Senin, 17 Juli 2017

osteoporosis management

osteoporosis management

hello, i'm norman swan. welcome to this program on the clinicalguideline 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 limitstructural damage of the joints and improve quality and length of lifeas well as other health outcomes. this program is the secondof four programs on the new musculoskeletal guidelines.

the clinical guidelinesfor general practitioners and other primary health-careprofessionals have been developed by the royal australian collegeof general practitioners and approved by the national healthand medical research council. this program will cover the diagnosisof rheumatoid arthritis and discuss the recommendedinterventions for early ra in the australianprimary health-care setting. as always,you'll find a useful number of resources on the rural health educationfoundation's website:

i'll introduce our panel to you. john bennett is a gpat 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 rheumatologistat royal north shore hospital in the university of sydney. - welcome, lyn.- thanks, norman. lyn was also a memberof the guideline working group.

christine retallack isa community health nurse in rheumatology working in the albany rheumatologyclinic in western australia. - welcome, christine.- thank you. the community rheumatology nurse isa species unique to western australia? it doesn't happen anywhere elsein 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 theuniversity of sydney. welcome, louise.

louise has a strong interestin rheumatoid arthritis and similar diseases. to start, let's hear from four womenfrom western australia, liz, anne, terri and jill, abouttheir experiences of having early ra. 1983 was quite a stressful year for me. i felt that i was overweight, and i wasdoing an exercise program at home. each morning i would wake up soreand stiff, and think, how unfit i am. so i would push myself harderuntil i was unable to sleep or unable to function very well at all.

i couldn't get out of beda lot of the time. overwhelming fatigue. just really felt like i had a bad fluall the time. my body felt like i had the worst fluyou've ever had. it was getting worse and worse. i was finding it hardto 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 awayfrom 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 clothesthat 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 problemswith 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 rheumatoidarthritis from western australia. i'm not sure that we'll find there'slevel-one evidence for retail therapy, as one of our respondents therewas telling us.

john, how typical are those stories? very typical. it's interesting how each one withoutfail had a strong psychological element. suffering that went beyond the physical. we weren't hearing muchabout joint problems, lyn. patients don't tell you that their crpis raised and their joints are swollen. norman: how inconvenient. they tell you thingsthat matter to them - the fatigue and the overwhelmingsystemic effect.

i think that's the cytokinesof inflammation. but they don't tell you those words. how dominantis that psychological element, louise? well, certainly when people developrheumatoid arthritis, there's good evidence that about one infive at any one time will be depressed of clinical magnitude. we found in some of our early researchlooking at early arthritis that that actually increasesin the early phase of the illness. if you don't help people to manage it,

the symptoms are so all-encompassingand 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 difficultto do the things they need to do to actually manage the illness better. is treatment of depressionthe treatment of the illness or treatment of the depression? if the depressionis a response to the illness, if you help people to take control overtheir illness and manage it better,

the symptoms of depressiondo actually lift. you can use good strategies that havebeen 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 aboutearly detection and active management of somebodywith early rheumatoid arthritis. for success, how important is it - it sounds like a dorothy's easy to say, very important! - to see the whole patient,how important is it?

it is extremely importantto see the whole patient and not just the swollen joints. if you can help people to do well withthe emotional side of their condition as well as functional stuff,they do do so much better. what do people tell youbothers them the most? they've been diagnosed witha chronic illness, quite a serious one. there's probably two thingsthey worry about. one is the overwhelming fatiguethat they experience. the other one is the introductionof drugs

that they have never seenthe like of before. it's really importantto discuss the drugs with them so they do understand that they needto take them and how they work and that they do need to havefollow-up blood tests and so on to monitor how they're going. what's the evidence, lyn, that early diagnosis and interventionmakes a difference? there's overwhelming evidence nowthat it's the right thing to do. ten years agowe thought it was the right thing to do.

now we really know, in terms ofimproving outcomes, quality of life, preventing the joint damage and evenimproving mortality - lengthening life. severe rheumatoidreduces life expectancy. norman: from coronary heart diseaseas much as anything. yeah. particularly in males, it lowerslife expectancy by at least five years. treatment early helps improve that. i've heard, john, rheumatologists saythat flail joints, ulnal deviation, horrible hands is a thing of the pastyou don't see anymore

apart from peoplewho may be really elderly who have had rheumatoid for a long time. from modern treatment, you don't seethat anymore. is that your experience? i guess both are true. the newer drugs certainlyoffer much greater promise than we've seen before. hopefully they will becomemore of a thing of the past. what figures are we seeing, lyn? my understanding is that it's commonerthan people think.

