Rheumatoid Arthritis PDF

CENTRE FOR PHARMACY
POSTGRADUATE EDUCATION
Supporting people
to live well with
inflammatory arthritis
A CPPE workshop Workshop book
W/INFLAMAR19/HO
July 2019
CPPE programme developers
Supporting people to live well with inflammatory arthritis – Workshop book
Cate Dawes, education supervisor

Helen Middleton, lead pharmacist – general practice education (London and South East)
Project team
Salim Abatcha, neighbourhood pharmacist, Tameside and Glossop Integrated Care NHS Foundation Trust
Dawn Bell, rheumatology pharmacist, Manchester University NHS Foundation Trust (Wythenshawe)
Annett Blochberger, South West London commissioning pharmacist, interface and secondary care
prescribing support, North East London Commissioning Support Unit
Angela Branch, senior clinical pharmacist, Carlisle Healthcare
Louise Carr, education supervisor, CPPE
Nahim Khan, senior clinical pharmacist, Warrington Health Plus and senior lecturer, University of Chester
Jennifer Lowe, practice pharmacist, The Westongrove Partnership, Buckinghamshire
Andrew Pothecary, lead pharmacist for rheumatology and biologics, Royal Cornwall Hospitals NHS Trust,
Truro, Cornwall
Emily Rose-Parfitt, specialist pharmacist, rheumatology, North Bristol NHS Trust, Southmead Hospital
Oluwaseyifunmi Rotimi, clinical practice pharmacist, Bury GP federation
Caroline Sokhi, clinical pharmacist, Mayflower Medical Centre, Harwich
Acknowledgement
With thanks to Rekha Williams, a person living with inflammatory arthritis, for generously sharing her
experiences and suggestions for how pharmacy professionals can improve care for people and support them
to ‘live well with inflammatory arthritis’.
Reviewer
Kalveer Flora, rheumatology specialist pharmacist, deputy chair, Rheumatology Pharmacists UK, London
North West Healthcare NHS Trust
CPPE reviewers
Caroline Barraclough, regional manager
Michelle Styles, regional manager
Piloted by
Sneha Varia, education supervisor, CPPE
Charlotte Collins, practice pharmacist, The Hammersmith Surgery
Shona King, senior clinical pharmacist, Brook Green Medical Centre
Shelina Shah, clinical pharmacist, Gordon House Surgery
Paresh Virji, GP practice pharmacist, Barnabas Medical Centre, Northolt
Brand names and trademarks
CPPE acknowledges the following brand names and registered trademarks mentioned throughout this
programme: Depo-Medrone®, FRAX®, Gedarel®, Orabase®, QRISK®3.
Disclaimer
We have developed this learning programme to support your practice in this topic area. We recommend
that you use it in combination with other established reference sources. If you are using it significantly after
the date of initial publication, then you should refer to current published evidence. CPPE does not accept
responsibility for any errors or omissions.
External websites
CPPE is not responsible for the content of any non-CPPE websites mentioned in this programme or for the
accuracy of any information to be found there.
All web links in this resource were accessed on 1 August 2019.
Published in August 2019 by the Centre for Pharmacy Postgraduate Education, Division of Pharmacy and
Optometry, The University of Manchester, Oxford Road, Manchester, M13 9PT. www.cppe.ac.uk
Production
Design and artwork by Gemini West Ltd
Printed by Gemini Print Ltd
Printed on FSC® certified paper stocks using vegetable-based inks.
© Copyright controller HMSO 2019

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Contents

Learning with CPPE 4
About this CPPE workshop resource 5
Overall aim 6
Workshop activities 7
Activity 1 – Clinical decision-making scenarios – Emma Partridge’s journey 7
Activity 2 – Patient safety incidents with DMARDs 14
Activity 3 – Rheumatoid arthritis – Richard Arnold’s annual review 15
25
Next steps
Suggested answers 26
Reference 41
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Learning with CPPE
The Centre for Pharmacy Postgraduate Education (CPPE) offers a wide range of learning opportunities
in a variety of formats for pharmacy professionals from all sectors of practice. We are funded by Health
Education England to offer continuing professional development for all pharmacists and pharmacy
technicians providing NHS services in England. For further information about our learning portfolio,
visit: www.cppe.ac.uk
1 2 3
We recognise that people have different levels of knowledge and not every CPPE programme is suitable for
every pharmacist or pharmacy technician. We have created three categories of learning to cater for these
differing needs:
1 Core learning (limited expectation of prior knowledge)
2 Application of knowledge (assumes prior learning)

3 Supporting specialties (CPPE may not be the provider and will direct you to other
appropriate learning providers).
This is a 2 learning programme and assumes that you already have some knowledge of the
topic area.
Revalidation
You can use this programme to support revalidation and your continuing professional development
(CPD). Consider what your learning needs are in this area. For more information about revalidation and
to record your entries, visit: www.mygphc.org
Keeping up to date
To ensure this learning resource is up to date we will review it every year. A CPPE programme manager
will check through the material to ensure the content is current and relevant, and that the quality of the
learning experience is maintained. You will find the latest version of this resource on the CPPE website.
Feedback
We hope you find this learning resource useful for your practice. Please help us to assess its value and
effectiveness by completing the feedback form at your event, or by emailing us at: feedback@cppe.ac.uk
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About this CPPE workshop resource

You are about to take part in training to acquire the knowledge, develop the skills and demonstrate the
behaviours needed to support people taking medicines for inflammatory arthritis to live well with their
condition.
Patient outcomes
Healthcare professionals working in primary care can support people to live well with their inflammatory
arthritis condition by understanding the issues facing them, establishing safe systems of prescribing,
monitoring and optimising medicines and establishing more effective shared care and working
relationships with secondary care colleagues.
This has the potential to improve patient outcomes by:
n reducing disease and treatment burden

n improving adherence with treatment
n improving co-ordination of care across services
n individualising treatment planning and care
n improving clinical outcomes.
This book will help to support your learning during the workshop and provide you with a useful reminder
of the notes and plans you make to develop your everyday practice in this subject area. We have included
activities at the workshop to stimulate your thinking and support you in developing the skills and attitudes
required to establish safe systems of prescribing, monitoring and optimising medicines for people with
inflammatory arthritis.
The workshop will last two hours.
A note about web links
Where we think it will be helpful we have provided web links to take you directly to an article or specific
part of a website. However, we are aware that web links can change. If you have difficulty accessing any
web links we provide, please go to the organisation’s home page or your preferred internet search engine
and use appropriate key words to search for the relevant item.
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Overall aim
The overall aim of this workshop is to enable healthcare professionals working in general practice to
support people with inflammatory arthritis to live well with their condition by establishing safe systems of
prescribing, monitoring and optimising medicines.
Learning objectives
You can use our programmes to support you in building the evidence that you need for the different
competency frameworks that apply across your career. These will include building evidence for your
Foundation pharmacy framework (FPF) and supporting your progression through the membership stages
of the Royal Pharmaceutical Society (RPS) Faculty.
As you work through the programme consider which competencies you are meeting and the level at which
you meet these. What extra steps could you take to extend your learning in these key areas?
After completing all aspects of this programme, you should be able to:
n r ecognise the signs and symptoms of inflammatory arthritis and discuss the management of pain and
acute flares
n d
emonstrate a person-centred approach to support shared decision-making with people who have
inflammatory arthritis
n d
escribe the shared care arrangements for people with inflammatory arthritis taking disease-modifying
antirheumatic drugs (DMARDs) in your practice locality
n apply evidence-based practice for safe prescribing and monitoring for patients taking DMARDs
n undertake person-centred rheumatoid arthritis (RA) annual reviews in primary care.
The workshop is a practical learning session, designed to increase your knowledge of inflammatory
arthritis and to build your confidence and capability in an extended clinical care role.
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Workshop activities

