and finally advances in rheumatic disease management

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and finally advances in rheumatic disease
management

• Dr Peter Lanyon
• Consultant Rheumatologist
• Nottingham University Hospitals

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

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potential diagnoses

• rheumatoid arthritis
• biomechanical (hypermobility, RSI )
• fibromyalgia

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medical prestige

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

500 GP, 300 Consultants, 490 students BMJ, 2007
335 632
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assessment

• widespread pain poor sleep
• workforce change, huge backlog
• Fibromyalgia
• trials of amitriptylline, NSAIDS
• sort of got better

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6 months later
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best possible care

• analgesics, NSAIDS, steroids
• Disease Modifying drugs
• intensive physiotherapy
• occupational therapy
• several hospital admissions

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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

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what happened ?

• applies for medical retirement
• not likely to ever work again

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one year later

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

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IL-1
TNF?
overwhelmed
pro-inflammatory
anti-inflammatory
weight loss, fatigue, low mood central
sensitisation
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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

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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
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risk factors

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

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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

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9 months out of work

• re-referred with sciatica and night pain
• second MRI unchanged

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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

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progress

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

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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

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care worker

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

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3 years later

• anti-CCP antibodies
• Palindromic arthritis
• cured with hydroxychloroquine
• often considered mad

Hench Archives Internal Medicine 1944 Russell
J Rheumatol 2008
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checkout worker

• aching in hands
• recent change in duties
• looked slightly large
• definitely not arthritis

MCP
phalanx
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implications

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

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manager

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

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the patient journey

• exclude demyelination
• other symptoms
• chest pain
• dyspnoea
• refer to cardiology

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cardiology

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

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gastroenterology

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

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haematology

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

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fibromyalgia
11/18

• chronic widespread pain
• entirely clinical diagnosis
• no diagnostic tests
• many auxiliary symptoms

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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
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exclusions

• fatiguing medical conditions
• sleep apnoea
• organic brain disease, MS, muscle disease
• endocrine disorders, coeliac
• psychiatric conditions
• schizophrenia, bipolar, eating disorders
• alcoholism

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2299 random subjects Manchester
Int J Epid 2006 35 468-476
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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

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• 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
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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
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predictors of chronic fatigue

• greater pre-morbid physical activity
• exercise in early adult life, lower BMI
• occupational stress
• 65 mention contributory
• somatic attributions

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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

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Transition acute to chronicadaptive short term
reactions

• cognitive
• higher attention to sensations, catastrophising
• physiological
• higher autonomic arousal, muscle tension
• behavioural
• avoidance

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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
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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

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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
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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
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Land based exercise vs deep water running in FMS
Arthritis Rheum. 2006 Feb 1555(1)57-65.
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FDA approval pregabalin

• 300 - 450 mg for 8 weeks
• outcome 50 reduction in pain score
• 13 placebo
• 30 pregabalin

Arthritis Rheum 2005521264
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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

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prognosis

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

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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

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poor outcome..

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

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ill health retirement

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

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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?

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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