The window of opportunity to educate about rheumatoid

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By Dr Irwin Lim, Rheumatologist

I met her at the start of 2012. A young lady with a new husband. She presented with a very swollen knee. The diagnosis was rheumatoid arthritis and it was an easy one to make, given she had very raised autoimmune serology (RF and anti-CCP) and her mother also had the disease.

They were trying for a baby so treatment options were limited. And it was just the one joint involved, so treatment was localised to aspiration and cortisone injection.

I think I got to see her three times. Then she disappeared. She cancelled a follow-up appointment, said she’d reschedule, and didn’t.

In a busy rheumatology clinic, it’s hard to have a good follow-up system for patients who don’t want to return. And, I forgot about her.

She’s now back. And the rheumatoid is rampant.

Over 21 months since review and she now has over 20 joints involved, both big and small. Her fingers are all deviated at the MCP joints (knuckles), her wrist movements are restricted and her thumbs are shaped like a Z.

The window of opportunity to switch off her rheumatoid is well and truly over. We missed it.

I had a window period to educate her on how serious her disease could potentially become. I missed that.

I figure all rheumatologists would spent a lot of time up front trying to explain this beast called rheumatoid arthritis. I thought I was relatively effective at this but this sort of occurrence brings me back to earth.

Why didn’t she return?

Well, she was still trying to fall pregnant. And she thought that as long as she was trying, she couldn’t be treated. I suspect she has had difficulty coping with having a chronic disease and just plodded along, accepting her symptoms. Even now in the face of very active, deforming rheumatoid, she tells me she is coping and has little pain.

I feel disappointed and sad at what’s happened. Especially as it was likely to have been preventable.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
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Help us design the Rheumatology Centre you’d like to attend

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Our Parramatta clinic

Our Parramatta clinic

 

By Dr Irwin Lim, Rheumatologist

BJC receptionEffective space. This has been on my mind a lot recently.

Our most established clinic is based in Parramatta, a suburb in Western Sydney.

We’ve been in a 2-storey house since 2005. During this time, we’ve grown and added new staff and new services, squeezing ourselves into all corners, redividing rooms and making do with what space we have.

This has meant compromise. The workflow could and should be much better. We lack a room for staff to congregate. We would love more space to enhance the experience for our patients.

There’s 2 years left on the lease so we’re starting to plan.

A huge, somewhat scary move for us.

Small group exercise area

 

In this planning phase, we’ve decided not to worry about budget and cash flow. I know. Wishful thinking.

BJC IL room

As it stands, we want a site to accommodate:

  • 6 Consulting rooms, to be used by doctors, a nurse, a rheumatology educator, allied health professionals
  • 1 room for musculoskeletal ultrasound
  • 1 room to house a Bone Densitometer
  • A pathology collection area
  • 6 treatment rooms for physiotherapists
  • 2 treatment rooms for remedial massage therapists
  • Office space for the physiotherapists/exercise physiologists
  • A compact central gym area including space for small group exercise classes
  • An area next to the gym for biomechanical testing/assessment
  • Showers & Toilets
  • 2-3 offices, to be used by administrative workers, the practice manager & the managing director
  • A large staffroom which can also function as a small (20 seat) lecture theatre/staff meeting space
  • The staffroom needs to incorporate a functional kitchen which can be utilised for group healthy cooking demonstrations
  • A reception area with space for 5 front-line reception staff
  • A range of seating options for patients & their families
  • An area built for patient self-education utilising smart pads or computers (ala Apple Store)
  • An area to display & demonstrate useful products & devices which are used in managing arthritis
  • An area for kids with TV, DVD, books to entertain

I’m thinking lots of glass, natural light, and parking!

Can you think of anything else that you would like to see in a rheumatology centre?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
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Fish Oil: will you now use this for Rheumatoid Arthritis?

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Courtesy of photobucket.com

Courtesy of photobucket.com

 

By Dr Roberto Russo, Rheumatologist

Fish oil has literally become the flavour of the month!

So much so that there are now a host of variants available on the shelf, including Super Fish oil, liquid fish oil, and Krill oil, with each option promising an advantage over the other! The popularity of the product seems to be ever increasing, particularly in the management of cardiovascular disease and joint conditions. The latter is the primary focus of this article.

The beneficial constituents of Fish oil are the omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexanoic acid (DHA). These have been shown to suppress inflammatory mediators including:

  • Proinflammatory lipid mediators
    • Prostaglandin E2
    • Leukotriene B4
  • Peptide mediators
    • TNF-alpha
    • IL-1 beta

These are effectively the same inflammatory mediators that are inhibited by the use of NSAIDs and the biological TNF blockers (albeit at a much lesser extent), thereby providing a biological plausibility to their use (especially in inflammatory joint conditions)!

However, the amount of EPA+DHA required to obtain symptomatic benefit in this context is relatively high at greater than 2.7g each day, which is more than is required for cardiovascular benefit.

The standard Fish oil capsule contains about 400mg of EPA+DHA and as such a patient would need to take at least 7 of those capsules a day, which would challenge even the most ardent of patients to comply with such a regime!! No wonder there are so many options available (as mentioned above).

But does Fish oil have a real benefit in patients with Rheumatoid arthritis, especially in the context of the modern management of the disease, which often involves the use of a combination of immunomodulating drugs to render the disease into remission?

That is the exact question that a group of our colleagues from South Australia set out to answer.

They chose to divide a cohort of patients with early Rheumatoid arthritis (defined as <12 months) into two groups, whereby one received 10mL of liquid Fish oil (providing 5.5g/day) and the other a low dose equivalent to 400mg/day, which is the dose often taken for cardiovascular disease.

Both groups were then treated for their disease according to the current standard approach, whereby disease modifying medications (DMARDs) were introduced in sequential order (including TNF blockers if required), with the aim being to achieve remission (a strategy termed treat to target).