Warm-up quiz
To assess your general knowledge of inflammatory arthritis.
Only old people get rheumatoid arthritis – true or false?
Treatment with DMARDs can be delayed until symptoms are severe – true or false?
Exercise should be avoided by people with RA because inflamed joints require rest –
true or false?
Patients should stop taking methotrexate if they have any signs of infection, eg, colds, sore
throat or UTI – true or false?
‘ Behind the smile’ is the theme of a series of short films produced by the National
Rheumatoid Arthritis Society (NRAS) to promote World Arthritis day in 2016.
What was the aim of the campaign?
Activity 1 – Clinical decision-making scenarios – Emma Partridge’s

journey
In this activity, we will discuss some scenarios that follow Emma Partridge’s inflammatory arthritis
journey and these will enable you to focus on clinical decision-making and communication.
Introduction
Emma Partridge is 32 years old, she works as a secretary and lives with her partner, Alex, and their
three-year-old daughter Lilly. Emma was fit and well until recently. In the last couple of months she
started to experience throbbing, aching pain, swelling and stiffness in her wrists and hands first thing in
the morning.
Emma initially thought this might be a repetitive strain injury related to her job and took some over-the-
counter ibuprofen for a few days without much benefit.
Emma made an appointment with her GP after talking to her mum, Angela, who has rheumatoid arthritis.
Angela had noticed that Emma was struggling to fasten Lilly’s coat buttons, and Emma shared that she
was finding it difficult manage her housework.
The GP explained to Emma that he suspected she may have inflammatory arthritis and recommended
that she start taking naproxen tablets, 250 mg three times a day after food. He arranged blood tests for
Emma and an X-ray of her hands and wrists.
Emma was referred urgently to the local rheumatology clinic where she was seen within two days.
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Consultation one
Emma comes to your medication review clinic following her appointment with the consultant
rheumatologist. She is quite shocked that she has been diagnosed with rheumatoid arthritis.
Emma tells you that she has a prescription for methotrexate and folic acid, but she is worried about taking
methotrexate as she read in the patient booklet that it might make her hair fall out.
The hospital nurse also told Emma that she should book an urgent appointment at the GP surgery for
influenza and pneumococcal vaccinations, but she doesn’t want to have these as she thought they were
‘just for older people’. Emma is unsure why this is all being done in such a hurry.
Referring to the NRAS Medicines in Rheumatoid Arthritis booklet, consider how you would approach the
consultation and respond to Emma’s concerns.
How will you establish Emma’s understanding of inflammatory arthritis and the aims of
treatment?
How will you establish Emma’s understanding of methotrexate and its potential side
effects?
How would you explain to Emma why it will be important for her to receive the
recommended vaccinations?
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Consultation two

Emma has been taking methotrexate 15 mg once a week for six weeks and has come to discuss how she
is getting on with her medicines.
Emma confirms that she is currently taking methotrexate 15 mg once a week (six 2.5 mg tablets as a
single dose each Monday), naproxen 250 mg tablets twice a day and one or two tablets of co-codamol
30 mg/500 mg when needed for extra pain relief. You ask Emma about her hand and wrist symptoms
and how she is getting on with pain control – both are a little better.
You notice that Emma is looking tired and that she appears to be experiencing some discomfort when
she is talking. Emma tells you that she is having difficulty sleeping and is feeling weary and a bit down
because she is finding it difficult to cope with work, housework and caring for Alex and Lilly. She hasn’t
eaten much this week as her mouth is sore and she has been feeling sick. Emma consents to a mouth
examination and you observe two erythematous aphthous mouth ulcers.
Emma tells you that she didn’t get the prescription for folic acid dispensed because she has been taking
some folic acid tablets that she had left over from her pregnancy with Lilly.
Emma advises you that she is due to see the consultant again next week and is worried because the
hospital nurse said she may be asked to start more medicines. She doesn’t understand why this is
necessary and asks ‘unless the methotrexate isn’t working?’
How would you address Emma’s concerns about methotrexate ‘not working’?
What treatment plan would you suggest for Emma’s mouth ulcers?
How would you support Emma to understand the importance of adherence to treatment to
minimise side effects?
What additional actions should you take to ensure Emma’s safety?

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Consultation three
A month later Emma returns to your clinic, she is now taking methotrexate 20 mg once a week
(eight 2.5 mg tablets on a Monday), folic acid 5 mg twice a week on Wednesday and Friday and
hydroxychloroquine 200 mg once a day. She takes one or two co-codamol 30 mg/500 mg tablets when
needed for pain relief and has stopped taking naproxen.
Emma explains that her inflammatory symptoms have continued to improve. She is pleased to tell you
that she is now back at work, though she still feels tired much of the time.
Emma asks for a repeat of her oral contraceptive pill, Gedarel 30/150 and wants to check with you if this
is safe to take with her current medicines.
Emma mentions that the family are going on holiday in a couple of weeks to south west France with a
couple of other families. They will be visiting several vineyards and it could be ‘quite a boozy’ week. Emma
asks if she should stop taking methotrexate whilst she is on holiday, because she has been told that she
shouldn’t drink whilst taking it.
How would you respond to Emma’s question about Gedarel 30/150?
How would you respond to Emma’s question about stopping methotrexate?
What ‘holiday’ advice could you give Emma regarding alcohol intake, sun exposure and
safekeeping of medicines?
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Consultation four

