medication is often required.
The National Institute for Health and Care Excellence (NICE) has produced clinical guidance on the management of OA. (3) The management includes assessing the effect of OA on the person’s function, quality of life, mood, relationships and leisure activities. Exercise is regarded as a core treatment and weight loss should be encouraged for people who are overweight or obese. Pharmacological management options include oral analgesics (paracetamol, NSAIDs, COX-2 inhibitors, opioid analgesics), topical treatments (topical NSAIDs, capsaicin) or intra-articular corticosteroid injections. Referral for consideration of joint surgery is an option for people whose symptoms are refractory to non-surgical treatment.
The management of inflammatory arthritis
The aetiology of inflammatory arthritides such as RA is largely unknown. However, they are believed to be autoimmune in nature and environmental factors, such as cigarette smoking or infection, are postulated to trigger the onset of an inflammatory arthritis in genetically susceptible individuals.
When treating an inflammatory arthritis, the physician has to think about modulating the immune system in order to stop the progression of disease and prevent damage to the cartilage and underlying bone. If this is not achieved, joint damage, joint deformity and subsequent loss of function often ensue.
Although inflammation in individual joints often varies on a day-to-day basis, joint damage accrues and once significant damage has occurred in a particular joint then treatment often becomes symptomatic.
In recent years, many large international studies have highlighted the fact that early recognition and aggressive treatment play key roles in the effective management of an inflammatory arthritis.
Delays may occur anywhere along the pathway to early aggressive treatment. This may include delays in patients presenting to the primary care physicians, primary care physicians referring patients to rheumatologists, and rheumatologists initiating immunomodulatory treatments.
There are published British Society for Rheumatology (BSR), European League Against Rheumatism (EULAR) and NICE standards of care and guidelines highlighting the early recognition and management of RA and other inflammatory arthritides. (2,4,6)
The BSR recommendations state that people presenting in primary care with a suspected inflammatory arthritis affecting the hands or feet should be offered a specialist opinion within six weeks of symptom onset. (4) They also recommend that people with active RA have access to immunomodulatory medications within three months of persistent symptoms. (4)
In order to provide an effective service to meet these standards, many rheumatology departments around the UK have now developed early inflammatory arthritis clinics (EIAC). The EIAC in Newcastle-Upon-Tyne aims to see people with potential inflammatory arthritis within a couple of weeks from referral.
Patients have an ultrasound of their small joints, radiographs of their hands and feet as well as routine bloods taken to allow diagnosis prior to them being reviewed by a consultant rheumatologist. The Newcastle-Upon-Tyne EIAC has been running for about three years and has reviewed over 1,000 patients.
There are a number of immunomodulatory medications that are currently in use in the UK and the rest of the world used to treat RA and other inflammatory arthritides. Oral disease modifying anti-rheumatic drugs (DMARDs) are recognised first-line treatments for RA and include methotrexate (MTX), leflunomide, sulfasalazine and hydroxychloroquine.
MTX is regarded as the ‘gold-standard’ DMARD and is commonly prescribed first-line, often in combination with one or more other DMARDs. MTX can be administered orally or subcutaneously and is taken once a week. MTX (particularly in its oral preparation) can cause nausea and this side effect is often reduced by the co-administration of folic acid 5-10mg the day after MTX.
Like several other DMARDs, MTX can cause blood-test abnormalities including cytopaenias and raised liver function tests. Patient’s bloods are checked regularly to monitor for these abnormalities and may necessitate a temporary or permanent cessation of the drug. However, overall MTX is well tolerated and, if used in a timely manner, can induce low disease activity or indeed disease remission. One of the issues with using MTX and other DMARDs is that they can take a significant period of time (i.e. about three months) to have an effect. For this reason, patients are commonly prescribed either oral or intramuscular corticosteroids at diagnosis in order to provide rapid symptomatic relief and reduce acute inflammation.
After a patient has been diagnosed with RA, they should be reviewed regularly by the rheumatology team to assess their response to DMARD medication. This can be done using a disease activity score (DAS28). The DAS28 is a composite score based on a 28 tender and swollen joint count as well as an inflammatory marker (ie. CRP or ESR) and a patient global visual analogue scale (VAS). The DAS28 is used to classify the patient as being in disease remission, having low disease activity, moderate disease activity or high disease activity. The idea of a treat-to-target strategy has recently been adopted in the management of RA. The target for many patient-physician relationships should be low disease activity or indeed disease remission. (4) If a patient is assessed and found to have active disease then the rheumatologist should consider escalation of DMARD therapy either by increasing the dose of the medication or adding another DMARD.