2% to 3% of australiansin national health surveys think they have rheumatoid arthritis. maybe it's a bit less than that. at least 1% of the populationhas rheumatoid arthritis. in terms of new cases, even though theincidence is declining around the world, probably at least 1,000 new cases inaustralia, based on our population, every year will have a range of severityof rheumatoid arthritis. but at least 1,000 new cases every year. norman: most gps will have a patientin their practice?

most gps will come across it,i guess not every day. you were saying earlierthat it's commoner on an incidence basisthan type-1 diabetes? yes. it's more common than that,and than multiple sclerosis and more common than other thingsthat attract a lot more attention. rheumatoid arthritis has been - everyonegets it. we can't do anything about it. clearly that's not the case. i've heard some say that the windowof opportunity is six weeks. that's what we're recommending.

the evidence is that the earlieryou 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 geta response, but it won't be as good. you might have already had erosionsby that time, and joint damage. that's a pretty tight rope to put gps onfor diagnosis, john. it's difficult. as we're saying,it is an uncommon disorder, but hopefully there's an opportunity topick it up early and make a difference,

to improve people's lives. christine,you've done work with colleagues on the incidencein indigenous communities. this is a condition people sayis genetic, related to hla type. how common is itin indigenous communities? the research showed that in 2001, there were only 15 cases of rheumatoidarthritis in the indigenous population in far north queensland. i'm talking to a colleague who visitsthe kimberley as a rheumatologist.

he has no cases of rheumatoid arthritis. research showed that the majorityof cases of rheumatoid arthritis in indigenous populationswas where parentage was mixed of caucasian or other ethnic groupsthat carry ra. what do we know about causation, lyn? there's definitely a genetic element. there's no single genethat's been identified, but there's strong family history, strong in dizygoticand 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 generateantibodies to citrullinated peptide, but smoking is a risk factor.morbid obesity is a risk factor. norman: vitamin d levels? there's some associationin terms of inflammation. but it's commoner in tasmaniathan it is in sydney. it hasn't been as strongly linkedas some of the other conditions

like multiple sclerosis. we're looking into some treatmentsfor that. the oral contraceptive pillmight be protective. norman: pregnancy? usually the symptoms of rheumatoid abateduring pregnancy. pregnancy-related hormoneshave an anti-inflammatory effect. there's no evidence that pregnancyincreases or decreases your risk. blood transfusions might be a risk. occasionally the immune systemis triggered by immunisations.

norman:there might be a viral aetiology? possibly. there's never beena single infective agent found, though. you find it early. what's your aim with treatment? the aim of the rheumatologistor the clinician is to put the disease into remission. norman: what's that? remission is when the diseasehas gone away but you still need drugs. it's very rare that we cure the disease.

so when peopletalk about drug-free remission, those might not be peoplewith rheumatoid arthritis? a small percentagecan go into drug-free remission, but our knowledge of the diseaseis that it always tends to come back, even when you've got peopleunder 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 somerheumatoid disease. to the patient though,that means nothing. well, it means means their pain is gone. it also means usuallythat their fatigue is under control. so again, the patient is looking forimproved quality of life, energy levels back, that sort of thing. as a doctor, we're looking mainlyto see no erosions, no joint damage. in order to get that, you have to havezero to very low joint count

and normal inflammatory markers. there's this debateabout new biologicals - people walk in the door saying, 'can ihave my etanercept or my rituximab,' or whatever is the latest one advertisedin the united states. what is the role of thesebiological agents in treatment? they're very powerfuland very useful agents. in australia, we have them for peoplewho still have very active disease after they've failed two or three otherdisease-modifying agents and still have active disease.

they have an important role, but they're not without some potentialfor side effects. they need to be used appropriately. john, we'll come to some case studiesin a moment, but give us a sense of what thesenew guidelines tell you to do in terms of diagnosis. we are asking the gpto 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 featuresthat would be suggestive of arthritis - the classic of symmetricalsmall-joint disease, fatigue, stiffness persists for an hour or moreinto the morning on awakening. then follow that up with blood tests -esr, crp as a marker of inflammation, the time-honoured rheumatoid factorin the anti-ccp. if you were suspecting rheumatoid, theywould 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 gpto make the diagnosis. sometimes if you waituntil 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 erosionsand joint damage. the key message out of the guidelineson 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 beingswollen beyond six to eight weeks because there's potentialfor joint damage. norman: regardless ofwhat the biochemistry shows? yes, try to work up the diagnosis. that saves time for the patientand for all the treating doctors. don't wait till you're totally convincedit's rheumatoid. it's often too late. christine, gps watchingfrom rural and regional australia, and we'll find out in a momentwhat proportion are those,

they'd say, 'it could take me a yearto 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 inflammatorycondition or where i'm suspicious, i can follow those people up,i can talk to their gp and make sure that they get into be seen. norman: the gp knows there's a clinicin town run by an expert nurse?