Emma comes in to see you a couple of weeks after her holiday. The family had a great time away, but
Emma tells you that she stopped taking methotrexate and her other arthritis medicines before she went on
holiday – hoping that the warm climate would help to improve her symptoms.
However, now she feels exhausted, quite miserable and feels as if she is ‘back to square one’. She has
not been able to go to work today and has needed extra help at home from her family with dressing. She
hasn’t been able to manage any housework or cooking.
Emma explains that she has been taking eight co-codamol 30 mg/500 mg tablets a day over the past week
– she has needed the extra pain relief to relieve the aching pain, swelling and stiffness in her wrists and
hands.
Her mum, Angela, brought her to see the GP yesterday and took her to an appointment with the
rheumatology consultant who explained that she is having a ‘flare’. The hospital letter states that Emma
had six tender joints (out of a possible 28) and four of these were also swollen. Her ESR lab result from
yesterday was 40, giving a DAS28 score of 4.51.
Emma was given a Depo-Medrone injection, a course of naproxen and her DMARD medicine was
restarted. She has also been referred for physiotherapy and wax baths to ease the discomfort in her hands.
Emma said she was asked lots of questions about her holiday and what tablets she had been taking. She
was also given a booklet about DAS28 scores, her score was 4.51 and she was told this was ‘moderate
disease’ – she is anxious to understand what this means for her.
Emma asks what she can do to manage her pain and her RA better.
Referring to the NRAS Medicines in Rheumatoid Arthritis booklet, the Pain and arthritis booklet from
Arthritis Research UK and the NRAS Know your Disease Activity Score booklet (www.nras.org.uk/data/
files/Publications/DAS%20patient%20guide.pdf) consider how you would approach the consultation
and respond to Emma’s concerns.
What advice would you discuss with Emma about pharmacological measures for pain
relief?
What advice would you discuss with Emma about non-pharmacological measures for pain
relief?
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How would you explain to Emma what the DAS28 score is?
(www.4s-dawn.com/DAS28).
What does a DAS28 score of 4.51 mean for Emma?
What approaches could you discuss with Emma to help her to understand and learn to
manage her RA symptoms?
What advice and support could you discuss with Emma to help her to manage her acute
flare symptoms?
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How would you explain to Emma why the hospital team needed to take a careful drug and
travel history?
Consultation five
Emma returns to see you six months after her acute flare. She likes the RheumaBuddy App, it has helped
her to manage her activities and lifestyle more effectively and to better understand her RA. She is pleased
to tell you that her latest DAS28 score was 1.9 – which means her RA is in remission.
She is taking methotrexate 20 mg once a week (eight 2.5 mg tablets on a Monday), folic acid 5 mg twice
weekly (on Wednesdays and Fridays), sulfasalazine EC tablets 1000 mg twice a day, hydroxychloroquine
200 mg once a day and one or two co-codamol 30 mg/500 mg tablets when needed for extra pain relief.
Emma feels well and she is coping with work. She tells you that Alex proposed to her whilst they were in
France and they recently got married. She mentions that she is keen to come off the pill as she would like
another baby and asks if it is safe to continue taking the medicines for her RA if she gets pregnant?
What advice and guidance would you give Emma in relation to her desire to have another
baby?
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Activity 2 – Patient safety incidents with DMARDs
Pharmacy professionals have an important role to play in supporting effective strategies which ensure
safety for patients receiving care from more than one team of clinicians and for those taking DMARDs.
The purpose of pre-workshop Task 3 – Ensure medicines use is as safe as possible, was to help you think
about how national best practice guidance informs local shared care guidelines and how both aim to
inform and improve patient care within general practice. We asked you to find out if there have been any
near-miss errors or significant incidents with DMARDs recorded at your practice.
In pairs, now briefly discuss the potential contributing factors leading to the errors/incidents and then note
any common themes emerging in the boxes below.
Patient factors Communication factors
Prescribing factors Monitoring factors
Reflect on the comments and issues raised by peers during this activity and consider what steps could be
taken to make your practice system for DMARD monitoring even better.
Opportunities for me to support and improve DMARD monitoring in my practice.
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Activity 3 – Rheumatoid arthritis – Richard Arnold’s annual review

In this activity, we will consider the annual review in primary care for Richard Arnold, a patient with RA,
and focus on communication and clinical decision-making.
Statement 7 of Rheumatoid arthritis in over 16s, NICE Quality statement 33, recommends that people with
rheumatoid arthritis should have a comprehensive annual review that is co-ordinated by the rheumatology
service:
“Annual review is important to ensure that all aspects of the disease are under control. It provides a regular
opportunity to holistically assess the patient in terms of the current management of the disease, and any
further support they may need in the future, to enable them to maximise their quality of life.
Elements of the review may need to occur more or less often than once a year. For example, it may be
most appropriate to assess for fracture risk at 24-month intervals, whereas advice on self-management
or treatment review may occur more regularly. It is not expected that all elements of the annual review
would occur at the same time. Some aspects may be undertaken in primary care, for example checking for
comorbidities such as hypertension.”1
A comprehensive annual review includes:
n a ssessing disease activity and damage, and measuring functional ability (for example, using the
Health Assessment Questionnaire)
n c hecking for the development of comorbidities, such as hypertension, ischaemic heart disease,
osteoporosis and depression
n a ssessing symptoms that suggest complications, such as vasculitis and disease of the cervical spine,
lung or eyes
n organising cross referral within the multidisciplinary team
n assessing the need for referral for surgery
n a ssessing the effect the disease is having on a person’s life, for example their employment status and
prospects (validated questionnaires are available for assessing quality of life)
n symptom control and pain management
n care planning
n offering educational activities and self-management programmes.
Guidance to support RA annual reviews in primary care is also included in the Resources for quality
improvement section of the RCGP Inflammatory arthritis toolkit (www.rcgp.org.uk/clinical-and-
research/resources/toolkits/inflammatory-arthritis-toolkit.aspx#). Use of a standardised template
for annual reviews has been shown to improve compliance with NICE guidance – is this something that
your practice could adopt?
Undertaking rheumatoid arthritis annual reviews is considered an extended clinical care role in the
clinical pharmacist role progression handbook – this activity is an opportunity to practise applying your
knowledge and person-centred decision-making skills.
Now let’s meet Richard Arnold (aged 62), who has come to see you for his RA annual review
appointment.
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Introduction
Richard confirms that he understands that the annual review will involve talking about his RA symptoms,
his medicines, his ideas, expectations and any concerns to better appreciate Richard’s lifestyle and health
priorities and to establish how RA is affecting his quality of life. An aim of the review is to support
Richard to live well with his condition.
Richard hasn’t been feeling at his best lately and is keen to find out if the review will be helpful for him.
He is pleased to hear that together you will be able to discuss strategies to support him to feel better and
be healthier.
Richard was diagnosed with seropositive RA four years ago and his medication record indicates that he
is prescribed methotrexate 20 mg (eight 2.5 mg tablets) once weekly on Saturday, folic acid tablets 5 mg
once daily except on Saturday and leflunomide tablets 10 mg once daily.
Richard has been on this regimen for the last three years, with monthly blood monitoring. His RA has been
stable, with no recent flares. Richard is up to date with both the pneumococcal and annual flu vaccine.
Richard is also prescribed paracetamol tablets 1000 mg four times a day when needed for pain relief
(x100 tablets) – he has ordered this more frequently over the last six months.
Richard lives at home with his wife, Betty and their two youngest children, Amy (17) and Karl (15).
Richard confirms for you that he is a smoker (ten cigarettes/day), he does not drink alcohol and he enjoys
walking the dog.
Richard works for the local council as head gardener. He mentions that in recent months both his knees
have been ‘playing him up’ and he has been offered a ‘desk job’ at work, which he is upset about. He
quickly tells you that he doesn’t want ‘any operations’ because his brother had ‘problems’ after his knee
operation.
You ask Richard to clarify what he means by his knees ‘playing him up’ and he explains that his knees
have been more painful, swollen and sore to touch. It is taking him a long while to get going in the
mornings - this is happening almost daily.
Richard’s recent measurements
Height 180 cm
Weight 98 kg
BMI 30.2
Waist measurement 114 cm
BP 160/96 mmHg
Pathology data
eGFR 80 mL/min/1.73 m2 (60-89 mL/min/1.73 m2)

serum sodium 135 mmol/L (133-147 mmol/L)
serum potassium 4.7 mmol/L (3.5-5.0 mmol/L)
serum urea 7.2 mmol/L (2.5-7.5 mmol/L)
serum creatinine 90 micromol/L (60-120 micromol/L, male)
total cholesterol 5.5 mmol/L
HDL cholesterol 0.8 mmol/L
TC: HDL ratio 6.88
ESR 20 mm/hour (men over 50: <20 mm/hour)
Full blood count Normal
LFTs Normal
DAS28 score 2.86 six months ago, pain and swelling in right knee only
Since Richard has mentioned that his knees are ‘playing him up’, you need to find out more about how his
RA symptoms are affecting him. Richard ranks his symptoms as 5/10 (or 50 mm) on the DAS 28 patient
global assessment scale.
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Part one – Assessment of disease activity

Using the information in Richard’s history and results, what is your assessment of Richard’s current level
of disease activity?
Calculate Richard’s current DAS28 score

