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Educational Solutions for Workforce Development
Pharmacy
Rheumatoid Arthritis
Carole Callaghan
Principal Pharmacist
NHS Lothian
Educational Solutions for Workforce Development
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.
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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.
Educational Solutions for Workforce Development
Pharmacy Rheumatoid Arthritis
A chronic systemic inflammatory disease,
characterised by potentially deforming
symmetrical polyarthritis and extra-
articular features.
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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
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Pharmacy Pathogenesis
• cause remains unknown
• toxic substances found in synovium
• destruction of joints
• immunological disturbances identified
• RA is an autoimmune disease
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Pharmacy Pathology
• disease of the synovium
• inflammation due to infiltration of
lymphocytes, macrophages etc
• proliferation of cells results in ”pannus”
formation
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Pharmacy Pathology
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Pharmacy Pathology
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Pharmacy Symptoms
• joint pain (usually worse on waking)
• morning stiffness (can vary in duration)
• general symptoms e.g. fatigue, malaise,
bone ‘ache’
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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
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Pharmacy Signs
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Pharmacy Joint involvement
• hands/wrists
• elbows/shoulders
• cervical spine
• knees
• ankles/feet
• unpredictable pattern
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Pharmacy Investigation
• Imaging e.g. x-ray, ultrasound, MRI
• FBC and ESR
• Other tests e.g RhF, anti-CCP
(antibodies)
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Pharmacy Management (1st stage)
• lifestyle – maintain where possible
• multidisciplinary e.g.
– physiotherapy
– occupational therapy
– podiatry
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Pharmacy Management (2nd stage)
• relief of symptoms
Educational Solutions for Workforce Development
Pharmacy NSAIDs
• more effective than simple analgesics
• variation in response
• balance efficacy
• and toxicity
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Pharmacy NSAID toxicity
• related to dose and duration of therapy
– GI
– renal and cardiovascular
– elderly more at risk
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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
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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
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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
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Pharmacy Management (3rd stage)
• long-term suppressive drug therapy with
disease modifying anti-rheumatic drugs
(DMARDs)
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Pharmacy Early DMARD
• stabilise joint function as early as
possible = better outcome
• greater awareness of NSAID toxicity
• DMARDs slow disease progression
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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
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Pharmacy DMARDs (cont)
• DAS28 (Disease Activity Score)
-swollen joints
-tender joints
-ESR
-patient’s general health score
• Monitoring
-FBC
-LFTs
-U&Es
-BP
-urinalysis
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Pharmacy Systemic corticosteroids
• not recommended for routine use
• if necessary, use lowest dose, shortest
time
• monitor due to side effect profile
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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
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Pharmacy Biologic Pathways
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Pharmacy Nomenclature
-ximab Chimeric antibody
-zumab Humanised antibody
-umab Human antibody
-cept Fusion protein
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Pharmacy Immunogenecity
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Pharmacy
Eligibility Criteria for Biologic Therapy
(BSR)
DAS28 >5.1
At least 2 previous DMARDs
Adequate response at 3 months
3-monthly monitoring
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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)
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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
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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
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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
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Pharmacy Vaccination
Data limited
Influenza and pnuemococcal
recommended
Live vaccines not recommended
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Pharmacy Malignancy
No increased risk of solid tumours or
lymphoproliferative disease
Investigate/stop therapy
Caution in pre-malignant conditions
Preventative skin care/ongoing surveillance
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Pharmacy Rituximab
With MTX only
Inadequate response or intolerant of other
DMARDs, including at least one anti-TNF
By specialists in accordance with criteria
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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
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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
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Pharmacy Summary
• RA = inflammatory & destructive
• symptomatic relief
• early disease modification