What they found was the group receiving a high dose of Fish oil:

  • Required a shorter time to achieve a meaningful improvement in their disease control
  • Achieved a higher the rate of remission (according to the American College of Rheumatology criteria)
  • Had a lower failure rate to triple DMARD therapy, thereby requiring less use of TNF blockers
  • Required less use of NSAIDs

No differences though were found in overall disease activity, dose of Methotrexate or Prednisone used, or physical function.

The concern for an increased risk of bleeding was not found in their study, albeit I would remain cautious in prescribing Fish oil in those on blood thinning medications such as Warfarin or a combination of anti-platelet agents.

In conclusion, it would appear that there are indeed benefits to be gained with the use of high dose Fish oil as an adjunct to the current approach of treating Rheumatoid arthritis.

I would encourage you to read the article in full, which can be found in the Annals of Rheumatic Diseases (reference given below).

Whilst I am already in the habit of suggesting my patients take Fish oil, these results strengthen my conviction in this recommendation and remind me to ensure they are taking a sufficient amount.

I look forward to reading similar high quality research regarding the use of Fish oil in other joint diseases, especially in Osteoarthritis.

If you are a doctor, I would be most interested to know if you recommend fish oil, and if so what doses to you suggest?

If you are a patient, have you been recommended fish oil, and if so what doses do you take?

Reference: Proudman SM, James MJ, et al. Fish oil in recent onset Rheumatoid arthritis: a randomised, double-blind controlled trial within algorithm-based drug use. Annals of Rheumatic Disease, 2013; 0: 1-7. doi:10.1136/annrheumdis-2013-204145

Can reducing stress on the legs of Mice teach us about Spondyloarthritis?

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http://i650.photobucket.com/albums/uu221/dunc_89/mouse-cute.jpg

Courtesy of photobucket.com

By Dr Irwin Lim, Rheumatologist

Professor Dirk Elewaut visited us at our Parramatta clinic today. He’s on a speaker tour around Australia and kindly agreed to come to talk to our team (I’m really ticked off that I forgot to get a photo for this post).

He talked about many aspects of Ankylosing Spondylitis (AS) and spondyloarthritis (SpA). It was entertaining and engaging. One particular topic has been playing on my mind so I thought I’d give you my simple man’s interpretation.

In a series of experiments, his group looked at how mechanical stress can lead to enthesitis (learn about enthesitis here) and new bone formation, features common to AS/SpA.

  • They convinced some genetically modified mice to take part. These mice get a spondyloarthritis-type disease.
  • The first signs of inflammation in these mice occur at the enthesis, and typically at the achilles tendon insertion and/or plantar fascia insertion.
  • When they looked under a microscope, these areas in these mice show lots of inflammatory cells. This is what would be expected.
  • They then (as ethically & comfortably as possible) suspended the hind limbs of the mice. This meant that there was much reduced load on these hind limbs.
  • In these unloaded hind limbs, there was very much less accumulation of inflammatory cells at the enthesis. There is also less new bone formation.

The conclusion is that these findings provide proof of the concept that actual mechanical strain drives both entheseal inflammation and new bone formation (click here for the abstract).

Now, mice and humans are quite different.

But, let’s assume that these findings can be applied to patients with SpA.

We know our patients with AS and SpA get a lot of heel pain and achilles problems, in addition to enthesitis elsewhere.

If a trigger for this is mechanical load or stress, some questions arise:

  • is this why males get the disease in their early adulthood when they’re running around and playing more vigorous sport?
  • exercise usually helps patients with AS and SpA greatly but could it possibly be detrimental?
  • perhaps, the type of exercise matters more: high impact like jogging versus lower impact like swimming
  • is a desk-based sit-on-your-bum job better than a stand-all-day type of job?

I am by no means advocating stopping or changing exercise if you have AS or SpA. We just don’t know yet.

A lot more research in mice (they’re convincing some mice to now run very far and very fast to see what this does to the entheseal region) and some research in humans will be needed.

But, I thought it would be interesting for you to ponder.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
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An Easy Case of Rheumatoid

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By Dr Irwin Lim, Rheumatologist

My rheumatology colleague, Andrew Jordan just presented a rheumatoid arthritis case at our GP meeting.

A 60-something year-old lady presenting with swelling and pain involving the small joints of her hands. Early morning stiffness and some carpal tunnel symptoms. A pretty classic story.

The diagnosis was made even easier by the presence of an elevated rheumatoid factor in her blood tests, and raised inflammatory markers.

The GP was astute and referred her early. She presented to a rheumatologist within 2 months of the onset of her symptoms.

Methotrexate was commenced with a small dose of Prednisone to help calm her symptoms. Within a few weeks, Prednisone had been weaned and ceased. She continued only on Methotrexate and was doing well.

One and a half years since her presentation, she remains in remission, both from her point of view and from the point of view of DAS-28 remission. She is symptom-free with absence of synovitis, the swelling rheumatologists look for when they examine joints.

All this on Methotrexate alone. 2 small tablets (10mg each) once a week only.

Easy.

This is a near-perfect example of the window-of-opportunity.

Rob Russo then made a telling comment. A decade or two ago, it would be strange to talk about an “easy” case of rheumatoid.

And of course, many cases don’t pan out like this. Some patients have terribly aggressive disease. Sometimes, there are all sorts of logistical issues preventing early rheumatology review and early treatment.

There’s a lot of debate currently about the very expensive treatments we use for rheumatoid (read about triple therapy vs biologics).

There are massive cost savings to be had if we can treat patients early.

Within this window-of-opportunity, Methotrexate, a very cheap medication, works well for those who tolerate it.

Within this window-of-opportunity, this difficult disease becomes somewhat easier.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
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