What does this DAS28 score indicate?
How does this result compare to Richard’s level of disease activity six months ago?
What other clinical signs and symptoms support your assessment of Richard’s current level
How would you summarise these findings for Richard and what actions would you need to
consider with Richard?
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Part two – Assessment of pain management
Referring to the NRAS Medicines in Rheumatoid Arthritis booklet and the Pain and arthritis booklet from
Versus Arthritis, consider how you would approach a discussion with Richard about pain management.
What approaches could you suggest which would support Richard to optimise his pain management?
How would you establish Richard’s understanding of inflammatory arthritis and what is
causing his knee pain?
What pharmacological approaches to pain management could you discuss with Richard?
What non-pharmacological approaches to pain management could you discuss with

Richard?
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Part three – Assessment of cardiovascular risk and other comorbidities

such as hypertension and diabetes
Using the information in Richard’s history and results, how would you assess Richard’s level of
cardiovascular risk and comorbidities?
Calculate Richard’s current level of cardiovascular risk using the QRISK3 2018 tool
(https://qrisk.org/three/).
How would you summarise the implications of this result for Richard?
What action plan would you suggest regarding Richard’s current blood pressure?
Calculate Richard’s risk of diabetes using the Diabetes UK risk assessment tool
(https://riskscore.diabetes.org.uk/start).
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How would you summarise the potential implications of this result for Richard?
At this point, what would be your suggested action plan for supporting Richard to reduce
his current level of cardiovascular risk?
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Part four – Assessment of comorbidities, eg, fracture risk

Using the information above in Richard’s history and results, how would you assess Richard’s future risk
of fracture?
Calculate Richard’s FRAX* score

(www.sheffield.ac.uk/FRAX/tool.aspx?country=1).
*Note: The FRAX® algorithms give the ten-year probability of fracture. The output is a ten-year probability of hip fracture and the
ten-year probability of a major osteoporotic fracture (clinical spine, forearm, hip or shoulder fracture).
RA is a risk factor for fracture, in contrast to osteoarthritis which can be protective. For this reason,
reliance should not be placed on a patient’s report of ‘arthritis’ unless there is clinical or laboratory
evidence to support the diagnosis.
Now follow the link to the NOGG interpretation of Richard’s results from the FRAX
calculation and access the NOGG patient information leaflet
(www.sheffield.ac.uk/NOGG/NOGG%20PIL%202017.pdf).
What are the advantages of sharing the NOGG interpretation, rather than the FRAX
scores, with Richard?
What lifestyle guidance could you share with Richard that will support him to maintain and
optimise his bone health?
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Part five – Assessment of Richard’s mental health, level of fatigue and
ability to work
NICE guidelines recommend that patients with inflammatory arthritis should be screened annually for
mood disorders. As with other chronic diseases, affective disorders such as depression and anxiety are
more common in patients with arthritis than in the general population.
The NICE recommended questions are:
n a re you feeling nervous, anxious or on edge, having difficulty being able to sleep, or difficulty
controlling worrying
n how are you sleeping?
Consider how you could approach assessment of Richard’s mental health, level of fatigue and the impact
of his condition on his ability to work using more person-centred language – what questions could you ask
and what support could you provide?
What questions could you ask Richard to help assess his mood?
What questions could you ask Richard to help assess his level of fatigue?
What questions could you ask Richard to help assess the impact of his condition on his
ability to work?
improve his mental health?
What guidance could you share with Richard that will support him to remain healthier and
maintain his job?
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Part six – Agreeing medicines optimisation options with Richard

What advice could you share with Richard regarding medicines optimisation measures that
will support him to achieve and maintain effective control of his inflammatory arthritis
condition?
Part seven – Exploring Richard’s concerns, eg, need for referral or

surgery
Richard has stated that he would not be happy to consider surgery. However, his RA is less well controlled
at present and he would benefit from an early review with the rheumatology team – how would you
approach a discussion about the options or benefits of referral with Richard?
What questions could you ask Richard to help understand his expectations, or concerns,
about referral to the rheumatology team?
How could you summarise your recommendations about referral to Richard?

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Part eight – Lifestyle changes to support Richard to live well with his
inflammatory arthritis condition

During the annual review, you have discussed several lifestyle measures with Richard that will support
him to live well with his inflammatory arthritis condition.
How could you summarise the overall benefits of lifestyle change for Richard?
What lifestyle changes would be most beneficial for Richard?
Summary – agreeing an action plan with Richard

Now consider how you would summarise and close the annual review consultation with Richard.
What questions and strategies could you use that would help Richard to make an action
plan?
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Next steps

Reflect on the activities in the workshop and undertake the following post-workshop activities which will
give you an opportunity to apply your learning to practice.
Write down the actions you will take in your practice as a result of completing this workshop, we have
made some suggestions to get you started.
1. Familiarise yourself with the Versus Arthritis website and look at the healthcare professional
information and support section (www.versusarthritis.org/about-arthritis/healthcare-
professionals), which features a wide range of reading, e-learning and video resources to support
the development of musculoskeletal core skills, history-taking and clinical assessment skills.
2. Familiarise yourself with the RCGP/BSR Inflammatory arthritis toolkit (www.rcgp.org.uk/clinical-

and-research/resources/toolkits/inflammatory-arthritis-toolkit.aspx) and ask your practice
colleagues how they approach the RA annual review.
3. Consider how you could develop your scope of practice and support better care for those with
inflammatory arthritis, eg, patient safety. Can you contribute to ensuring that:
n shared care documentation is recorded/flagged in the patient record
n a ll DMARDs are ‘recorded/flagged’ on the patient record, including conventional synthetic
(csDMARDs – methotrexate, sulfasalazine), biological (bDMARDs – adalimumab, tocilizumab)
and targeted synthetic (tsDMARDs – baricitinib, tofacitinib)
n all people taking DMARDs carry a patient-held monitoring booklet
n people who ‘default’ from monitoring are followed up
n trends in pathology results are monitored for people taking DMARDs.
4.
5.
6.
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Suggested answers
Warm-up quiz
Only old people get rheumatoid arthritis – true or false?
False – Rheumatoid arthritis primarily affects people of working age, but it can occur at any age and
within ten years of diagnosis around 40 percent of people with RA are unable to work. In older people,
RA more often presents with polymyalgia and with large joint involvement.
Treatment with DMARDs can be delayed until symptoms are severe – true or false?
False – Systematic reviews of randomised controlled trials show that early treatment with
disease-modifying antirheumatic drugs (DMARDs) started within three months can control symptoms,
induce remission, minimise irreparable damage, and protect against the mortality and morbidity
associated with inflammatory arthritis, especially cardiovascular disease.
NICE recommend early treatment for RA and this approach has been shown to be cost effective.
Management principles for RA are broadly applicable to all forms of inflammatory arthritis.
Joint damage is detectable in 80 percent of patients just one year after diagnosis. The goal of early
treatment for rheumatoid arthritis is to achieve clinical and radiological remission and reduce functional
limitations and permanent joint damage.
Exercise should be avoided by people with active inflammatory arthritis, because inflamed
joints require rest – true or false?
False – Inactivity is particularly unhelpful for people with RA as it can increase the risk of joint damage
and deformity. Regular exercise including gentle stretching increases muscle strength which helps to
keep joints stable.
Doctors and physiotherapists can advise regarding an appropriate exercise routine, how to protect
joints and pace activities and will also advise if it is appropriate to rest or protect an inflamed joint from
excessive strain.
Patients should stop taking oral methotrexate if they have any sign of infection (a cold, sore
throat, chills, UTI, etc.) – true or false?
False – current British Society for Rheumatology/British Health Professionals in Rheumatology