Some patients with RA unfortunately have active disease despite the use of DMARD therapy. In these patients, a group of medications called biologic therapies can be considered. The use of biologic therapies for RA has become common practice in the UK over the last 10 years or so and their use is largely based upon patients fulfilling NICE criteria.
Biologic therapies available for use in RA include the anti-tumour necrosis factor (anti-TNF) therapies (etanercept, adalimumab, infliximab, certolizumab and golimumab), rituximab (a B-cell inhibitor initially developed for use in the treatment of lymphoma), tocilizumab (an IL-6 receptor antibody) and abatacept (a t-cell co-stimulation inhibitor). NICE recommends that biologic therapies are options for the treatment of patients with RA who have active disease (as measured by a high DAS28 score on at least two occasions at least one month apart) and have failed trials of at least two DMARDs, including MTX. (7) All these therapies are administered either subcutaneously or intravenously and are administered at varying intervals.
Evidence suggests that all these biologic therapies work better in combination with MTX rather than in monotherapy. The main concern over the use of biologic therapies is the potential increased risk of infection (although multiple analyses of biologic registries around the world have demonstrated this increased risk to be very small). However, doctors, nurses and any other allied health care professionals (HCPs) involved in the care of patients should be aware of this risk, and have a lower threshold to seek expert health if they have any concerns.
The NICE recommendations for biologic use in RA are largely governed by the cost of the therapies (any of the current biologic therapies cost somewhere between £7,000 and £9,000 per year per patient). However, several biologic therapies are now coming off patent and biosimilar biologic therapies are currently in development and undergoing clinical trials. It remains to be seen how biosimilars may affect the market and whether guidelines will be altered to reflect potential cost savings to the NHS.
The availability of DMARD and biologic therapies have revolutionised the management of RA and other inflammatory arthritides over the past 15 to 20 years. The outcome of someone diagnosed with inflammatory arthritis now is much better than one diagnosed prior to the availability of these drugs. The aims of all these therapies are to reduce inflammation, prevent joint damage and therefore subsequent functional disability. Although drug induced low disease activity or even disease remission are now realistic goals, drug free remission is rare and patients may undergo a difficult, and often physically and mentally painful period of time before the desired outcome is achieved. It is still impossible to predict which DMARD or biologic therapy will work best for an individual patient. There are still some patients who are refractory to these therapies in whom disease proves difficult, if not impossible, to control adequately. Personalised medicine based on genotyping and disease phenotype may provide some answers in the years ahead.
It is still important to bear in mind that patients with an inflammatory arthritis often require the input of multiple members of the multidisciplinary team (MDT) to provide education, support and individual expertise. Patients with an inflammatory arthritis are also at increased risk of comorbidities such as cardiovascular disease and osteoporosis – they should be routinely screened for these. (2,6) Rheumatology specialist nurses play a key role in the patient’s journey and EULAR have published recommendations for the role of the nurse in the management of chronic inflammatory arthritis. (8) These recommendations suggest that nurses should be involved in education and disease management as well as addressing the physical, psychological and social needs of the patient.
1. Arthritis Care. Annual Report 2013. http://www.arthritiscare.org.uk/AboutUs/annual-reports (accessed 4 April 2015)
2. NICE. NICE CG79 Rheumatoid arthritis: The management of rheumatoid arthritis in adults. https://www.nice.org.uk/guidance/cg79 (accessed 4 April 2015)
3. NICE. NICE CG177 Osteoarthritis: Care and management in adults. https://www.nice.org.uk/guidance/cg177 (accessed 4 April 2015)
4. BSR. Top Ten Quality Standards for RA. http://www.rheumatology.org.uk/includes/documents/cm_docs/2012/t/top_10_... (accessed 4 April 2015)
5. Smolen JS, Landewe R, Breedveld FC et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Ann Rheum Dis 2014;73(3):492-509
6. NICE. NICE QS33 Quality Standard for rheumatoid arthritis. https://www.nice.org.uk/guidance/qs33 (accessed 4 April 2015)
7. NICE. NICE TA130 Adalimumab, Etanercept and infliximab for the treatment of rheumatoid arthritis. https://www.nice.org.uk/guidance/ta130 (accessed 4 April 2015)
8. van Eijk-Hustings Y, van Tubergen A, Bostrom C et al. EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis. Ann Rheum Dis 2012;71(1):13-9
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