The main speaker was Dr Killian O’Rourke, Consultant Rheumatologist at Midlands Regional Hospital, Tullamore. Dr O’Rourke delivered an excellent presentation which focused on two main areas:-
o Update on Midlands Rheumatology Services to Oct 2016
o Advances in RA treatment
Dr O’Rourke gave an overview of the extensive range of facilities now available at the service in Tullamore. One other really positive development within the unit was the extensive training programme for Midlands GP’s, hosted by Dr O’Rourke. On completion, each GP will have had around 400 hours of Rheumatology related training, which is then immediately relevant at point of first contact for most people (ie) the GP Surgery. This greatly assists with early diagnosis and subsequent quick referral.
New National Electronic Referral Form
To support the many recognised benefits of very early diagnosis, Dr O’Rourke outlined a new referral system of suspected IJD (Inflammatory Joint Disease) for GP’s using the new extremely detailed National Early Inflammatory Arthritis Referral form, developed in association with the charity Irish Society of Rheumatology and the HSE, full patient details along with supporting information (x-rays, pictures, history etc) can be sent electronically to rheumatology departments like Tullamore with a commitment to see referrals within six weeks.
Waiting list for Tullamore Rheumatology Department
Dr O’Rourke gave an update on the current waiting list position for new RA patients with recent improvements now sits at 15 months (down from 30 months), with those awaiting DEXA / MRI now at 12 months. In addition, whilst there has been recent positive progress in staffing levels, he outlined those shortfall areas that still exist to reduce the “waiting list” issue. The rheumatology department have a triage system which allows them to see more urgent cases quickly (eg) newly diagnosed early RA which needs early and aggressive treatment to prevent joint damage.
Risk factors for RA
Dr O’Rourke went on to discuss RA Risk factors. At the top of the group are two primary genetic factors followed by a list of over 12 “Higher Risk” factors….. of note here were:- Female Gender also Pregnancy and 12 months after giving birth; Occupational risks related to dust (mining, oil, woodwork, electrical, asbestos); Lifestyle factors (Smoking, High BMI, Coffee Consumption). Some developing evidence show that there may be a link between gum disease and development of RA.
Dr O’Rourke then gave an insight as to how RA is classified and the various systems that are used to evaluate severity. Two main organisations ACR (American College Rheumatology) and EULAR (European League against Rheumatism) have combined resources to produce a harmonised scoring system that provides some common classification criteria against which presenting symptoms can be measured, scored and which treatment pathway to take based on the outcome. The newly simplified scoring system aims: - Initially to REDUCE Disease activity, which through time PREVENTS structural damage, which then through remission, DECREASES disability. These factors are then translated into the recognised DAS28 scoring system which when used to indicate exactly where an individual lies within the goals above which dictate / prioritise immediacy and type of treatment.
Future of RA treatment
Looking to the future of RA treatment, the audience learned of a variety of current scientific initiatives and advancements that aim to help and assist with the earliest diagnosis of RA, perhaps even long before physical symptoms have appeared.
Gene screening to maximise treatment
Gene screening, currently in use in America, could help predict which drugs would be most effective for a given patient, which then enables the most effective treatment to be used right from the start. Leading on from this, Dr O’Rourke suggested that at some time in the future, everyone could have their complete genome screened with the result showing what diseases or ailments they may be predisposed to. This is more likely to be reality in the coming years, something that would have been the realms of science fiction 25 years ago.
An RA vaccine?
Again, currently in progress is the possibility of a vaccine to prevent RA. Research in Australia is developing a vaccine to re-educate the immune system and the T-Cells (which currently attack in RA) to act in support of the immune system and prevent attack. Whilst an outcome may be a long way off and hugely expensive currently, it may be reality in within most of our lifetimes.