yes. how often does that happen anywhere elsein australia, lyn? not any other states have that luxury. it is a problem for gps at timesto get access to rheumatology services. the australian rheumatology associationhas a website. the public can seewhere rheumatologists are. gps can look. not every rheumatologist is on that, but if someone is in an area where theycan't get access to a rheumatologist, they should email or call the australianrheumatology association secretariat,

and we'll get them in touchwith someone. those women who said they had fatigue and weren't talking about their jointsapart from the last lady, if the gp wasn't to take thisas fatigue but ask the next questions, because they might be thinkingof gluten enteropathy or thyroid or a lot of things, but they doask the questions about joints, in what proportion of caseswhen it is rheumatoid are they going to get a joint story? a high percentage.

the majority will have somejoint 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 scenariowhen 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 seeif there's an associated inflammation.

you'll occasionally see people who don'thave 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 sensitiveas rheumatoid factor. if your rheumatoid factor is positive, the ccp doesn't help youmake an additional diagnosis

if you've got the clinical picture,but it is more specific. rheumatoid factor can be positivein other things - chronic infection,part of an ageing phenomenon. whereas ccp at this stage appearsto be quite specific for rheumatoid. but it's also a poorerprognostic marker, particularly if you haverheumatoid-factor positive and anti-ccp-positivelooking 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 bothrheumatoid-factor-positive and ccp-positive, your chances of havingerosive, damaging rheumatoid arthritis at two years are very high. it's like a 90% predictive value thatyou will have an erosive disease. so they're quite strongprognostic 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 thatprognostic-marker stuff, it means a bit more to them,

that it is worth the trade-offof the potential for side effects and the things they worry aboutwith their drugs. it's worth taking that trade-off. john, what's the role of the gpin all this? we've alluded that we expect the gpto refer promptly, maybe do tests first. what else? because if you taketype-1 diabetes an an example, most gps run for the hills. if you don't run for the hills, the local children's hospitaltakes 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 persistentjoint swelling and other symptoms, with or without the testsbeing positive or not, they need to consider that diagnosis. in the longer term, there's that rolefor gps as in so many chronic diseases, to help maintain the patient, help to coordinate care withprofessionals that would be involved. lyn, some people would argue

that remission is no more erosionsin your joints. in addition to what you said,you stop the disease in the joints dead. is that what you aim forin your remission? that's the ideal, that you seeno more damage in the joints. x-ray is the crudest wayto see erosions. as time progresses and maybe mribecomes cheaper and doppler ultras, at the momentthey're research techniques. there are a number of techniques to showvery early changes in the joints. you'd want to see that those changeswere switched off. that's remission.

people who appear to bein 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 somebodyin rural australia, where it's not easy to getallied health professionals, how early in an ideal worldwould someone like you, louise, be brought in? our research suggests that the earlieryou intervene, the better. what's important is,the time when people are least likely

to do what's bestfor their own management is early on, when they're just adjusting to illness. they're adjusting to the ideathat they have an illness. if you don't believethat you have an illness, you won't do thingsthat will manage that illness. part of needing to acceptthat you need to take medication, that you need to develop a balancebetween rest and exercise and listen to your body, that you need to have an optimisticbut realistic attitude about the future

is really helpfulin terms of how you manage it. my own studies showedthat 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 usefewer health-care resources because they have managed their illnesswell enough in the shorter term that they actually become less disabledover time. that's doing evidence-based therapyas a psychologist, cognitive-behavioural therapyor interpersonal psychotherapy?

helping people to change what they doto respond to the illness so that they don't become overactiveon inflamed joints or at the same time don't respond tothe stiffness by inactivity, but foster that balancebetween rest and exercise and try and teach people skillsto 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 surgerywith stiffness of both her hands, wrists and shoulder joints. when john examines them, they'reslightly swollen, tender and painful. it's developed over the last few monthsand 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 torunning around with her children. - there's lots of tired mums out there.- there are. norman: it's winter. there's lotsof people with sore, aching joints.