(BSR/BHPR) guidance (https://academic.oup.com/rheumatology/article/56/6/865/3053478)
recommends temporary discontinuation of (methotrexate, leflunomide, sulfasalazine, azathioprine,
apremilast, mycophenolate, cyclosporin or tacrolimus) during serious infections until the patient has
recovered from the infection.
Continuation of DMARD therapy is appropriate during episodes of minor infections, eg,

uncomplicated UTI treated with a short course of antibiotics.
‘Behind the smile’ is the theme of a series of short films produced by the National
Rheumatoid Arthritis Society (NRAS) to promote World Arthritis Day in 2016.
What was the aim of the campaign?
The film aims to illustrate what goes on ‘behind the smile’ for someone with RA, suggesting that people
frequently answer, “I’m fine” when asked “how are you today?”
We know that for people living with RA, many symptoms are frequently ‘invisible’.
The feedback NRAS has received from both people with or without RA has been that it has been an
emotive and thought provoking campaign.
26
Activity 1 – Consultation one

Emma comes to your medication review clinic following her appointment with the consultant
rheumatologist. She is quite shocked that she has been diagnosed with rheumatoid arthritis (RA).
Emma tells you that she has a prescription for methotrexate and folic acid, but she is worried about taking
methotrexate as she read in the patient booklet that it might make her hair fall out.
The hospital nurse also told Emma that she should book an urgent appointment at the GP surgery for
influenza and pneumococcal vaccinations, but she doesn’t want to have these as she thought they were
‘just for older people’. Emma is unsure why this is all being done in such a hurry.
How will you establish Emma’s understanding of inflammatory arthritis and the aims of
treatment?
n A
sk how the symptoms are affecting Emma and ask about her ideas, concerns, expectations and
feelings (L(ICE)F) about the condition.
n I n Emma’s case, it is important to establish effective treatment quickly within the window of
opportunity as her symptoms have been present for almost three months.
n T
he likely goal of treatment will be to induce remission – early, aggressive treatment will be offered
with the aim of controlling her symptoms, minimising joint damage and enabling her to remain
active and independent.
How will you establish Emma’s understanding of methotrexate and its potential side
effects?
nY
ou need to establish what Emma knows about methotrexate. Emma’s mum Angela has RA so some
of Emma’s concerns may reflect this.
n G
ive Emma a person-centred resource such as the NRAS Medicines in Rheumatoid Arthritis
booklet and use this in your consultation to answer Emma’s questions.
n C
heck that Emma understands that some side effects could indicate a serious problem and she
would need to contact the GP or hospital team for advice. Examples would be the onset of any
feature of blood disorders (eg, sore throat, bruising, and mouth ulcers), liver toxicity (eg, nausea,
vomiting, abdominal discomfort, and dark urine), fever and symptoms of infection and respiratory
effects (eg, shortness of breath).
n C
aution: this needs to be done in a tactful way to ensure Emma remains safe, but isn’t put off from
engaging in treatment.
n O
ffer reassurance that Emma’s response to treatment and her tolerance of the medicines used will
be closely monitored by the practice and hospital teams working together via a shared care guideline
agreement.
n C
heck whether Emma has been given a patient-held methotrexate monitoring booklet
(www.nras.org.uk/data/files/NRLS-0267-Oral-methotrexa-osage-record-2006-v1.pdf).
How would you explain to Emma why it will be important for her to receive the
recommended vaccinations?
n C
heck with Emma what the consultant or nurse has explained about the reasons why she needs
certain vaccinations.
n E
mma’s immune system will be less effective when she is taking DMARDs – she will be at greater
risk of catching infections and at greater risk of these becoming serious.
n R
eassure Emma that an annual influenza vaccine should be given, and a pneumococcal vaccine
should be given preferably before starting the DMARD.
n V
accination of close family members can also help to protect patients with a lowered immune
system.
2
27
Consultation two
Emma has been taking methotrexate 15 mg once a week for six weeks and has come to discuss how she
is getting on with her medicines.
Emma confirms that she is currently taking methotrexate 15 mg once a week (six 2.5 mg tablets as a
single dose each Monday), naproxen 250 mg tablets twice a day and one or two tablets of co-codamol
30 mg/500 mg when needed for extra pain relief. You ask Emma about her hand and wrist symptoms
and how she is getting on with pain control – both are a little better.
You notice that Emma is looking tired and that she appears to be experiencing some discomfort when
she is talking. Emma tells you that she is having difficulty sleeping and is feeling weary and a bit down
because she is finding it difficult to cope with work, housework and caring for Alex and Lilly. She hasn’t
eaten much this week as her mouth is sore and she has been feeling sick. Emma consents to a mouth
examination and you observe two erythematous aphthous mouth ulcers.
Emma tells you that she didn’t get the prescription for folic acid dispensed because she has been taking
some folic acid tablets that she had left over from her pregnancy with Lilly.
Emma continues that she is due to see the consultant again next week and is worried because the hospital
nurse said she may be asked to start more medicines. She doesn’t understand why this is necessary and
asks ‘unless the methotrexate isn’t working?’
How would you address Emma’s concerns about methotrexate ‘not working’?
n R
eassure Emma that DMARDs can take 8 to 12 weeks to be effective and encourage her to discuss
any concerns with the consultant at her hospital appointment.
n E
xplain that the specialist team will be following recommended practice to help Emma achieve
the best possible control of her RA (treat to target, T2T) – the first target is remission (leading to
sustained remission) and the alternate target is low disease activity. This will initially involve regular
reviews (one to three months) to assess Emma’s response to treatment.
n E
mma can expect to be offered additional DMARD therapy according to her response to treatment
and/or her tolerance of treatment.
What treatment plan would you suggest for Emma’s mouth ulcers?
n F
irstly, exclude RED FLAGS – you should confirm that Emma can eat and swallow solid
food, though not without discomfort, and that apart from nausea she is not suffering any other
gastrointestinal symptoms, specifically she has no diarrhoea. Note – diarrhoea and ulcerative
stomatitis can be toxic effects of methotrexate and require interruption of therapy as haemorrhagic
enteritis and intestinal perforation may result.
n R
eassure Emma that her aphthous ulcers should heal over one to two weeks and prescribe treatment
for symptomatic relief, eg, a protective paste such as Orabase.
n E
xplain to Emma that most adverse reactions to methotrexate occur within the first three months
of treatment and that mouth ulcers and nausea are some of the more common side effects of
methotrexate.
n E
xplain that methotrexate interferes with the absorption of B vitamins, such as folic acid, from the
diet and for this reason a supplement of folic acid is usually prescribed.
n T
he folic acid tablets on Emma’s prescription were 5 mg and she should take these once a week but
not on the same day as methotrexate.
n The pre-conception 400 microgram folic acid dose that Emma is taking is too low to be effective.
n A
dvise Emma about avoiding ‘trigger factors’ including oral trauma and certain foods and drinks
(such as coffee, chocolate, peanuts, and gluten-containing products).
heck that Emma isn’t experiencing any local trauma (eg, from sharp and/or broken teeth, dentures
n C
and orthodontic appliances, and biting during chewing) – if so, appropriate dental treatment should
be advised.
28
How would you support Emma to understand the importance of adherence to treatment to
minimise side effects?
n M
and F is a good way of remembering which day to take the medicines, eg, taking methotrexate on
a Monday and folic acid on a Friday.
n E
ncourage Emma to take methotrexate after her evening meal - her nausea will be less on waking
and explain that folic acid also helps reduce nausea.
n I f Emma finds the nausea problematic, there is some evidence that drinking mint tea and ginger (tea
