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Practice Nurse

Inflammatory arthritis

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The inflammatory arthropathies affect both young and old and are immune modulated diseases. The three main conditions are rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA) which also encompasses ankylosing spondylitis (AS).

Early diagnosis and effective treatment is very important in order to maintain physical function and prevent deformity and further systemic complications to the patient. NICE and SIGN have published a number of guidance documents, along with technology appraisals, to ensure patients are treated appropriately.

This resource, consisting of nine assessment questions at intermediate level, tests your knowledge of the treatment of inflammatory arthritis based on national guidance. Complete the resource, including some or all of the reflective activities, to obtain a certificate of completion of continuing professional development to include in your revalidation portfolio. Record the time spend on this resource in your CPD log.

On completion of this resource you should have an understanding of:

The role of medication in controlling various types of inflammatory arthritis

The importance of maintaining a healthy lifestyle in patients with inflammatory arthritis

The importance of effective and ongoing monitoring to assess and optimise the impact of interventions

Oxford Handbook of Musculoskeletal Nursing, Oliver S (ed) OUP, 2009, ISBN 9780199238330

NICE CG79 Rheumatoid arthritis in adults: management 2009

BSR and BHPR guideline for the treatment of axial spondyloarthritis (including ankylosing spondylitis) with biologics, Hamilton L, et al Rheumatology 2016 56 (2) 313-316

Psoriatic arthritis: a case for shared care

Inflammatory arthritis: Part 2 – Axial Spondyloarthritis

Elizabeth is 48 years old and has just been diagnosed with rheumatoid arthritis (RA) by the local rheumatology department. She is overweight with a BMI of 29.7 kg/m

, smokes 10 cigarettes per day, works full time as a receptionist and has a sedentary life-style. She has 2 children of school age. Which of the following does NICE suggest should be first line treatment for Elizabeth?

The NICE guidelines for the management of Rheumatoid Arthritis (CG79) suggest that newly diagnosed patients should be offered a combination of disease modifiying antiarthritis drugs (DMARDs), including methotrexate and at least one other DMARD, plus short-term glucocorticoids, as first-line treatment as soon as possible, preferably within 3 months of the onset of symptoms. Oral NSAIDs can be offered for symptom control.

Elizabeth’s life-style is clearly not ideal and healthy life-style advice is therefore appropriate as well, but should not replace adequate, first line pharmacotherapy.

Disease activity should be monitored and the patient reviewed in 4-6 weeks.

Access the information on the Arthritis Research UK website at 

http://www.arthritisresearchuk.org/arthritis-information/conditions/rheumatoid-arthritis/treatments/dmards.aspx

What information do you hold in the practice that would be helpful for patients?

Question 1

Six months later Elizabeth is tolerating her medication – methotrexate, folic acid and hydroxychloroquine and has been reviewed regularly in the rheumatology department, her disease is under good control and she feels well. It’s autumn and you are looking at who is eligible for flu vaccination. Should Elizabeth be offered flu vaccination?

Yes - DMARD therapy works by suppressing inflammation modulated by the immune system and is therefore immunosuppressant. People who taking an immunosuppressant should be offered the annual flu vaccine along with the pneumococcal vaccine. The pneumococcal vaccine is normally given before DMARDs or biologic drugs are commenced. Only live vaccines should be avoided in patients who are taking immunosuppressants.

http://www.arthritisresearchuk.org/arthritis-information/daily-life/vaccinations.aspx

Which of the vaccines that you administer in the practice are ‘live’ and therefore contraindicated in patients taking DMARD and biologic therapies? Review the 

Do you routinely ask about the treatments that patients are taking before you administer vaccines?

Question 2

Elizabeth has been advised by the rheumatology department to stop smoking as this has been linked to the development of RA, reduced response to DMARD therapy and increase in progression of the disease. What other lifestyle choices could help Elizabeth manage her disease?

Maintaining a healthy weight – and taking regular exercise – is extremely helpful in reducing the impact of RA on the patients’ life:

Obesity decreases the odds of achieving remission in RA and negatively impacts disease activity and patient-reported outcomes during therapy.

Elizabeth needs to learn to strike a balance between rest and exercise. Rest makes inflamed joints feel more comfortable, but without exercise joints stiffen and muscles become weaker. High impact exercise, such as step exercise or road running, are best avoided, but lower impact exercise, such as walking, cycling, swimming, yoga and aquarobics can be beneficial.

Impact of Obesity on Remission and Disease Activity in Rheumatoid Arthritis: A Systematic Review and Meta-Analysis Yang Liu et al Arthritis Care and Research Volume 69, Issue 2 February 2017 Pages 157–165 

http://onlinelibrary.wiley.com/doi/10.1002/acr.22932/full

What facilities are available in your area that you could refer patients like Elizabeth to? For example, is there an exercise on prescription scheme?

Review the patient information you hold in the surgery about healthy exercise. Is it suitable for patients with inflammatory arthritis?

Question 3

Mike is a 36 year old builder who was diagnosed with ankylosing spondylitis (AS) 10 years ago. He is currently managed on naproxen 500mg bd. He has an appointment with the nurse practitioner in the GP surgery, as he has had ongoing problems with diarrhoea and cramping in his abdomen for 3 months. He says he has noticed some blood in his stools. Following investigations he is diagnosed with Crohn’s Disease and prescribed mesalazine 1.5gm daily.

What is the incidence of clinical inflammatory bowel disease in people with AS?

Inflammatory bowel disease is a known extra articular manifestation of ankylosing spondylitis (AS) and can occur at any time during the course of the disease, or even precede it. Other extra articular manifestations include uveitis, cardiac disturbances and psoriasis.