it's part of that challenge,that soup you see in general practice, of trying to pick out the bitsyou 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 markersthat you should at least be thinking that this woman has the potentialfor 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 swellingin those areas as listed. i think with that presentation, it would be reasonable to do the testswe've discussed - an esr, crp,looking for evidence of inflammation and the time-honoured rheumatoid factorand an anti-ccp. what are you going to doif they're all negative? i suppose it would be reasonableto institute some therapy.

you'd be doing that in either sense, 'cause she's clearly in pain, it'sinfluencing her ability to function. norman: she says she's taken panadoland it doesn't make any difference. because she's young, it would be worthtrying anti-inflammatories. suggest ibuprofen if there weren'tany other reasons not to take that. see what that brought herin the short term. even just whileyou're waiting for the test, you could do the two thingsconcurrently, see if you can bring reliefwhile 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 uponhow she's functioning. we're talking about a six-week windowof 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 evidencethere was of inflammation.

if that was up, you'd want to get herto see someone much more rapidly. are non-steroidals liable to havean effect if it's rheumatoid, lyn? they'll help in early rheumatoid andmild disease, for early symptom control. they don't have any impacton 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 newbaby and tired, those sorts of things - but the alarm bells herethat she's got joint swelling. it's only slight, but it is alwaysonly slight in early rheumatoid.

the fact that that's persisted,you can't put that down to tiredness. there might be some hormonal changesand all of that sort of thing. she might be still breastfeeding. you'd need to weigh thatinto your decision-making for her. she might be thinking of more babiessoon, so that also influenceswhat you might do. non-steroidals could help hera little bit, but you wouldn't wantto 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 timeshe's seeing the rheumatologist, she can cancel the appointment. the other thing i'd try with her wouldbe 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 asnon-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 brandsnow.

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 upthe dosage of the dha and epa of the omega-3. norman: what's the equivalent doseyou're looking for? you need probably 3g to 4g of actual dhaor epa. norman: a day?- a day. which is quite a lot of omega-3, but it does take three to four weeksat least

to have its fullanti-inflammatory effect. but as a stop-gap measureif you're all negative. how often does a woman like thisturn up with negative tests, and do they become positive over time? rheumatoid factor and ccponly have about an 80% sensitivity. up to 20% of peoplewho have classic rheumatoid arthritis, including damaging and erodingtheir joints, are never positive. it's a very common scenario thatthey're negative in the first instance. in someone like lily,it's very common they would be negative.

they would become positiveover the next 12 months or so. unusual for the crp and esrto be totally normal. very unusual. you occasionally see very low levels, but people are stilldestroying their joints. it gets back again to, if you seejoint 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 rheumatologistfrom north queensland who said he's got a two-year waitto be seen.

yes, they might have a two-year wait, but i think all rheumatologists, if thepatient's been worked up appropriately and they get the call from the gp, all rheumatologists will respondto that in some way. if you've got the luxuryof the western australian situation, the community nurse will respond. most rheumatologists would welcomethe call from the gp that said, what tests will i dowhile they're waiting to see you? norman: john,what alternatives should you look for?

what's the differential diagnosisthat you should be eliminating? a younger female, it would be reasonableif you're ordering tests, do her ana. if that was positive, they'd do the morespecific things looking for lupus. with that number of joints, you wouldn'tbe thinking of things like gout. she's in the wrong age and gender. norman: does joint aspiration haveany role, if she's got a swollen knee? ah, yeah,you could certainly have a look. i'd have to depend uponringing 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 aspiratingbecause it might be infected. there might be crystals.there's no definitive diagnosis. sometimes you find the rheumatoid factorin the synovial fluid and you don't find it in the blood yet. in early rheumatoid,that can be positive. the white-cell countgives you some clues. and it can be therapeuticat 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 havebeen compared to, is methotrexate. we really put that upas the gold standard. but not every patientwants to take methotrexate. norman: but it's less toxicthan a non-steroidal. it is less toxic, but one does have tolimit alcohol intake

and you have to be monitored. not everyone is in a position to bemonitored or want to be monitored in terms of monitoring blood tests. not everyone wants to maintain healthyalcohol intake or no alcohol intake. some people want to become pregnant. there's a number of people that youdon't prescribe methotrexate to. you might just use methotrexateas a monotherapy, a single therapy, but there's a reasonablebody of evidence that if you havemore aggressive disease,

you're better off with a combination oftherapies that work in different ways. norman: hydroxychloroquine, salazopyrin. are the main threethat 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 remissionand early-symptom control, yes. but if they aren't workingwithin three to six months, according to our guidelines,you could get onto a biologic.

