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Guided learning

Rheumatoid arthritis 2: exploring treatment options to achieve early control and remission

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Long term disability and unemployment are common in people with RA. Aggressive treatment on diagnosis promotes symptom control and aids remission

 

Authors

Cath Thwaites, PGCHE, MSc, DipN, ONC, RGN, is lecturer/practitioner in rheumatology nursing, School of Nursing and Midwifery, Keele University and Staffordshire Rheumatology Centre; Andrew Finney, PGCHE, BSc, DipN, RN, is clinical skills lecturer, School of Nursing and Midwifery, Keele University.

Abstract

Thwaites C, Finney A (2010) Rheumatoid arthritis 2: exploring treatment options to achieve early control and remission. Nursing Times; 106: 10, early online publication.

This second in a two-part unit on rheumatoid arthritis discusses its impact on patients and treatment and management options. Part 1 examined background, signs and symptoms and diagnostic tests.

Keywords Rheumatoid arthritis, Self management, Treatment

  • This article has been double-blind peer reviewed

 

Learning objectives

1. Know the multidisciplinary team members who may be involved in managing people with rheumatoid arthritis.

2. Be able to identify the different groups of drugs used to control the condition.

 

Introduction       

Rheumatoid arthritis (RA) is an autoimmune systemic inflammatory condition that causes pain, swelling and stiffness in many joints. It is a long term condition that varies in severity and is unpredictable, with fluctuating episodes of disease activity (Arthur and Hill, 2006). RA can also cause flu like symptoms and fatigue. Treatment aims to control the inflammatory process, reduce symptoms and delay joint destruction. Early management through a combination of drug therapy and multidisciplinary team input aims to promote disease control/remission and self management (Luqmani et al, 2006).

Patients’ individual needs must be assessed to provide optimum care from the most appropriate healthcare professional/s. An understanding of the possible impact of RA is essential before assessing and planning care, as its effects can be wide-ranging, including physical, psychological, social and financial wellbeing.

The impact of RA

Chronic inflammation, muscle wasting and joint destruction, which contribute to deformity and altered body image, can occur in more established RA. However, the physical effects are not always visible, especially in the early stages. Although synovitis may be present, it may not be evident without the use of specific examination tests; recently synovitis has been identified through the use of ultrasound technology (Kane et al, 2004).

The absence of obvious signs of arthritis can lead to misunderstandings with work colleagues and cause friction in family relationships, particularly if pain is affecting the patient’s social functioning.

The unpredictable physical pain and reduced function associated with RA can also affect ability to work, which can reduce earning capacity. The National Rheumatoid Arthritis Society (2007) reported that many people with RA stop working within six years of diagnosis. Loss of income and social contact with colleagues can contribute to low self esteem and lack of confidence.

Other visible physical changes may occur as a result of specific or prolonged drug treatments such as glucocorticoid steroid therapy, which can cause weight gain, muscle wasting and hirsutism. These are also likely to impact on patients’ self-esteem and body image.

The psychological impact of RA varies as people may respond in different ways following diagnosis. Some feel relieved at being given a diagnosis whereas others may experience feelings of disbelief similar to feelings of grief, working through shock, distress, fear, denial, anger and finally adjustment (Griffith and Carr, 2001). Feeling systemically unwell can affect confidence in coping with everyday events, which over time can lead to feelings of helplessness and depression (Ryan et al, 2003).

Coping and adaptation can be influenced by many factors including family and social support (Homer, 2005). There is evidence that patients with good social support cope better than those who are isolated (Affleck et al, 1988). Similarly, those who feel confident in managing their condition have been shown to feel more in control and therefore show fewer signs of depression (Fitzpatrick et al, 1988).

Improving self efficacy in patient self management has been explored through education and lay-led self management programmes (Lorig et al, 2001). The Expert Patients Programme (National Primary Care Research and Development Centre, 2006) is one example of the latter. This has been shown to be beneficial in chronic disease management, and more recently disease specific programmes have been accessed through patient support groups, such as the NRAS pilots.

Historically, patient education programmes run by healthcare professionals have aimed to provide specific information about RA, disease management, drug therapy, exercise, pacing activities and goal setting. While such programmes may provide relevant information from a variety of practitioners, they cannot guarantee changes in behaviour (Hill, 2006). Evidence suggests that the timing of information giving is important, as providing too much information immediately after diagnosis can increase anxiety in some people and ultimately contribute to depression (Donovan et al, 1989).

Depression has been estimated to affect 21-34% of people with RA and is often unrecognised and untreated (Dickens and Creed, 2001). The relationship between pain, disability and depression has been recognised, highlighting the importance of a bio-psychosocial approach to care, rather than purely managing the physical effects of the condition (Ryan, 2006).

Management options

Rheumatology nurse specialists often coordinate patients’ care with the multidisciplinary team. The initial aim is to control pain and inflammation through drug therapy, which is complex as different groups of drugs are often used simultaneously.

Drug therapy

Analgesia

Pain control is achieved through regular analgesia and, where appropriate, non-steroidal anti-inflammatory drugs (NSAIDs), although these must be used cautiously as they may exacerbate hypertension, cardiac and renal impairment and asthma. Short term NSAID use only is recommended in older people, as they may be taking medication for comorbidities. It could be argued that people taking numerous medications are more prone to mistakes in taking their drugs in terms of either dosage or frequency, at risk of drug interactions and may be reluctant to adhere to prescribed regimens. There is also a risk of duodenal ulceration with NSAIDs, especially with prolonged use or if taken without food.

Glucocorticoid steroid therapy

Glucocorticoids are used sparingly but are helpful and quick in reducing inflammation. They may be given by intramuscular depot injection, intravenous infusion, directly into a joint or soft tissue, or in tablet form. They are often used as “bridging” therapy to reduce pain and inflammation until long-acting drugs (disease-modifying anti-rheumatic drugs) begin to work. However, glucocorticoids cannot be given if infection is present as they can exacerbate the problem.

