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and finally advances in rheumatic disease management

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what is likely to happen to your employee. optimum rehabilitation 'pathways' ... refer to cardiology. cardiology. non cardiac chest pain. other symptoms. bloating ... – PowerPoint PPT presentation

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Title: and finally advances in rheumatic disease management


1
and finally …advances in rheumatic disease
management
  • Dr Peter Lanyon
  • Consultant Rheumatologist
  • Nottingham University Hospitals

2
  • what is likely to happen to your employee
  • optimum rehabilitation pathways
  • likelihood of retirement DDA territory
  • is your employee receiving the best care

3
potential diagnoses
  • rheumatoid arthritis
  • biomechanical (hypermobility, RSI )
  • fibromyalgia

4
medical prestige
  • heart attack
  • spleen rupture
  • 3 leukaemia
  • 4 brain tumour
  • 38 fibromyalgia

500 GP, 300 Consultants, 490 students BMJ, 2007
335 632
5
assessment
  • widespread pain poor sleep
  • workforce change, huge backlog
  • Fibromyalgia
  • trials of amitriptylline, NSAIDS
  • sort of got better

6
6 months later
7
best possible care
  • analgesics, NSAIDS, steroids
  • Disease Modifying drugs
  • intensive physiotherapy
  • occupational therapy
  • several hospital admissions

8
RA work disability
  • 12 000 new cases per year (aged 25-55)
  • 25 stop work in 2 years, 40 in 5 years
  • ¼ m lost productivity per person
  • biggest predictors
  • severity of morning stiffness at baseline
  • early control of disease

9
what happened ?
  • applies for medical retirement
  • not likely to ever work again

10
one year later
  • could you write to the OH dept of my new
    employer certifying that I am completely fit for
    full time work

11
IL-1
TNF?
overwhelmed
pro-inflammatory
anti-inflammatory
weight loss, fatigue, low mood central
sensitisation
12
targeted therapy
Methotrexate /- steroids for all patients
  • biologic agents safe and effective
  • screen for TB
  • no workplace risks
  • are your employees in remission
  • if not, ask why not

13
OH implications
  • early practical support
  • fatigue, morning stiffness
  • not retirement unless anti-TNF ?
  • should employees have earlier access?
  • fibromyalgia not all that it seems

NRAS publications
14
risk factors
  • occupational factors
  • silica asbestos dust
  • health professionals?
  • smoking, eating red meat
  • but alcohol protective

15
plumber
  • 6 months low back pain
  • rheumatologist mechanical pain
  • spinal unit minor disc disease on MRI
  • vortex of progressive disability
  • very little prospect for work adjustment

16
9 months out of work
  • re-referred with sciatica and night pain
  • second MRI unchanged

17
work disability
  • 200,000 people living with spondylitis
  • young men of early working age
  • 3x higher unemployment rate
  • 23 retire early due to health
  • more likely to have depression/anxiety

18
progress
  • anti-TNF eligibility on pain scores
  • off all analgesia in 2 week
  • spinal movements all improved
  • back in full time work

19
OH implications
  • iceberg of inflammatory back pain
  • therapies for untreatable disease
  • many of these patients have left work
  • if not in remission why not
  • workplace adjustments less important than getting
    the right medical treatment

20
care worker
  • intermittent severe joint pain
  • lasted 1-2 days
  • never witnessed by any doctor or employer
  • rheumatologist
  • tests normal
  • no explanation (probably fibromyalgia)

21
3 years later
  • anti-CCP antibodies
  • Palindromic arthritis
  • cured with hydroxychloroquine
  • often considered mad

Hench Archives Internal Medicine 1944 Russell
J Rheumatol 2008
22
checkout worker
  • aching in hands
  • recent change in duties
  • looked slightly large
  • definitely not arthritis

MCP
phalanx
23
implications
  • potential for earlier diagnosis
  • US and anti-CCP
  • sceptical about non-organic labels
  • some inflammatory arthritis has a mechanical
    trigger

24
manager
  • shoulder, neck pain, tennis elbow
  • recurrent sore throat
  • tinnitus, blurred vision, headaches, tingling
  • I need to see a specialist about all this

25
the patient journey
  • exclude demyelination
  • other symptoms
  • chest pain
  • dyspnoea
  • refer to cardiology

26
cardiology
  • non cardiac chest pain
  • other symptoms
  • bloating
  • alternating bowel habit
  • refer gastroenterology

27
gastroenterology
  • OGD colonoscopy normal
  • new symptoms
  • sweats
  • mild lymphadenopathy
  • recurrent sore throats
  • refer haematology

28
haematology
  • normal CT and bone marrow
  • borderline neutropenia
  • ? autoimmune disease
  • refer rheumatology

29
fibromyalgia
11/18
  • chronic widespread pain
  • entirely clinical diagnosis
  • no diagnostic tests
  • many auxiliary symptoms