if you look at what's happeningat the joint level, synovial level, erosion level,the rate of remission is probably greaterif you add in a biologic early as well. by and large, the majority of peopleget very good response to early and pretty aggressive therapy,like treating to a target, treating to get their crp and esrin 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 drugshave 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 wantthe side effects of the drugs too because they see it as arthritis and notsomething that's going to kill them. the message with rheumatoid arthritisis, 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 killyou, or stroke, from the inflammation. at what point do the guidelines tell you to institute aggressivecoronary 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 womanwith two children fit that? hopefully not. hopefully she doesn'thave other factors. she is a smoker. you'd obviously be strongly into herabout, 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 evidencethat it helps symptoms, but people with rheumatoid arthritisget bad lung disease, bronchiectasis. if they smoke as well as have rheumatoidarthritis, they are at high risk. she should stop smokingfor lots of reasons, but cardiovascular risk-factormonitoring is critically important. all the traditional risk factorsare important, but maintaining a normal crpis important for the cardiovascular risk long-term. christine, how important ismultidisciplinary care,

particular in a country town,for somebody with rheumatoid arthritis? extremely important. cardiovascular disease and the likeare all slightly higher percentage in country and rural areas. if we've got rheumatoid arthritisadded 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 therapyto help them with daily activities. norman: psychologically, louise,what would you do for lily? the first thingyou'd want to talk to her about is what the long-term prognosis is, to help her, not to be concernedinappropriately about the future, but to take the illness seriously enough that she's motivated to try to get thatbalance between rest and exercise, even at a demanding timewhere she has so much going on. the need to prioritise her healthin 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 agentscan 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 usingthe shortest-acting anti-inflammatory

and timing when you breastfeed. listening to rheumatologiststalking about rheumatoid arthritis, they say prednisone is out. the occasional intra-articularinjection, but it's a matter of pride that they have an almost zeroprescribing of prednisone. they might all say that. and almost zero non-steroidals as well. it's certainly our aim to havepeople's disease controlled on disease-modifying agents alone.

but if you look at most long-standingrheumatoid patients, a vast majority - 40%, 50% -will be on some prednisone because it works so well. early regimens that treat to targetwith combination therapies all have some componentof the corticosteroid, either as intra-articular,multiple intra-articular, intramuscular or orallyor intravenously. steroids work very, very, well. they probably are also disease-modifyingagents in terms of reducing erosions.

norman: but you get hooked on them.- yes. it's hard to get back off it. they're very effectivefor controlling symptoms, and if there is some sort of delay, even though most rheumatologistsdo 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 yetor 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 modificationearly, but the trade-off is,you get atherosclerosis and coronary heart diseaseand risk factors longer-term. the surprise isthat something like methotrexate isn't as toxic as you think? that's right. it's got its potential forside effects and needs to be monitored, but it's safer than non-steroidals. somebody told me that a reducedwhite-cell count is good news - it shows it's working.

that's right. if your lymphocyte countis down a bit, it means it's having some modificationof 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 therefor the more common disorder, which is always a good conceptto go with first. does she have depression?that's the thing that may explain it. it's a difficult one, but that's whatgeneral 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 askingin 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 morefingers, than the base of the wrists. norman: distal ip joint ratherthan her metacarpophalangeal joint? yep. thinking of the classic gnarlidgeyou see in an elderly aunt or something. if she had other joints involved, that would make you think more stronglyrheumatoid, and maybe test for thatat the initial consultation, particularly if she hasn't feltshe'd had adequate response from taking paracetamoland anti-inflammatories. this is bilateral,whereas osteoarthritis

is usually one sideworse than the other. usually one side worse than the otherin terms of presentation. an obese female is more at riskof getting bilateral knee oa. she's had these recurrent attacks,she's got the joint swelling. she probably does have osteoarthritisand a bit of depression, but she seems to havea superimposed inflammation on that. a small percentage of osteoarthritiswill 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 presentationfor 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 peakof onset of rheumatoid, where you see it a bit later -late 60s, early 70s. males are often equally affectedas females.

they often have a polymyalgic onset, so looking a bit likepolymyalgia rheumatica. it can trick you sometimes. she's already triedthe anti-inflammatories. the mild inflammation of oawould 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 personthat 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 somethingto the gp, thinking it's unimportant. in spending a little more time, we find out something else thattriggers them being referred earlier. norman: which could save considerabledisability 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 questionscoming in.

