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The role of the practice nurse in treating rheumatoid arthritis

Gail Burbage
RGN DON SEN
Rheumatology Specialist Nurse/Head of Service
Birmingham University
Sherwood Forest Hospitals NHS Foundation Trust

A number of national initiatives have emphasised that support and treatment for patients with long-term conditions, such as rheumatoid arthritis (RA), should be as close to home as possible. Such support should be holistic, addressing both psychological and social needs alongside conventional treatment. The primary care team can play a key role in early recognition and monitoring of treatment. Primary care nurses are at the forefront of local health needs, and play an invaluable role in health promotion and improving the quality of life of those with chronic disease. To act as the patient's advocate in facilitating this, it is vital to have a working knowledge of RA, its management and drug monitoring.

There are two main types of musculoskeletal disease: osteoarthritis (OA) and inflammatory arthritis (IA). OA is a mechanical problem within the joint and is colloquially called "wear and tear" arthritis. IA is an umbrella term used to describe a group of musculoskeletal diseases that develop as a result of the body's immune system attacking its own tissues. As a nurse it is important to understand the pathology and clinical presentation of both processes before exploring the pathology and treatment of RA.
 
Osteoarthritis and inflammatory arthritis
OA is a degenerative disease process that develops over several years and is localised within the joint; most commonly, the hands, hips, knees, feet and spine. Our bodies were not designed for us to live beyond 40–50 years, so over time the cartilage between the bones becomes thin and damaged, with osteophytes (extra bone) forming at the outer edge of the joint. This results in joint space narrowing and loss of cartilage, leading to bone articulating on bone. The presenting symptom is pain that worsens after activity and at night, and occasionally the presence of swelling.

IA is an umbrella term encompassing the group of conditions that develop as a result of the immune system releasing chemicals that create a response against the body's own tissues (autoimmunity). The most common forms of inflammatory disease are:

  • RA (seronegative or seropositive).
  • Ankylosing spondylitis (AS).
  • Psoriatic arthritis (PsA).
  • Polymyalgia rheumatica.
  • Systemic lupus erythematosus (SLE).
  • Gout.

These are categorised by the tissue targeted by the autoimmune response, diagnostic criteria (presentation), predisposing factors and age of onset. The first three listed are the most common forms of inflammatory joint disease.
 
What is rheumatoid arthritis?
RA is a chronic, progressive, degenerative disease process with no known cure. Approximately 400,000 people in the UK have RA, 1% with severe disease. One in 200 women are affected and one in 600 men.1 It can present at any age but peak onset is reported between 35 and 50 years. The exact cause is unknown, although it is believed that an environmental trigger such as infection combines with a genetic predisposition to set off an autoimmune response, targeting the synovial tissues, leading to swelling, pain, stiffness and systemic features, such as tiredness, fatigue, weight loss and anaemia.

RA is a potentially devastating disease with a severe physical and emotional impact, which can lead to social isolation and depression. However, the prognosis of RA can be uncertain. If left untreated, the disease can cause progressive joint destruction and life expectancy can be shortened by up to 10 years. This compares to the impact of diabetes, non-Hodgkin's lymphoma and strokes.2 Approximately 50% of patients are registered disabled within three years of diagnosis.3 This costs the NHS around £240m per year, with the total cost to the nation (including health costs and lost working days) estimated at £1.3bn.2 Getting a diagnosis within six months of the first symptoms and early treatment is critical to preventing damage and leading a decent quality of life. Practice nurses see a multitude of patients in their surgeries and can identify early signs of this condition and facilitate referral to specialist care.

Presentation and diagnosis
Symmetrical early morning stiffness and pain in the small joints of the hands, wrists and feet are the most common early symptoms. These can come and go and be so severe they reduce the ability to undertake the basic activities of daily living such as getting washed and dressed. The underlying disease process can also progress, resulting in permanent joint damage and disability. These progressive symptoms magnify pain and fatigue, leading to low mood and malaise, having a major impact on quality of life, social, psychological and economic wellbeing.

In 1988, the American College of Rheumatology (ARC) developed a classification for RA (see Box 1),4 although no definitive diagnostic criteria for RA exists. It can be difficult to distinguish from other forms of arthritis; however, swelling of three or more joints, involvement of the metacarpophalangeal or metatarsophalangeal joints or early morning stiffness of at least 30 minutes duration should be considered important pointers requiring prompt early referral to secondary care.

[[Box 1 rheum]]

RA is a systemic disease; due to autoimmunity constitutional symptoms such as fatigue or weight loss are frequently reported. Many patients are not referred to specialist care because they are rheumatoid factor (RF) negative; although the ACR criteria clearly state that this does not exclude the diagnosis. However, a positive RF test is a predictor of persistent disease. In contrast, the newly developed anticyclic citrullinated protein antibody (anti-CCP) has a greater specificity for RA and predicts development of erosive disease. This can act as a useful test to assist in appropriateness to refer and future management.

Management
The disease can progress very quickly, leading to irreversible damage of the joints; this damage may be prevented or at least delayed by early treatment to suppress the inflammatory processes. This is known as "the window of opportunity" and occurs immediately after disease onset. Pharmacological intervention is only one facet that impacts on disease progression and quality of life; others include:

  • Social and psychological needs.
  • Supporting self-care.
  • Relief of symptoms.
  • Preservation of joint function.
  • Prevention of joint damage and deformity.
  • Achievement of remission.
  • Maintenance of quality of life.

The British Society for Rheumatology (BSR) has developed guidance on the management of patients in the first two years of disease.5 This outlines the need for holistic care and the involvement of the full multidisciplinary team working in combination across boundaries.

The pharmacological component of treatment can be subdivided into three main groups: symptom control, disease management and biologicals. Early intervention leads to improved disease outcome, quality of life and a reduced prevalence of side-effects. In the new NHS, the practice nurse has a key role to play in early recognition and coordinating these ongoing needs.

