rheumatoid arthritis - nhs education for scotland...rheumatoid arthritis. • define the current...

Educational Solutions for Workforce Development

Pharmacy

Rheumatoid Arthritis

Carole Callaghan

Principal Pharmacist

NHS Lothian


Pharmacy Aim

To update pharmacists on the current

management of rheumatoid arthritis and

explore ways to implement

pharmaceutical care for this patient group

as part of normal working practice.


Pharmacy Objectives

• Describe the common signs and symptoms associated with

rheumatoid arthritis.

• Define the current therapeutic management for both the

alleviation of symptoms and for modifying disease progression

in rheumatoid arthritis.

• Identify pharmaceutical care issues and appropriate

management solutions when responding to symptoms in patient

scenarios.

• Explore how to implement the principles of a pharmaceutical

care needs assessment tool in practice.


Pharmacy Rheumatoid Arthritis

A chronic systemic inflammatory disease,

characterised by potentially deforming

symmetrical polyarthritis and extra-

articular features.


Pharmacy Epidemiology

• prevalence approx. 1% in UK

• 3:1 ratio of females:males affected

• peak onset 40 and 50 years of age

• genetic, environmental and infective

factors involved in disease development


Pharmacy Pathogenesis

• cause remains unknown

• toxic substances found in synovium

• destruction of joints

• immunological disturbances identified

• RA is an autoimmune disease


Pharmacy Pathology

• disease of the synovium

• inflammation due to infiltration of

lymphocytes, macrophages etc

• proliferation of cells results in ”pannus”

formation


Pharmacy Pathology


Pharmacy Symptoms

• joint pain (usually worse on waking)

• morning stiffness (can vary in duration)

• general symptoms e.g. fatigue, malaise,

bone ‘ache’


Pharmacy Signs

• swelling

• tenderness

• reduced range of movement

• deformities (if untreated over long-term)

• extra-articular features e.g. nodules,

anaemia of chronic disease, pleural

effusion


Pharmacy Signs


Pharmacy Joint involvement

• hands/wrists

• elbows/shoulders

• cervical spine

• knees

• ankles/feet

• unpredictable pattern


Pharmacy Investigation

• Imaging e.g. x-ray, ultrasound, MRI

• FBC and ESR

• Other tests e.g RhF, anti-CCP

(antibodies)


Pharmacy Management (1st stage)

• lifestyle – maintain where possible

• multidisciplinary e.g.

– physiotherapy

– occupational therapy

– podiatry


Pharmacy Management (2nd stage)

• relief of symptoms


Pharmacy NSAIDs

• more effective than simple analgesics

• variation in response

• balance efficacy

• and toxicity


Pharmacy NSAID toxicity

• related to dose and duration of therapy

– GI

– renal and cardiovascular

– elderly more at risk


Pharmacy GI toxicity

• well documented in literature

• identifiable risk factors e.g. age, previous history, other medication (steroids, warfarin), alcohol

• improved use secondary to identifying those at risk and using gastroprotection


Pharmacy NSAID summary

• use lowest dose compatible with

symptom relief

• use gastroprotection in “at risk” patient

• reduce and, if possible, withdraw when

good response from DMARD


Pharmacy COX-2 Inhibitors

• selectively block COX-2 isoenzyme

• provide pain relief (as efficacious as NSAIDs)

• less GI bleeding than NSAIDs (less significant

GI symptoms remain e.g. dyspepsia)

• CV risk


Pharmacy Management (3rd stage)

• long-term suppressive drug therapy with

disease modifying anti-rheumatic drugs

(DMARDs)


Pharmacy Early DMARD

• stabilise joint function as early as

possible = better outcome

• greater awareness of NSAID toxicity

• DMARDs slow disease progression


Pharmacy DMARDs

• efficacy .vs. toxicity

– methotrexate and sulfasalazine have

the best efficacy:toxicity ratio in meta-

analyses

• Increased use of combination therapy –

TICORA, COBRA, BeST.

– better than sequential monotherapy


Pharmacy DMARDs (cont)

• DAS28 (Disease Activity Score)

-swollen joints

-tender joints

-ESR

-patient’s general health score

• Monitoring

-FBC

-LFTs

-U&Es

-BP

-urinalysis


Pharmacy Systemic corticosteroids

• not recommended for routine use

• if necessary, use lowest dose, shortest

time

• monitor due to side effect profile


Pharmacy Intra-articular corticosteroids

• “target” joint i.e. one or two large joints affected, can avoid systemic steroid

• maximum number per joint/time – but no evidence for this theory

• evidence lacking for this practice,

but patients report benefit


Pharmacy Biologic Pathways


Pharmacy Nomenclature

-ximab Chimeric antibody

-zumab Humanised antibody

-umab Human antibody

-cept Fusion protein


Pharmacy Immunogenecity


Pharmacy

Eligibility Criteria for Biologic Therapy

(BSR)

DAS28 >5.1

At least 2 previous DMARDs

Adequate response at 3 months

3-monthly monitoring


Pharmacy TNF a

Four agents currently licensed in UK and

SMC approved:

infliximab (human antichimeric antibody)

etanercept (fusion protein)

adalimumab (fully humanised monocloncal antibody)

golimumab (human monoclonal antibody)


Pharmacy Effects of Blocking TNFa

Immunology

RF, T cell function restored

Inflammation

Cytokine production in joints (IL1, IL6, TNF)

Angiogenesis

levels of angiogenesis

Joint destruction

damage to bone and cartilage

Haematology

platelets, fibrinogen, restoration of Hb


Pharmacy Infection

Do not initiate in presence of serious

active infection or in patients at high risk

of infection

Discontinue in presence of serious

infection


Pharmacy Tuberculosis

Screen for TB

Active TB needs to adequately treated

Prophylactic anti-TB therapy for potential latent

disease

Monitor during/after biologic; treat if required


Pharmacy Vaccination

Data limited

Influenza and pnuemococcal

recommended

Live vaccines not recommended


Pharmacy Malignancy

No increased risk of solid tumours or

lymphoproliferative disease

Investigate/stop therapy

Caution in pre-malignant conditions

Preventative skin care/ongoing surveillance


Pharmacy Rituximab

With MTX only

Inadequate response or intolerant of other

DMARDs, including at least one anti-TNF

By specialists in accordance with criteria


Pharmacy Abatacept

Selective T cell co-stimulation modulator –

blocks the co-stimulatory signal required for full

T cell activation

Not recommended by SMC and reserved for

refractory disease. However, this advise superseded by

NICE MTA 195 and can now be used in those who have failed

DMARDs or anti-TNF

With MTX only and available as IV infusion or SC injection


Pharmacy Tocilizumab

Recommended by SMC for combination

or monotherapy

Can be used as first-line biologic in those who are

intolerant of MTX or where continued MTX not suitable

ADRs - monitoring important e.g. liver enzymes,

neutropenia, lipids


Pharmacy Summary

• RA = inflammatory & destructive

• symptomatic relief

• early disease modification

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