from anne, a nurse in queensland - 'can having a blood transfusiontrigger rheumatoid?' there's epidemiological evidence that people who develop rheumatoidhave an increased chance of having had a blood transfusionin the past, so, yes is the answer to that. in terms of of absolute risk of everyonehaving rheumatoid after a transfusion, i'm not sure about the exact level. you'd need a genetic tendency as well.

a question from a physiotherapistin nsw - 'how often should patients with ra bereviewed by the general practitioner?' i'll quote back to the guidelines - you'd think at least three or four timesa year would be reasonable. it would depend on their clinical state and what other thingswere happening for them. a question froma gp in south australia - 'should a gp be prescribingcombination therapy?' i would be a bit reluctantunless the gp was very knowledgeable

and had other patientswith rheumatoid arthritis. there really isn't an exact numberof joints or an exact level of esr, crp that i would always prescribecombination therapy. i would be reluctant to recommendthat a gp did that. i would prefer that was donein 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 ofwhich one you ramp up or down and which ones to bring inat different times. christine, people often tell you thingsthey won't tell the doctor. a gp in nowra in nsw asks, 'many patients are reluctant to takemedications such as methotrexate early in ra. how would youconvince 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 thingthat happens when people hearthey're going to take methotrexate

is that they listen to everybodyaround them who says, it's toxic, don't take it. the way i use educationis 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 takein rheumatoid arthritis are very tiny and the toxicity is less. also, educate themabout the side effects. it would convince me if you told meit 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 whenpatients don't adhere well to medication it's because they have misunderstandingsabout the medications. it can be effective to ask the patienttheir concerns about taking them. nine times out of ten you'll find theirconcerns are based on misinformation or something they've been told. but you need a healthy respectfor the drug. you want them to have some concernbut not too much.

you want them to have enough concernto monitor it and take it properly, but not so muchthat they miss out on effective therapy. particularly in that early phase.they're often confused and overwhelmed. that's whenthey can't make the decision. it's the same balance you need themto have about the disease. you need them to have a respect for itbut not a fear of it. a question from janet atthe greater western area health service, which i assume is in new south wales - 'what's the earliest diagnosed agefor rheumatoid arthritis?' lyn?

you had the programfor juvenile idiopathic arthritis. in that spectrum of juvenile arthritis,there is a small subset who get a rheumatoidlike illnesseven 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 percentageof juvenile. but it can occur at any age.

it can start at any agelater in life as well. it's unusual to see it startingover 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 epacombined, at least 3g. you really need to look at theindividual preparations to see how much. they all saythey'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 oilthan capsules? lyn: cheaper to do it by liquid oil. elizabeth also asks, 'is there a rolefor paracetamol at any stage?' we say for any chronic-pain management,paracetamol should be first-line. it's a very good adjunctin that first setting - with paracetamoland perhaps some non-steroidals. at any time people have a flare, sometimes just a little additionalanalgesia is all that's needed to get back a little control.

yes, it does have a role. what do the guidelines say about whento refer to a rheumatologist, john, particularlyin someone like jean's case? she's had symptoms for some time, so you'd probably be doing testsand treat and refer within a tight time frame, a week or two depending on the resultsof initial tests. norman: do you agree? yes, i agree. jean would be onethat 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 certainlyget symptom relief from putting some corticosteroidin early. that might mean you'd need to referto the rheumatologist to do that. christine, what's the role of exercise,weight loss, lifestyle interventions? the role really comes aftertreatment has been instituted.

if people are suffering, they're ina lot of pain, they feel fatigued, then exerciseis probably fairly difficult. you can talk to them about it. nutrition is important. they needgood nutrition when they're unwell. well, all of the time,but particularly when they're unwell. but even in the settingof inflamed joints, a lot of people think it's getting backto your point of the right balance - a lot of people think they shouldn'tmove the swollen, painful joint. but some movementis how you get rid of the toxins,

how it actually improves mobility. norman: can you damage the jointwith exercise? very hard to damage the jointwith exercise. if you actually push it a little bit,you won't do any harm? you won't do any harm. it might flare upand be a bit more painful. even in acute inflammation,some gentle range of movement, some maintenancewith isometric exercises... muscles around an inflamed jointwaste very quickly. someone like jean, being olderand got poor quad strength already,

if she doesn't do any walkingor anything, she puts herself at riskof lots of other things. john, what do the guidelines sayabout complementary medicines? we've been talking about fish oilsas a therapy. that's pretty mainstream. there'srandomised control-trial evidence. ok, then. if we take the other sidearound 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 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 thisis that some things, that particular one is a chinese herb, the key thing for a gp is to know allthe things their patients are taking, because they're all taking something.

