Early Rheumatoid Arthritis: Clinical Guideline for Diagnosis and Management

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

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