VOL: 98, ISSUE: 13, PAGE NO: 34
Gillian Hosie, MB, ChB, GP, is a general practitioner, Knightswood Medical Practice, Glasgow, and a past president of the Primary Care Rheumatology SocietyGillian Hosie, MB, ChB, GP, is a general practitioner, Knightswood Medical Practice, Glasgow, and a past president of the Primary Care Rheumatology Society
Rheumatoid arthritis affects about 1% of the population and is three times more prevalent in women than in men. Some patients have only mild disease, but others develop severe problems which lead to progressive joint destruction and eventually deformity.
The disease can present suddenly, with acute onset of joint pain and stiffness, or more insidiously, with gradually increasing joint problems resulting in decreasing functional capacity. Patients with early rheumatoid arthritis may also have systemic symptoms such as fever and fatigue.
The condition can affect parts of the body other than the joints and may give rise to rheumatoid nodules and vasculitis, as well as pulmonary, cardiac, ophthalmic, neurological and dermatological complications.
Patients experience pain and stiffness, but may also be at risk of losing their independence and ability to work because of their limited mobility and dexterity, and systemic symptoms such as fatigue.
Maintaining a social life can be difficult and many patients become socially isolated and depressed. They are also at risk of premature mortality.
Cost of treatment
Treating rheumatoid arthritis is expensive. First, there are the medical costs: medication, physiotherapy, primary and secondary care appointments, inpatient treatments and other therapies. Second, there are the costs of social care, the costs to society at large when patients are unable to work and the costs incurred by patients (Cooper, 2000).
In addition to analgesics, there are two main pharmacological treatments. The first-line treatment is generally with non-steroidal anti-inflammatory drugs (NSAIDS), which reduce pain and stiffness but have no effect on the long-term outcome of the disease.
Then there are disease-modifying antirheumatic drugs (DMARDs). These offer long-term benefits to patients as they affect the course of the disease by reducing bone erosion and destruction, and consequently deformity and disability.
In the past, patients with rheumatoid arthritis were initially treated with analgesics, physiotherapy and NSAIDs (Scottish Intercollegiate Guidelines Network, 2000). The more toxic DMARDs were reserved until the bone erosion caused by the disease was visible on an X-ray or when the patient's clinical condition deteriorated.
However, more recent studies (Egsmose et al, 1995; Van der Heide et al, 1996) have shown that early treatment with DMARDs reduces joint destruction, resulting in a better prognosis. For this reason all patients with a definite or suspected diagnosis of rheumatoid arthritis should be referred to a consultant rheumatologist as soon as possible for assessment, with a view to starting DMARDs therapy.
Early referral also means an earlier patient assessment by the multidisciplinary team, which includes specialist nurses, physiotherapists, occupational therapists and podiatrists, and can provide support, education and practical help.
It is important to remember that the management of rheumatoid arthritis should be holistic rather than being based solely on drug treatment.
Many patients with the condition say that complementary therapies, such as reflexology and relaxation techniques, are useful. However, these should be used in addition to drug therapy, not as an alternative.
When patients are diagnosed with rheumatoid arthritis they are usually treated with NSAIDs and analgesics, and referred to secondary care. Depending on the patient's clinical needs, there may also be referrals to physiotherapy or occupational therapy at this stage, although these services are often easier to access from secondary care.
Some primary care centres may involve the practice nurse at this stage. However, the practice nurse's main input generally comes later, as part of the primary care team, after patients have started taking DMARD therapy and require regular monitoring of blood or urine.
The nurse's role
Practice and district nurses play an important part in the long-term care of patients with rheumatoid arthritis as they monitor not only laboratory tests but also the clinical state of the patients, referring them back to the GP or hospital clinic as required.
Nurses usually become the mainstay of support for such patients in primary care. Many secondary-care centres have specially trained rheumatology nurses who have specific expertise in dealing with patients with the condition. They can provide education and support, and manage any problems caused by DMARD therapy.
Many units have set up telephone helplines to deal with these problems. These are staffed by rheumatology nurses and are used by primary care staff. Some units have patient helplines, also staffed by rheumatology nurses.
Most DMARDs are fairly toxic and require regular monitoring of blood and urine to prevent patients from developing severe and potentially life-threatening abnormalities. The requirements vary from drug to drug, so specific monitoring regimes are shown in Table 1.
Although patients with rheumatoid arthritis usually start taking DMARD therapy in secondary care, a lot of the routine monitoring is done in primary care. For this reason it is important for the primary care team to be aware of the rationale for using DMARDs and to set up a system to organise relevant monitoring for each patient.
Patients should be seen regularly, as required by the individual drug protocols, and any non-attenders should be contacted for follow-up. There should be a system to ensure that all relevant blood results are reviewed by a doctor and that any decisions to continue treatment or change dosages are noted and discussed with the nurse and the patient.
Most rheumatology units send the primary care team a shared-care information sheet detailing the monitoring requirements. This should include information on what to check and how often, how to recognise abnormalities, and how to deal with abnormal results and minor side-effects.
The most commonly used DMARDs are hydroxychloroquine, sulfasalazine, methotrexate and intramuscular gold (sodium aurothiomalate). Less commonly used medications include penicillamine and azathioprine. Leflunomide and minocycline have also been introduced recently.
Minocycline is used when other drugs have failed, although it does not yet have a specific licence for the treatment of rheumatoid arthritis. Some DMARDs are more toxic than others. The least toxic is probably hydroxychloroquine, which is used in milder forms of the disease.
Some of the side-effects of DMARDs (Table 2) are potentially serious, while others are common and minor, and are easy to treat.
Some side-effects can be tolerated by patients if they are given information and reassured. It is important that all members of the primary care team are aware of the side-effects associated with specific drugs, and that they recognise potentially serious problems and refer accordingly.
It is also important that nurses and doctors who manage patients use monitoring visits to make an overall assessment, not simply to focus on the drug treatment regime.
Nurses have an important role to play in caring for patients with rheumatoid arthritis. They can use their regular drug monitoring visits to review patients' clinical condition, assessing them and any specific difficulties that may have arisen. Nurses are ideally placed to provide education, support and a listening ear for patients with this chronic and painful condition.