30
CFS/ME, FMS
  • fatigue, post exertional
  • not relieved by rest
  • poor sleep
  • low mood
  • headaches, dizzyness
  • sensitive to noise, lights
  • reduced concentration
  • blurred vision
  • tingling numbness

facial pain abdominal pain irritable bladder dry
skin raynauds
31
exclusions
  • fatiguing medical conditions
  • sleep apnoea
  • organic brain disease, MS, muscle disease
  • endocrine disorders, coeliac
  • psychiatric conditions
  • schizophrenia, bipolar, eating disorders
  • alcoholism

32
2299 random subjects Manchester
Int J Epid 2006 35 468-476
33
medically unexplained
  • functional somatic syndromes
  • not conventionally defined diseases
  • 20 of primary care
  • 35 of OPD (each specialty)
  • not the worried well
  • more disabled than MS or RA

34
  • no intrinsic abnormality
  • usually painful (not just FMS)
  • pain response to normal stimuli
  • 25 with no pain have gt5 tender points
  • assoc with distress/somatisation of distress

more likely to get CWP if more tender points
Ann Rheum Dis 200766517-521
35
associations of chronic widespread pain
  • common factors
  • female gender 1.8
  • health anxiety 3.5
  • adverse life events 2.3
  • predictors
  • somatic symptoms 1.8
  • illness attitude 3.3
  • sleep problem 2.7
  • but not low pain threshold

Prospective 3171 subjects, free of CWP, 15 month
FU Rheumatology. 46(4)666-71, 2007
36
predictors of chronic fatigue
  • greater pre-morbid physical activity
  • exercise in early adult life, lower BMI
  • occupational stress
  • 65 mention contributory
  • somatic attributions

37
where does it start ?
  • onset sudden or gradual
  • after illness or stress event
  • may not present with fatigue and pain
  • symptoms evolve in intensity
  • delayed symptoms after activity
  • diagnosis rests on alert clinician

38
Transition acute to chronic adaptive short term
reactions
  • cognitive
  • higher attention to sensations, catastrophising
  • physiological
  • higher autonomic arousal, muscle tension
  • behavioural
  • avoidance

39
practical management
  • acknowledge reality and impact
  • causes and course
  • discuss intervention strategies
  • early information on return to work
  • joint clinic with Liaison Psychiatry

definite diagnosis reduces resource utilisation
40
cognition and behaviour
  • perpetuates symptoms and disability
  • If I carry on being active I will be off work
    for weeks
  • CBT effective in 10 RCTs, NNT 2
  • reduced symptoms
  • improved functioning and QOL
  • 70 much or very improved at 5 years

41
80 of trials show benefit
  • mainly sleep and well-being
  • prozac amitriptylline better than either
  • citalopram ineffective
  • trazadone personal choice
  • duloxetine gt30 pain reduction
  • 55 vs 30
  • independent of mood

EULAR Ann Rheum Dis Feb 08 Cochrane Reviews
42
graded exercises
  • professionally mediated and agreed
  • patient in control of activity and rate
  • improves mental and physical fatigue
  • disability, sleep, mood, cognition
  • effect at 3 -9 months
  • greatest benefit in most disabled

EULAR Ann Rheum Dis Feb 08
43
Land based exercise vs deep water running in FMS
Arthritis Rheum. 2006 Feb 1555(1)57-65.
44
FDA approval pregabalin
  • 300 - 450 mg for 8 weeks
  • outcome 50 reduction in pain score
  • 13 placebo
  • 30 pregabalin

Arthritis Rheum 2005521264
45
not recommended
  • no evidence
  • steroids, thyroxine, magnesium
  • NADH, amphetamines
  • diet supplements except vitamin D
  • keeping activity at less than full capacity
  • complete rest during setback

46
prognosis
  • 20-50 improve in medium term
  • 6 achieve normality
  • 10 severely disable
  • interventions difficult to sustain
  • better in primary care

47
Occupational liaison
  • resolve work satisfaction
  • bullying culture
  • workplace adjustments
  • work capability influenced by
  • number of physical complaints
  • difficulty getting on with people
  • not an important part of my life

48
poor outcome…..
  • pursuit of retirement or disability claim
  • co-existent psychiatric disorder
  • high focus on bodily symptoms
  • low sense of control
  • but NOT severity

49
ill health retirement
  • is diagnosis correct
  • treatment of associated depression
  • have all treatment avenues been explored
  • by an appropriate clinician
  • with a multidisciplinary team

50
suboptimal care
  • made to feel malingerers
  • exaggeration, inappropriate signs
  • but not conscious or controllable
  • if you have to prove you are unwell
  • how can you ever afford to get better?

51
conclusions
  • major advances in inflammatory disease
  • earlier diagnosis
  • targeted therapy may avoid retirement
  • better understanding of FMS/ME/CFS
  • evidence based treatment
  • greater awareness of complexity
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