or biscuits) can be helpful.
n M
inor adverse effects, such as nausea, mouth ulcers, and abdominal symptoms settle with time, dose
adjustments, or with additional treatments.
What additional actions should you take to ensure Emma’s safety?
n C
heck Emma’s most recent blood test results. Ensure that her full blood count and white cell count
are within the normal reference range.
n C
heck that Emma has been dispensed methotrexate 2.5 mg tablets, the correct number and that
these are labelled in accordance with the NPSA guidance ‘take six 2.5 mg tablets once a week on a
Monday’.
n W
rite a summary of the consultation outcome with Emma and send this to the rheumatology team
in advance of Emma’s next appointment.
Consultation three
A month later Emma returns to your clinic, she is now taking methotrexate 20 mg once a week
(eight 2.5 mg tablets on a Monday), folic acid 5 mg twice a week on Wednesday and Friday and
hydroxychloroquine 200 mg once a day. She takes one or two co-codamol 30 mg/500 mg tablets when
needed for pain relief and has stopped taking naproxen.
Emma explains that her inflammatory symptoms have continued to improve. She is pleased to tell you
that she is now back at work, though she still feels tired much of the time.
Emma asks for a repeat of her oral contraceptive pill, Gedarel 30/150 and wants to check with you if this
is safe to take with her current medicines.
Emma mentions that the family are going on holiday in a couple of weeks to south west France with a
couple of other families. They will be visiting several vineyards and it could be ‘quite a boozy’ week. Emma
asks if she should stop taking methotrexate whilst she is on holiday, because she has been told that she
shouldn’t drink whilst taking it.
How would you respond to Emma’s question about Gedarel 30/150?
n Reassure Emma that Gedarel 30/150 is safe to take with her current medicines.
n E
mphasise that an effective method of contraception is recommended for women of childbearing
potential who are taking DMARDs.
How would you respond to Emma’s question about stopping methotrexate?
n A
dvise Emma not to stop taking methotrexate, or hydroxychloroquine, as this could result in
worsening of her RA disease activity and symptoms and may even lead to an acute flare of her RA.
What ‘holiday’ advice could you give Emma regarding alcohol intake, sun exposure and
safekeeping of medicines?
n A
lcohol can be consumed by patients taking hydroxychloroquine – however, the use of methotrexate
is the critical factor to consider for Emma.
n E
mma should limit her intake to the minimum acceptable amount of ideally not more than one unit/
2
day of alcohol. Emma should not exceed three glasses of wine (based on 175 mL glass of 13% wine)
per week.
29
n Advise Emma that this is below current recommendations of 14 units per week.
n Explain to Emma that hydroxychloroquine could make her skin more sensitive to sunlight.
n A
general recommendation for patients taking DMARDs would be that exposure to sunlight and
UV light should be limited and patients should wear protective clothing, wear a hat and use (and
reapply frequently) a sunscreen with a high protection factor (eg, factor 50) to minimise the risk of
skin cancer and photosensitivity.
n C
heck that Emma is aware that hydroxychloroquine is toxic in overdose – especially in small
children and encourage her to keep all her medicines out of Lilly’s reach.
Consultation four
Emma comes in to see you a couple of weeks after her holiday. The family had a great time away, but
Emma tells you that she stopped taking methotrexate and her other arthritis medicines before she went on
holiday – hoping that the warm climate would help to improve her symptoms.
However, now she feels exhausted, quite miserable and feels as if she is ‘back to square one’. She has
not been able to go to work today and has needed extra help at home from her family with dressing. She
hasn’t been able to manage any housework or cooking.
Emma explains that she has been taking eight co-codamol 30 mg/500 mg tablets a day over the past week
- she has needed the extra pain relief to relieve the aching pain, swelling and stiffness in her wrists and
hands.
Her mum, Angela, brought her to see the GP yesterday and took her to an appointment with the
rheumatology consultant who explained that she is having a ‘flare’. The hospital letter states that Emma
had six tender joints (out of a possible 28) and four of these were also swollen. Her ESR lab result from
yesterday was 40, giving a DAS28 score of 4.51.
Emma was given a Depo-Medrone injection, a course of naproxen and her DMARD medicine was
restarted. She has also been referred for physiotherapy and wax baths to ease the discomfort in her hands.
Emma said she was asked lots of questions about her holiday and what tablets she had been taking. She
was also given a booklet about DAS28 scores, her score was 4.51 and she was told this was ‘moderate
disease’ – she is anxious to understand what this means for her.
Emma asks what she can do to manage her pain and her RA better.
Referring to the NRAS Medicines in Rheumatoid Arthritis booklet, the Pain and arthritis booklet
from Versus Arthritis and the NRAS Know your Disease Activity Score booklet (www.nras.org.uk/
publications/know-your-das) consider how you would approach the consultation and respond to
Emma’s concerns.
What advice would you discuss with Emma about pharmacological measures for pain
relief?
n R
eassure Emma that nonsteroidal anti-inflammatory drug (NSAIDs) and corticosteroids can
rapidly alleviate flares. The Depo-Medrone injection that she was given yesterday and a course of
naproxen should help to reduce her pain and inflammatory symptoms quickly.
n R
eassure Emma that naproxen is safe to take with low doses of methotrexate. Remind Emma that
the NSAID should be stopped as soon as possible when her flare symptoms have resolved.
n Emma can also continue to take co-codamol tablets, up to eight tablets in 24 hours.
What advice would you discuss with Emma about non-pharmacological measures for pain
relief?
n H
ot and cold therapy applied near to affected joints, eg, a hot water bottle for warm stiff joints and
cold ice packs for hot, red and inflamed joints can be helpful, though should not be applied directly
to the joint.
n Hot showers in the morning may help to relieve pain and stiffness.
n Rest and pacing and gentle mobility are helpful.
30
How would you explain to Emma what the DAS28 score is?
n U
sing the NRAS Medicines in Rheumatoid Arthritis booklet you could explain that the Disease
Activity Score (DAS) is a tool used to measure rheumatoid arthritis (RA) disease activity in a
person’s joints.
n T
he result (a calculation) is based on the number of tender and swollen joints that a person has –
there can be up to 14 joints affected on both sides of the body (hence DAS28 score) and an ESR or
CRP blood result – which are higher when there is inflammation occurring in the body.
n D
AS28 can be used to check whether the signs and symptoms of RA have reduced or stopped, and
if treatment needs to be adjusted.
What does a DAS28 score of 4.51 mean for Emma?
n T
he hospital letter stated that Emma had six tender joints (out of a possible 28) and four of these
were also swollen, her ESR lab result from yesterday was 40, giving a DAS28 score of 4.51.
mma was told that a DAS28 score of 4.51 meant she had moderate disease activity – you could
n E
say that this helps to explain why she is feeling so unwell and ‘back to square one’ and why the
hospital team gave her an injection and restarted her DMARD therapy.
nY
ou could remind Emma that the likely goal of RA treatment will be to induce ‘remission’ – early,
aggressive treatment will be offered with the aim of controlling her symptoms, minimising joint
damage and enabling her to remain active and independent.
n T
he specialist team will monitor Emma’s response to treatment with DAS28; her scores should
decrease and a result less than 2.6 would indicate her disease was in remission.
What approaches could you discuss with Emma to help her to understand and learn to
manage her RA symptoms?
n E
mma can also monitor her joint symptoms herself using the Know Your DAS App
(www.nras.org.uk/know-your-das-mobile-app) or
n RheumaBuddy App (www.rheumabuddy.com/english)
n Encourage Emma to consider using one of the apps to monitor her response to DMARD therapy
and learn how this impacts upon her symptoms and wellbeing.
What advice and support could you discuss with Emma to help her to manage her acute
flare symptoms?
n Emphasise the importance of adherence to treatment with Emma.