Symptom control
Pain and stiffness are the symptoms that patients seek advice about most. These are managed with a combination of simple or compound analgesia, nonsteroidal anti-inflammatory drugs (NSAIDs) or COX-II inhibitors; however, these control the symptoms rather than alter the disease process. Oral corticosteroids (steroids) are sometimes prescribed, although their long-term use remains controversial due to side-effects such as hypertension, osteoporosis and diabetes. Steroids by intravenous infusion or intramuscular injection are preferred during acute exacerbation (flare) of the disease or to bridge the gap while new therapies take effect. It is important to remember that if the flare only affects one or two joints, septic arthritis should be excluded before administration of intra-articular steroid injection.

Disease management
In slowing down the disease process and preventing the long-term impact of RA, early aggressive treatment with disease-modifying antirheumatic drugs (DMARDs) has become the cornerstone of treatment (see Table 1). These drugs are often used in combination, are slow acting, and can take months to produce a clinical response; therefore, sustained use is required to maintain efficacy. Methotrexate has become established as the gold standard and anchor DMARD since the 1980s, although unfortunately the effect of the drug therapy may wear off over time and some patients are intolerant, necessitating escalation of treatment.

[[Box 2 rheum]]

It is essential that patients are monitored to screen for drug toxicity. British Health Professionals in Rheumatology (BHPR) and the BSR have published advanced copy of the new guidelines for the monitoring of DMARD therapy on their website, in conjunction with the British Society of Dermatology (see Resources). The Department of Health recommends near-patient testing wherever possible, leading to the ongoing monitoring of DMARD therapy moving into the domain of primary care. Practice nurses can be instrumental in the development of a robust monitoring and recall system.

Biologicals
Our understanding of the disease process and immune system has advanced rapidly, leading to the development of more effective treatments collectively known as biological therapies. These offer patients a new treatment lifeline once standard therapy no longer works and have proven highly effective in combination with methotrexate, offering many patients with severe disease the possibility to live a near-normal life again. The biologicals target a protein in the immune system called tumour necrosis factor (TNF)-alpha, which plays a key role in the inflammatory cascade.

Three therapies have National Institute for Health and Clinical Excellence (NICE) approval for RA: infliximab (Remicade; Schering-Plough), etanercept (Enbrel; Wyeth) and adalimumab (Humira; Abbott). Infliximab is based on a mouse protein and administered by eight-weekly intravenous infusions. Patients are trained to self-administer etanercept and adalimumab by subcutaneous injection at home. Adalimumab is a "fully human anti-TNF-alpha antibody", meaning that it is identical to the antibody produced by the human body, whereas etanercept is a combination molecule. Before starting any of these treatments, patients are assessed and counselled about the risks and benefits of treatment (see Box 2).

[[Box 3 rheum]]

Practice nurses, especially those running triage clinics, should have a working knowledge of the risks for those receiving biological therapies. If an infection is suspected in a patient receiving biological treatment, further treatment should be withheld until they have been thoroughly assessed, and early intervention with antibiotics is recommended. As biological therapies block the normal immune response, failure to
recognise infections can have potentially life-threatening consequences.
 
Future management
In mid-2007, rituximab (Mabthera; Roche) was the first of a new generation of biologicals approved for use in the NHS by NICE. Rituximab requires two intravenous infusions two weeks apart, and retreatment only occurs once the RA starts flaring, approximately nine months after the first treatment. Rituximab targets B-cells, offering a new avenue for treatment, while other immune complexes such as interleukin–6 are under investigation. NICE is developing guidelines on the management of RA in adults and these are due for publication in December 2008.

In addition, annual assessment of long-term complications of disease such as osteoporosis, atherosclerosis and hyperlipidaemia is recommended to reduce the risk of premature cardiovascular disease mortality. This assessment can be easily incorporated into the drug review and the well men/women checks that already exist in primary care.

Conclusion
This is a challenging and exciting time in the treatment of RA, with advances in medical science leading to more effective treatments and better long-term outcomes for patients and their families. In the context of the current changes to healthcare delivery for long-term conditions such as RA, collaboration between primary and secondary care is required to ensure that early referral, management and ongoing assessment/treatment is provided to all. The primary care team, particularly the practice nurse, can play a key role in the field of chronic disease areas such as arthritis. This includes providing advice on pain management, education and support on learning to cope with the disease, pharmacological and nonpharmacological treatments, risk reduction and enhancing concordance relating to medications, monitoring toxicity and annual reviews.

References
1. Le Gallez P. Rheumatoid arthritis: effects on the family. Nurs Stand 1996;7(39):30–4.
2. Arthritis and Musculoskeletal Alliance (ARMA). Standards of care for people with inflammatory arthritis. London: ARMA; 2004.
3. Scott DL, et al. The clinical management of rheumatoid arthritis and osteo-arthritis: strategies for improving clinical effectiveness.
Br J Rheumatol 1998;37:546–54.
4. Arnett FC, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988;31:315-24.
5. Luqmani R, et al. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (the first two years). Rheumatology 2006;45:1167–9.

Resources
Arthritis Care
W: www.arthritiscare.org.uk

Arthritis Research Campaign
W: www.arc.org.uk
 
British Society for Rheumatology (BSR)
W: www.rheumatology.org.uk

BSR/BHPR guideline for disease-modifying anti-rheumatic drug (DMARD) therapy in consultation with the British Association of Dermatologists.
W: http://rheumatology.oxfordjournals.org/cgi/data/kel216a/DC1/1

National Institute for Health and Clinical Excellence
W: www.nice.org.uk

National Rheumatoid Arthritis Society
W: www.rheumatoid.org.uk