4/26/2020 Arthritis treatment | Nursing in Practice

Inflammatory arthritis is characterised by pain, stiffness and swelling in the affected joints

- Early recognition and aggressive treatment is key to effectively manage inflammatory arthritis and prevent joint
damage and disability

- Rheumatology specialist nurses play a key role in the management of a patient with chronic inflammatory arthritis

Arthritis is a commonly used term that means inflammation within the joints. It is a common condition, and it is
estimated that about 10 million people in the UK have arthritis and that it is the biggest cause of pain and physical
disability in this population. (1)

When health care professionals see someone with joint pain, also termed arthralgia, it is important to differentiate
between inflammatory and non-inflammatory arthritis. In general, inflammatory arthritis is characterised by pain,
stiffness and swelling in the affected joints, which is worst at the start of the day and on inactivity. In contrast, non-
inflammatory arthritis characteristically causes pain in the affected joints and is often worse with activity and at the
end of the day.

The most common chronic inflammatory arthritis is rheumatoid arthritis (RA). RA affects about 400,000 people in
the UK (2) and is characterised by a symmetrical arthritis typically affecting the small joints of the hands and feet,
although any synovial joint and many other organs can also be affected. The overall occurrence of RA is two-to-four
times greater in women than
in men. (2) It can affect anyone at any age. Other causes of chronic inflammatory arthritis include psoriatic arthritis
(PsA), ankylosing spondylitis (AS) and juvenile idiopathic arthritis (JIA).

The most common non-inflammatory arthritis is osteoarthritis (OA). It is felt that OA is largely a degenerative
condition and is more common in older people. However, OA is one of the leading causes of pain and disability
worldwide.

The general management of arthritis

The treatment of arthritis depends of the type of arthritis and is largely dependant on whether the arthritis is felt to be
non-inflammatory or inflammatory in nature. The treatment of any arthritis should be based around pain
management and assessment of physical function but, if the arthritis is inflammatory in nature, immunomodulatory
medication is often required.

The National Institute for Health and Care Excellence (NICE) has produced clinical guidance on the management of
OA. (3) The management includes assessing the effect of OA on the person's function, quality of life, mood,
relationships and leisure activities. Exercise is regarded as a core treatment and weight loss should be encouraged for
people who are overweight or obese. Pharmacological management options include oral analgesics (paracetamol,
NSAIDs, COX-2 inhibitors, opioid analgesics), topical treatments (topical NSAIDs, capsaicin) or intra-articular
corticosteroid injections. Referral for consideration of joint surgery is an option for people whose symptoms are
refractory to non-surgical treatment.

The management of inflammatory arthritis

The aetiology of inflammatory arthritides such as RA is largely unknown. However, they are believed to be
autoimmune in nature and environmental factors, such as cigarette smoking or infection, are postulated to trigger the
onset of an inflammatory arthritis in genetically susceptible individuals.

When treating an inflammatory arthritis, the physician has to think about modulating the immune system in order to
stop the progression of disease and prevent damage to the cartilage and underlying bone. If this is not achieved, joint
damage, joint deformity and subsequent loss of function often ensue.

Although inflammation in individual joints often varies on a day-to-day basis, joint damage accrues and once
significant damage has occurred in a particular joint then treatment often becomes symptomatic.

In recent years, many large international studies have highlighted the fact that early recognition and aggressive
treatment play key roles in the effective management of an inflammatory arthritis.

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4/26/2020 Arthritis treatment | Nursing in Practice

Delays may occur anywhere along the pathway to early aggressive treatment. This may include delays in patients
presenting to the primary care physicians, primary care physicians referring patients to rheumatologists, and
rheumatologists initiating immunomodulatory treatments.

There are published British Society for Rheumatology (BSR), European League Against Rheumatism (EULAR) and
NICE standards of care and guidelines highlighting the early recognition and management of RA and other
inflammatory arthritides. (2,4,6)

The BSR recommendations state that people presenting in primary care with a suspected inflammatory arthritis
affecting the hands or feet should be offered a specialist opinion within six weeks of symptom onset. (4) They also
recommend that people with active RA have access to immunomodulatory medications within three months of
persistent symptoms. (4)

In order to provide an effective service to meet these standards, many rheumatology departments around the UK
have now developed early inflammatory arthritis clinics (EIAC). The EIAC in Newcastle-Upon-Tyne aims to see
people with potential inflammatory arthritis within a couple of weeks from referral.

Patients have an ultrasound of their small joints, radiographs of their hands and feet as well as routine bloods taken
to allow diagnosis prior to them being reviewed by a consultant rheumatologist. The Newcastle-Upon-Tyne EIAC
has been running for about three years and has reviewed over 1,000 patients.

Treatment options

There are a number of immunomodulatory medications that are currently in use in the UK and the rest of the world
used to treat RA and other inflammatory arthritides. Oral disease modifying anti-rheumatic drugs (DMARDs) are
recognised first-line treatments for RA and include methotrexate (MTX), leflunomide, sulfasalazine and
hydroxychloroquine.

MTX is regarded as the 'gold-standard' DMARD and is commonly prescribed first-line, often in combination with
one or more other DMARDs. MTX can be administered orally or subcutaneously and is taken once a week. MTX
(particularly in its oral preparation) can cause nausea and this side effect is often reduced by the co-administration of
folic acid 5-10mg the day after MTX.

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