some of them, they're not harmful, butthey're not particularly useful either. does glucosamine have any influenceon ra? glucosamine doesn't have any rolein 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-managementand education program

run by arthritis western australiain perth. the course is a six-week program thatcovers a range of topics of interest to people with inflammatoryor rheumatoid arthritis, their partners and support people. we developed therheumatoid arthritis-education program because we had been runninggeneric arthritis programs and also the stanford chronic diseasesmanagement program, and it was apparent that we weren'tmeeting the needs of people with inflammatory arthritis

we did a needs assessmentand 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 weeksto 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 withhaving a chronic disease. we spend a whole sessionon the different types of medications and in which sequence they're given.

we talk about blood tests, what theymean, why they have them done. we talk about relaxation,we teach them relaxation techniques. it's important that they learnrelaxation and stress management. we talk about osteoporosis briefly because they're much more at riskof getting osteoporosis. we also encourage them to bring alongpartners and significant others. one of the issues they haveis telling people about this disease and how they cope with it. often, you don't talk openly amongstfriends or family or anybody

about the illnessbecause they're sick of hearing about it and you don't want to bore them. but when you are in a group like thatwith like-minded people sharing the experience,you realise, i'm very lucky. there are others far worse offthan i am. it's a support for each otherwithin that group framework that i found to be very valuable. for people to get into this program, they have to have a referralfrom their gp

or from their rheumatologistor other specialist. they have got to be diagnosed witheither 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 sortof people that we can help. people have got to learn to manage theirdisease, 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 thateither the disease can be in control or the doctor can be in controlor i can be in control. suddenly, i feel tremendousbecause i'm learning so much. i got a great sense of empowerment. it was to do with, i am the best personto 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 thoughtfor me. we now run this programin some of the rural areas. we run it in albany,we run it in kalgoorlie and manage it where we've gotrheumatology nurses. we're training health professionalsto run it in the eastern states. it's going to be run in victoria andqueensland and new south wales. i'm so alone with it. i didn't knowanybody with rheumatoid arthritis. i felt i was the only personwalking around - or limping around. the only person that takes two hoursto do the dishes.

the only personthat had to give up their job. just so many things i can't do -cross the road. can i cross the roadand have a cup of coffee? no, i can't. i wanted to know that there are otherpeople going through that with me. that was primarily the thingthat i wanted. but now i'm here, the information isinvaluable to me, it really is. i learned more in that six weeks' course than i had learnedin the previous 28 years of my illness. getting people, perhaps the elderlyones, back to playing bowls,

and just letting them know thatthey can play sport within their limits, and that they can have a lifewith rheumatoid arthritis. a lot of them seem to thinkthat their life was over. i thought, you're probably going to bein 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 destinywith the disease. hopefully it doesn't have to bethat difficult.

i've taken up exercise programssuch as tai chi. i do a lot more swimming than i used to to try and keep my fitness levelsand everything going while listening to my bodyand getting to know my body so that i don't do too much. but it has empowered meto take up a lot of the things that previously i had thoughtwere beyond me. one of the symptoms is depression. for many years, i did sufferquite severely with depression.

i was actually on medication for it. since doing the courseand understanding the illness, i have found other waysof overcoming depression. i no longer need to take medicationfor 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 knowledgethat the course brought me. the self-management and educationprogram in western australia.

is it widely applicable? people have criticised these programs,christine, saying it's fantasticfor middle-class, well-educated people who have got time to spend six weeks, and they're expensive and not broadlyapplicable to the general community. a lot of the generic programsare a bit like that. certainly in my experiencewith this particular program, patients are really interested inlearning more about their condition. you're saying it's got to behighly specific to the problem?

yes, i think so. this program fromwestern australia is disease-specific. people learn about their condition, about all the things that go withtheir condition - drugs, blood tests. they learn about communication, howto work with their health-care team. that sense of control can bean antidepressant in its own right. absolutely. you can see how peopleget 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 themselvesto do anything. then they have to take such small steps,they feel it's not even worthwhile. the key to the success of programslike this is when they get people to actuallychange what they're doing. if you can get people to changewhat they're doing, often you have a greater effecton behaviour. some of the old education programsdidn't translate the knowledge, which is essential, but not sufficientto affect behaviour change. what is the role of self-management?