n Establish how the flare is impacting on Emma’s daily life and activities (activities of daily living -
ADLs).
n Signpost Emma to the NRAS Medicines in Rheumatoid Arthritis booklet, the Pain and arthritis
booklet from Versus Arthritis, for advice about the recognition of flare-ups and triggers (eg,
overdoing things around the house - encourage Emma to ask for help before she becomes
exhausted) and ways that she can ease the flare symptoms.
n Patient self-management is important. Rest, pacing of activities and cognitive behavioural therapy
(CBT)-based pain management strategies can help patients to manage their symptoms.
n Conservative measures: gentle stretching and regular active range of motion (ROM) exercises can
help improve joint function. Movement can help keep joints flexible, reduce pain, and improve
balance and strength.
n Meditation.
n Yoga.
2
31
How would you explain to Emma why the hospital team needed to take a careful drug and
travel history?
n A drug history is needed to exclude any drugs that may be causing acute flare symptoms.
n A travel history – patients are always asked about any recent foreign travel to exclude the possibility
of infections which may cause joint pains, eg, chikungunya.
Consultation five
Emma returns to see you six months after her acute flare. She likes the RheumaBuddy App, it has helped
her to manage her activities and lifestyle more effectively and to better understand her RA. She is pleased
to tell you that her latest DAS28 score was 1.9 – which means her RA is in remission.
She is taking methotrexate 20 mg once a week (eight 2.5 mg tablets on a Monday), folic acid 5 mg twice
weekly (on Wednesdays and Fridays), sulfasalazine EC tablets 1000 mg twice a day, hydroxychloroquine
200 mg once a day and one or two co-codamol 30 mg/500 mg tablets when needed for extra pain relief.
Emma feels well and she is coping with work. She tells you that Alex proposed to her whilst they were in
France and they recently got married. She mentions that she is keen to come off the pill as she would like
another baby and asks if it is safe to continue taking the medicines for her RA if she gets pregnant?
What advice and guidance would you give Emma in relation to her desire to have another
baby?
n Explore Emma’s ideas, concerns and expectations in relation to having a baby and maintaining
control of her RA during pregnancy.
n Remind Emma that stopping DMARDs herself is not advisable as this could lead to worsening of
her RA symptoms and lead to another flare.
n Encourage Emma to continue with the pill, check that she understands that methotrexate may harm
the growing baby and cause birth defects.
n Reassure Emma that you will ask a GP to refer Emma to the rheumatology team promptly for
pre-conception advice and shared care with the obstetric team.
n Reassure Emma that some medicines are considered safer to take in pregnancy than others and
Emma’s specialists will review the risks and benefits of each DMARD that she is taking, considering
both the need to manage her symptoms and the possible risks to an unborn child.
n The specialists will jointly review Emma and support her throughout her planned pregnancy.
n Wish Emma well!
Activity 2 – Patient safety incidents with DMARDs

Group discussion - we have not included suggested answers for this activity.
32
Activity 3 – Rheumatoid arthritis – Richard Arnold’s annual review

Richard Arnold (aged 62) comes in to see you for an annual review appointment.
Richard confirms that he understands that the annual review will involve talking about his symptoms, his
medicines, his lifestyle, his ideas, expectations and concerns to better appreciate how RA is affecting his
quality of life.
Richard hasn’t been feeling at his best lately and is keen to find out if the review will be helpful for him.
He is pleased to hear that together you will be able to discuss strategies to support him to feel better and
be healthier.
Richard was diagnosed with seropositive RA four years ago and his medication record indicates that he is
prescribed methotrexate tablets 20 mg once weekly on Saturday, folic acid tablets 5 mg once daily - except
on Saturday and leflunomide tablets 10 mg once daily.
Richard has been on this regimen for the last three years, with monthly monitoring. His RA has been
stable, with no recent flares. Richard is up to date with both the pneumococcal and annual flu vaccine.
Richard is also prescribed paracetamol tablets 1000 mg four times a day when needed for pain relief
(x100 tablets) – he has ordered this more frequently over the last six months.
Richard lives at home with his wife, Betty and their two youngest children, Amy (17) and Karl (15).
Richard confirms for you that he is a smoker (ten cigarettes/day), he does not drink alcohol and he enjoys
walking the dog.
Richard works for the local council as head gardener. He mentions that in recent months both his knees
have been ‘playing him up’ and he has been offered a ‘desk job’ at work, which he is upset about. He
quickly tells you that he doesn’t want ‘any operations’ because his brother had ‘problems’ after his knee
operation.
You ask Richard to clarify what he means by his knees ‘playing him up’ and he explains that his knees
have been more painful, swollen and sore to touch. It is taking him a long while to get going in the
mornings - this is happening almost daily.
Richard’s recent measurements
Height 180 cm
Weight 98 kg
BMI 30.2
Waist measurement 114 cm
BP 160/96 mmHg
Pathology data
eGFR 80 mL/min/1.73 m2 (60-89 mL/min/1.73 m2)

serum sodium 135 mmol/L (133-147 mmol/L)
serum potassium 4.7 mmol/L (3.5-5.0 mmol/L)
serum urea 7.2 mmol/L (2.5-7.5 mmol/L)
serum creatinine 90 micromol/L (60-120 micromol/L, male)
total cholesterol 5.5 mmol/L
HDL cholesterol 0.8 mmol/L
TC: HDL ratio 6.88
ESR 20 mm/hour (men over 50: <20 mm/hour)
Full blood count Normal
LFTs Normal
DAS28 score 2.86 six months ago, pain and swelling in right knee only
Since Richard has mentioned that his knees are ‘playing him up’, you need to find out more about how his
2
RA symptoms are affecting him. Richard ranks his symptoms as 5/10 (or 50 mm) on the DAS28 patient
global assessment scale.
33
Part one – Assessment of disease activity
Using the information in Richard’s history and results; what is your assessment of Richard’s current level
Calculate Richard’s current DAS28 score

n Richard’s DAS28 score is 3.28, based on his global assessment score of 50 mm, both knees being
swollen and tender, and an ESR of 20.
What does this DAS28 score indicate?
n This indicates moderate disease activity, which may merit change in therapy for some patients
unless mutually agreed to be the best outcome on current treatment.
How does this result compare to Richard’s level of disease activity six months ago?
n Six months ago Richard’s ESR was 18, he had discomfort in his right knee only and his DA28 score
was 2.86 indicating low disease activity.
n Even a low DAS28 score could merit change in therapy for some patients because disease remission
(DAS28 <2.6) is the ideal goal of treatment – although this is not achievable for all patients.
What other clinical signs and symptoms support your assessment of Richard’s current level
n Signs – Richard has persistent swelling of one or more joints, he has symmetrical involvement of
joints (both knees) and joint tenderness.
n Symptoms – stiffness in the mornings lasting more than 30 minutes, pain in joints.
How would you summarise these findings for Richard and what actions would you need to
consider with Richard?
n You would explain that the DAS28 score indicates that his RA is more active at present.
n This supports what Richard has noticed – that his symptoms have increased in the last six months
and are impacting on his work and family life. He is more unwell and taking pain relief on a
regular basis.
n Richard might benefit from a change of medicines or treatment escalation and so referral to the
rheumatology team for their input and advice would be an action for Richard to consider. This
could also include local treatment of his two affected joints.
34
Part two – Assessment of pain management