Cannabis based painkillers
To conclude, another therapy currently under evaluation (and common practice in many countries) is the use of Cannabis based Medicine (CBM) to treat and alleviate the symptoms of RA. Dr O’Rourke gave examples from USA and Israel of how CBM treatment has been proven to reduce and eliminate pain in RA. Medicine is administered primarily through tablets or sprays so that the purity and dosage can be guaranteed, CBM has been shown in clinical trials to reduce symptoms across a range of “traditional” RA measures. Cannabis based painkillers have been shown to have significantly less side effects than many traditional painkillers. Dr O’Rourke pointed out the CBM is not currently available in Ireland in any form.
Other health professionals
Next up was a presentation from Dr Siafullah Khan from Mullingar Dental Centre. Dr Khan is qualified in Special Care Dentistry. Dr Khan gave an overview of how Special Care dentistry can be of benefit to those with Mental or Physical challenges. He mentioned that something as simple as scheduling the “right” appointment time can be helpful for those that may, for instance, experience stiffness in the morning, making an afternoon appointment a better option.
Kevin Conneely, Chartered Physiotherapist from Health Step Physio based at Whelehans Pharmacy suggested that physiotherapy treatment can help maintain or increase range of movement for those with mobility issues. Physiotherapy can also help people understand the limitations that RA presents, which in itself can be a benefit in helping people help themselves.
To conclude, the final speaker of the evening was Eamonn Brady, MPSI, Pharmacist at Whelehans Pharmacy who gave an initial overview of medications used to manage RA. So, initially, looking at medication to reduce pain and then drugs aimed at slowing down the progression of the disease, pointing out that whilst there is no cure for RA, the correct and appropriate use of medication can have a significant positive effect on living with the condition. Supporting Dr O’Rourke earlier position that the earliest possible diagnosis is ideal and then the initial introduction of DMARD’s (Disease Modifying Anti-Rheumatic Drugs) to slow disease progression.
Eamonn highlighted that paracetamol is rarely effective against the pain of RA but may be used to augment other pain killers while waiting for longer term solutions like DMARDs to work. He cautioned however against the long term use of codeine based medications such as tramadol and Solpadeine® and potential addiction risks.
Moving on to discuss NSAID’s (Non-Steroidal Anti-Inflammatory drugs), Eamonn indicated that whilst these offered relief, they would not affect the progression of RA and should not be used longer term. Giving examples such as diclofenac and etoricoxib, Eamonn stated that these should not be given to patients with heart problems or who had a high stroke risk.
Eamonn went on to discuss DMARD’s in more detail, giving an overview of how they work and, as they slow down the progress of the disease, the benefit of early referral. DMARD’s treatment can only be initiated by consultant, so, some of the initiatives mentioned earlier by Dr O’Rourke to speed the process of GP – Consultant referral will help massively.
Commonly used DMARDs include methotrexate, hydroxychloroquine and sulfasalazine. They can be slow to work, however Eamonn stressed the need to maintain the treatment as it can take some time to find the right one and for the benefit to materialise. A key point regarding Methotrexate was that it should only be taken weekly.
To conclude Eamonn discussed the various Biological treatment injections available. Traditionally, these would be a “last resort” for those with severe RA, however, with medical advances, these are now being promoted earlier to improve response to treatment overall. Mostly given by sub-cutaneous injection, can biologics can be used in conjunction with DMARD’s if needs be. In Ireland, Enbrel® and Humira® would be the most commonly used biological brands. More than 650 RA patients now take biological treatment at the Midlands RA Service.
Westmeath Branch of Arthritis Ireland supports a vibrant community of 17,000 people living with Arthritis in the County. The committee is made up of people living with arthritis so they understand the challenges that a chronic condition brings. Your local committee are here to support you and offers a wide range of activities, information and training that will help you to live well with arthritis. If you have any further queries, Westmeath Branch contacts are: Margaret Egerton, Chairperson 0857587171 or Secretary 0871413225 (Branch Phone). You can follow the Westmeath Branch of Arthritis Ireland on Facebook.
Check www.arthritisireland.ie or Locall 1890 252 846 for more information