it's very difficult to prove, usingconventional outcome measures, that it makes a difference. how do we provesomeone feeling more empowered? how do you measure empowerment,measure the change? how do you prove that those peopletake their medications better? in fact, maybe they don't. maybe they just feel better aboutmanaging 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 partof any chronic disease. there's certain generic elementsto all chronic-disease management. it's quite important that it's alsotailored and specific to the disease and the particular drugs. knowledge does help complianceand adherence with therapy. just some quick questions,'cause we're nearly out of time. any role in physiotherapy for heatin 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's an individual-patient thing. an acutely swollen joint -not so much hands - but an acutely swollen knee or anklecan respond to ice as well. a question from veronicain castlemaine in victoria - 'for patients who have avoidedmedications such as methotrexate for 10 or 20 yearsand have significant disability,

how much difference can biologicaltherapies 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 severeexacerbations and inflammation when they appear to have so-calledburned-out or damaged joints. so, yes, people with chronic damageare still getting benefit from biologics if they have ongoing inflammation. daniel from the universityof wollongong -

i think you've got this the wrong way. 'you mentioned methotrexatewas more harmful than nsaids.' we said it was less harmful than nsaids. could you elaborateon daniel's question? let's assume we're talking aboutless harmful than nsaids. this data comes fromepidemiological studies. there hasn't been a randomised-controltrial that compares the two. they're working in different ways. non-steroidals often have no benefitfor disease modification,

whereas methotrexatewill help put people in remission and control their disease. in terms of of the long-term effectsof the gi risk and cardiovascular risk from non-steroidals as people get older, those risks are higherthan the risk of methotrexate. the long-term risk of methotrexateis liver fibrosis, but that risk appears to be quite a bitlower than we used to worry about. people on methotrexate for many years,as long as that's monitored, they keep their alcoholto the reasonable controlled level -

two or less drinks and two alcohol-freenights a week, following the guidelines, the long-term risk of methotrexateis very low. there may be an increased riskof skin cancer in australia, but we have to be alert for that anyway. two questions from keith fromvictorian physiotherapy services - 'can the parvovirus trigger ra -the slapped cheek syndrome?' you can get a very classic polyarthritisfollowing a parvovirus infection. you can also gettransient rheumatoid-factor positivity. but mostly the polyarthritiswill be gone within four months.

occasionally you see people where it persistsas chronic rheumatoid arthritis. keith also asks, 'how often or whenshould an x-ray be taken of affected joints once a diagnosisof rheumatoid is made?' soon after commencing the dmards, it's useful to have a baseline x-rayof your hands and feet to identify whether you have erosions. it's not really worth repeating thatunder one to two years. you would at a time perhaps whenyou're thinking things are in remission

after a couple of years, to make sure. a question from roy froma therapy service in new south wales - 'what's the role of referral to occupational therapistsand hand therapists?' they're an important partof the multidisciplinary team. not every patient needs to see everymember 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 therapistis very important for helping with activities of dailyliving and joint-protection strategies. that's where you start to have problemswith access to servicesfor a lot of the multidisciplinary. although we say they should have it,not everyone has access to that. totally tangentially, one shouldn'tforget the feet in rheumatoid. the feet are sometimes to patientsthe most important part of them. that's part of what an occupationaltherapist or podiatrist can help with. we've covered flaxseed oiland preparation.

we're talking here about any omega-3preparation 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 alsofrom new south wales. the extent to which we shouldworry about the kidneys in ra? very unusual for the kidneys to beinvolved in the rheumatoid process. but it does happenthat you can get glomerulonephritis.

but that's unusual. you're thinking moreof vasculitis or lupus with that. some of the drugscan 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 muchimpact on the kidneys. it's been a very informative program. what are your take-away messages,louise? it's important to remember that patientsneed to understand about their illness. try and get that balancebetween rest and exercise

and try and develop that healthy respectfor the illness whereby they take itsufficiently seriously but not to the degree to which they'refrightened 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 ontodisease-modifying agents early is important, and linking in with yourrheumatologist as early as possible. ra is uncommon, but it's importantto 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 programon the new clinical guideline on diagnosis and managementof early rheumatoid arthritis. thanks to the department of health andageing for making the program possible. thanks to you in such large numbersfor attending and asking questions. if you're interested in obtainingmore information, there are a number of resourcesavailable, including links to the guideline, don't forget to complete and send inyour evaluation forms

to register for cpd points. i'm norman swan. goodnight. closed captions bycaptioning & subtitling international funded by the australian governmentdepartment of families, housing, community servicesand indigenous affairs�

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