Disease-modifying anti-rheumatic drugs

DMARDs are used to control the immune system, slow down the inflammatory process and delay joint damage. They are powerful in suppressing the body’s defence system but can take up to three months to become effective. They require careful administration and monitoring to prevent over suppression of the immune system. Regular blood tests enable rheumatology nurses to identify any early complications such as neutropenia, haemolytic anaemia and renal or liver toxicity. The consequences of late identification of any of these could result in hospital admission or, in more serious undetected cases, death.

Biological therapy

Biological therapy is currently used in adults when active RA remains uncontrolled despite having used other conventional DMARDS (see NICE [2009] guidance for full details on the necessary criteria for initiating each drug). Biological therapy currently approved by NICE includes the tumour necrosis factor alpha inhibitors (anti-TNF therapy) adalimumab, etanercept and infliximab and the B-cell depletion therapy rituximab.

Anti-TNF therapy targets specific cells in the immune system called cytokines. It aims to reduce the elevated level of tumour necrosis factor alpha, present within joints, which in excess contributes to joint damage. Rituximab is prescribed when patients do not respond to anti-TNF treatments, and it dramatically reduces B cells in the immune system. These cells are a type of white blood cell responsible for producing auto-antibodies. 

All biological medicines are administered either by infusion or injection. These treatments have been shown to be effective in approximately 70% of recipients (Emery et al, 1999). However, there are potential risk factors, such as an increase in infections, reactivation of latent tuberculosis and malignancy. Consequently, patients taking this treatment are monitored closely.

General principles

NICE (2009) advocated early diagnosis and treatment with combination therapy (two or three DMARDS taken simultaneously). More aggressive treatment on diagnosis is believed to aid remission of RA, with the possible future withdrawal of medication. This aims to avoid joint damage and disability, preserving independence and reducing work disability. Table 1 outlines pharmacological treatment options.

Healthcare professional roles 

Pharmacists play a key role in providing information for both patients and healthcare professionals about medicines used in rheumatology. However, rheumatology nurses are often involved in explaining possible benefits and side effects to patients. While individual assessment helps to identify the most effective drug for each person, it is ultimately their choice whether to comply with drug regimens.

DMARDS require regular blood monitoring for adverse reactions and toxicity. Many patients are monitored in the community and therefore practice and district nurses need to develop skills in these areas. Rheumatology nurse specialists remain a useful point of contact for advice about side effects and monitoring issues. Most rheumatology departments in the UK provide a telephone advice line for direct access to the department (Thwaites et al, 2008; Arthritis and Musculoskeletal Alliance, 2006). Patients can also be given psychological support via this advice line, although other support may be sought from the multidisciplinary team.

NICE (2009) recommended that all people with RA should have access to physiotherapy, and to occupational therapy and podiatry if required:

  • Specialist physiotherapy aims to promote general fitness and exercise for people with the condition, as well as teaching specific exercises for joint flexibility, muscle strengthening and managing functional impairments. Hydrotherapy and “land” exercises may be offered. Pain control may also be addressed through non-pharmacological methods such as acupuncture, transcutaneous electrical nerve stimulators (TENS), wax hand baths, and hot and cold treatments. It is recommended that patients continue with many treatments at home;
  • Specialist occupational therapy offers support to both newly diagnosed people and those with longstanding disease. Functional ability is assessed and aids to maintain independence may be suggested. Problems with hand function are also evaluated and appropriate management advice given. Aids to assist daily living may include gadgets to help with washing and dressing. Many OTs provide advice on coping and managing pain and fatigue and some offer relaxation sessions;
  • Specialist podiatrists provide advice about footwear and foot care. The feet are often affected in RA, causing mechanical damage and pain. Insoles and suitable footwear can be discussed.

At times other members of the multidisciplinary team may be involved in patients’ care, for example, psychologists or psychiatrists in cases where people may have mental health issues. Many rheumatology nurse specialists provide psychological support for those struggling to come to terms with their diagnosis.

In addition, people with arthritis run local patient support groups, including those organised by Arthritis Care and the NRAS, and they can give appropriate support to people in a similar situation to themselves.

Patient choice

Treatment options must be discussed with patients to enhance concordance. Many rheumatology services are hospital based and these are not always convenient for those with severe functional impairments or those who are working. Some rheumatology teams provide satellite clinics in primary care, and some can provide community support in the form of rheumatology nurses making home visits for monitoring or administering injections. Practice nurses may become more involved if they provide a local phlebotomy service.

In general fewer hospitals now provide inpatient care on specially designated rheumatology wards. Many of the newer treatments enable patients to attend on a daily basis and as a result rheumatology day case units have been set up. Evening clinics aim to meet the needs of those who work regular hours. Services are continuously evaluated to improve patients’ journey through the healthcare system.

Conclusion

Early referral to rheumatologists means the diagnosis of RA can be confirmed and treatment with disease-modifying drugs can be started. The aim of early treatment is to interrupt the inflammatory process and control synovitis within joints.

NICE (2009) recommended using more than one DMARD on diagnosis to achieve symptom control earlier. Quicker progression to more advanced treatment in the form of biological therapy should take place if indicated, irrespective of where in the UK patients live. Earlier control of RA can delay joint damage, reduce pain and disability and lower the incidence of work disability.

Caring for people with RA involves a team approach, relying on the expertise of the multidisciplinary team as well as input from patients themselves. Their values, beliefs and opinions must be considered when planning care to meet individual needs and promote concordance. Confidence in self management is paramount in maintaining independence and psychological wellbeing.

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