Mielants H and Van Den Bosch F. Extra-articular manifestations. Clin Exp Rheumatol.2009;27(4 Suppl 55):S56-61 

http://www.clinexprheumatol.org/article.asp?a=3709

How much do you know about the extra-articular manifestations of inflammatory arthritis? The Mielant and Van Den Bosch paper 

Question 4

Mike is reviewed by the rheumatology team and is found to have active ankylosing spondylitis (AS), a condition now included in the umbrella term axial spondyloarthritis (axSpa), a term that encompasses both AS and non-radiographic axSpA. Which of the following is NOT a characteristic of axSpA?

Not every patient with axSpA experiences severe symptoms or disability, and some patients do not seek treatment. For most, however, low back pain is accompanied by prolonged early morning stiffness, and which can be experienced as diffuse pelvic pain or sciatica, and progressive loss of function. Untreated, this can lead to long-term disability. The use of biologic agents has transformed the treatment of AS, and these will generally be initiated after assessment using the Bath Ankylosing Spondylitis Activity Index (BASDAI), the gold standard tool for measuring disease activity in people with this condition. It consists of six questions which relate to pain, stiffness and fatigue using a visual analogue score or 0-10 which the patients completes relating to his/her disease activity over the previous week. The score can range from 0 -10, and a score of over 4 is regarded as severe disease activity. BASDAI is a key factor when deciding whether to prescribe anti-tumour necrosing factor (TNF) treatment for patients with axSpA.

Garrett S et al. A new approach to defining disease status in ankylosing spondylitis: the Bath Ankylosing Spondylitis Disease Activity Index. J Rheumatol 1994; 21(12): 2286–2291.

Zochling J, Braun J. Assessments in ankylosing spondylitis. Best Pract Res Clin Rheumatol 2007; 21(4): 699–712.

National Institute for Health and Care Excellence. TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis. (TA383) February 2016. available from www.nice.org.uk Accessed March 2016

Inflammatory arthritis: Part 2 – Axial spondyloarthritis

 by Kate Gadsby and Tricia Cornell, which provides a more detailed explanation of the BASDAI and how it is used.

Question 5

Mike’s BASDAI is 4.5 and he meets the criteria to try anti-an anti-tumour necrosing factor (TNF) therapy for his AS. The Crohn’s disease will impact on the choice of biologic and Mike is commenced on a monoclonal antibody TNF inhibitor, as per NICE guidelines. The new medication is delivered via a homecare service, and is administered via a pen device. Mike is taught how to self-administer the drug. Six months after commencing his new medication Mike is seen in the surgery complaining of a sore throat, he has a slight temperature (37.5) and is asking for antibiotics. He is due to take his anti-TNF medication the following day.

Patients taking biologic medications have an increased risk of infection. If the patient has an infection it is important that they omit their biologic medication until the infection has passed. If a bacterial infection is suspected then antibiotics should be prescribed and the biologic therapy omitted until the course of antibiotics completed. If in doubt the practice nurse should always contact the rheumatology specialist nurse for advice.

Royal College of Nursing (2015) Assessing, managing and monitoring biologic therapies for inflammatory arthritis. RCN 

https://www.rcn.org.uk/professional-development/publications/pub-004744

Singh JA, Wells GA, Christensen R, et al. Adverse effects of biologics: a network meta-analysis and Cochrane overview. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD008794. DOI: 10.1002/14651858.CD008794.pub2

Do you know how to contact your local Rheumatology Specialist Nurse? If you do not, find out. Invite him or her to the practice to discuss how to improve shared care between primary and secondary care in your locality.

Question 6

Celia is 55 years old and has had Psoriatic Arthritis (PsA) for over 10 years. Her disease is generally under good control with methotrexate and anti-TNF therapy. She has an appointment with you for her annual flu vaccination and she tells you that she’s about to be admitted for an operation on her bunions – she asks which medication she should stop prior to surgery as she’s sure something has to be stopped but can’t remember which one.

It is advisable to stop biologic therapy prior to surgery and recommence following healing of the wound. Methotrexate can continue. However, this is a specialist area of practice and the practice nurse should seek further advice from the Rheumatology Specialist Nurse.

Question 7

Celia has had her foot operation and the wounds have healed well. She continued her methotrexate throughout this episode of care and has just recommenced her anti-TNF therapy. She is complaining that she has some stiffness in her joints and asks if there anything you can do to help. What is your advice?

It is not unusual for patients to suffer a flare of their disease if their medication is stopped for any reason. In Celia’s case she had been under good control and is likely to respond to the recommencement of her therapy. In the meantime it is reasonable for her to use self-management techniques to manage her stiffness. However if the stiffness does not abate than she should be encouraged to either call the surgery or the Rheumatology telephone advice line.

Review the patient information you hold in the practice for the safe use of hot and cold packs.

Take a look at the information on the Arthritis-Health website: 

http://www.arthritis-health.com/treatment/alternative-treatments/applying-heat-vs-cold-arthritic-joint

Question 8

Celia’s PsA has responded to the self-management techniques and the recommencement of her biologic therapy. She is with you for an annual review – what are you going to check?

PsA in common with other inflammatory arthropathies is associated with depression, metabolic syndrome, cardiovascular disease, type 2 diabetes and osteoporosis. Annual review is therefore recommended and can be carried out either by the rheumatology department or the GP practice.

Scottish Intercollegiate Guidelines Network Guidelines on the diagnosis and management of psoriasis and psoriatic arthritis in adults. October. 2010 SIGN Edinburgh 

http://www.sign.ac.uk/guidelines/fulltext/121/recommendations.html#

Search the practice database for patients with a diagnosis of PsA. Who conducts the annual review of these patients? If this is done in the practice review the practice template against the SIGN recommendations. Does the template cover all the required areas?

Inflammatory arthritis

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