Referring to the NRAS Medicines in Rheumatoid Arthritis booklet and the Pain and arthritis booklet from
Versus Arthritis, consider how you would approach a discussion with Richard about pain management.
What approaches could you suggest which would support Richard to optimise his pain management?
How would you establish Richard’s understanding of inflammatory arthritis and what is
causing his knee pain?
n L(ICE)F - explore Richard’s ideas about pain management and establish what approach he prefers.
n Explain that knee pain can be caused by several things, however in all cases exercise and
maintaining a healthy weight can reduce symptoms.
n Signpost Richard to the Versus Arthritis resources, eg, guidance that will be helpful for people
with knee pain and download a leaflet for him (www.versusarthritis.org/about-arthritis/
conditions/osteoarthritis-of-the-knee/#Exercises-to-manage-knee-pain).
What pharmacological approaches to pain management could you discuss with Richard?
n If he is willing, initially encourage Richard to take paracetamol four times a day regularly to
determine whether this is beneficial for him.
n Consider whether a short course of a NSAID, or corticosteroids, may be helpful to control
Richard’s current symptoms quickly – with his agreement you could contact the rheumatology team
for their advice.
What non-pharmacological approaches to pain management could you discuss with

Richard?
n Ask Richard what non-pharmacological approaches to pain relief he has tried and found effective
previously?
n Conservative measures are beneficial: Richard can try active range of motion (ROM) exercises
which help improve joint function. Stretching and movement can help keep joints flexible, reduce
pain, and improve balance and strength.
n Richard could wear comfortable boots with thick soles at work, memory foam insoles and may find
use splints/supports helpful.
n Hot and cold therapy applied near to affected joints, eg, a hot water bottle for warm stiff joints and
cold ice packs for hot, red and inflamed joints (not applied directly to the joint).
n Hot showers in the morning may help to relieve pain and stiffness.
n Rest and pacing and gentle mobility.
n Patient self-management is important. Meditation, yoga and CBT-based pain management
strategies can help manage symptoms and Richard may be willing to consider trying these
approaches in preference to taking additional pain relief.
n Remind Richard the pain in his knees will reduce and he will find exercise easier if he loses weight.
This should help him to remain mobile and in the job that he loves.
2
35
Part three – Assessment of cardiovascular risk and other comorbidities
such as hypertension and diabetes

Using the information in Richard’s history and results, how would you assess Richard’s level of
cardiovascular risk and comorbidities?
Calculate Richard’s current level of cardiovascular risk using the QRISK3 2018 tool
(https://qrisk.org/three).
n Richard’s ten-year QRISK3 score is 36.1 percent, compared with 9.7 percent for a healthy person
of same age, sex and ethnicity (relative risk is 3.7).
n Discussing the QRISK Healthy Heart Age score is a more person-centred approach – Richard’s
QRISK Healthy Heart Age is 83.
What action plan would you suggest regarding Richard’s current blood pressure?
n Richard needs additional BP checks to establish whether he has persistently raised blood pressure –
the recent 160/96 mmHg result may be an isolated high reading.
n Raised blood pressure can be a side effect of leflunomide – his blood pressure should be checked at
the same frequency as blood monitoring.
n Check the advice in the local shared care guideline – referral to the rheumatology team would be
appropriate for a BP >140/100 mmHg.
Calculate Richard’s risk of diabetes using the Diabetes UK risk assessment tool
(https://riskscore.diabetes.org.uk/start).
n Richard’s risk of diabetes score is 24.
n Richard has a moderate risk of developing type 2 diabetes.
What would be your suggested action plan for supporting Richard to reduce his current
level of cardiovascular risk?
n Consider how overwhelming this could be for Richard – L(ICE)F – you will need to explore
Richard’s concerns and establish his priorities.
Options for Richard to consider include:
n Richard’s ten-year QRISK2 score is 41.6 percent – you would offer him a statin.
n Supporting Richard with smoking cessation would be a priority.
n Consider anti-hypertensive treatment, but firstly, Richard needs additional BP checks to establish
whether he has persistently raised blood pressure and he would need to be referred to the
rheumatology team for a review if his BP remains persistently >140/100 mmHg.
n Richard is also at moderate risk of developing type 2 diabetes, you should recommend lifestyle
approaches to reduce this risk.
n It is important to share with Richard that encouragingly weight loss and exercise will be helpful in
reducing his blood pressure and risk of diabetes.
36
Part four – Assessment of comorbidities, eg, fracture risk

Using the information above in Richard’s history and results, how would you assess Richard’s future risk
of fracture?
Calculate Richard’s FRAX* score

(www.sheffield.ac.uk/FRAX/tool.aspx?country=1).
n Richard’s ten-year probability (risk) of major osteoporotic fracture is 5.2 percent.

n Richard’s ten-year probability (risk) of hip fracture is 1.1 percent.
n These results are not easy to explain – a slightly more person-centred explanation would be that
following the assessment of fracture risk using FRAX in the absence of a bone mineral density
(BMD) result, people may be classified to be at low, intermediate or high risk of fractures.
*Note: The FRAX® algorithms give the ten-year probability of fracture. The output is a ten-year probability of hip fracture and the
ten-year probability of a major osteoporotic fracture (clinical spine, forearm, hip or shoulder fracture).
RA is a risk factor for fracture, in contrast to osteoarthritis which can be protective. For this reason,
reliance should not be placed on a patient’s report of ‘arthritis’ unless there is clinical or laboratory
evidence to support the diagnosis.
Now follow the link to the NOGG interpretation of Richard’s results from the FRAX
calculation and access the NOGG patient information leaflet
(www.sheffield.ac.uk/NOGG/NOGG%20PIL%202017.pdf).
n The NOGG interpretation confirms that Richard is at low risk of a major fracture – reassurance,
lifestyle advice, and reassessment in five years (or less depending on the clinical context) would be
appropriate for him.
What are the advantages of sharing the NOGG interpretation, rather than the FRAX
scores, with Richard?
n The NOGG interpretation of FRAX results is a more person-centred visual representation of what
these results mean and helps to explain the relevant treatment recommendations.
optimise his bone health?
n The Royal Osteoporosis Society (https://theros.org.uk/) produce a range of useful guidance

leaflets for people with osteoporosis and those at risk of osteoporosis, for example:
n A balanced diet for bone health:
https://theros.org.uk/information-and-support/looking-after-your-bones/nutrition-
for-bones/
n Bone-building exercise:
https://theros.org.uk/information-and-support/looking-after-your-bones/exercise-for-
bones/
n Lifestyle choices for bone health:
https://theros.org.uk/information-and-support/looking-after-your-bones/lifestyle-for-
bone-health-checklist/
n Richard can maintain and optimise his bone health by stopping smoking, achieving and maintain a
healthy weight, ensuring an adequate dietary intake of calcium and vitamin D and completing 150
minutes of moderate exercise (any activity that makes him feel warmer and slightly out of breath)
over a week, with muscle-strengthening exercises on at least two days a week (UK government
recommendations).
2
37
Part five – Assessment of mental health, level of fatigue and ability
to work
NICE guidelines recommend that patients with inflammatory arthritis should be screened annually for
mood disorders. As with other chronic diseases, affective disorders such as depression and anxiety are
more common in patients with arthritis than in the general population.
The NICE recommended questions are:
n a re you feeling nervous, anxious or on edge, having difficulty being able to sleep, or difficulty
controlling worrying
n how are you sleeping?
Consider how you could approach assessment of Richard’s mental health, level of fatigue and the impact
of his condition on his ability to work using more person-centred language – what questions could you ask
and what support could you provide?
What questions could you ask Richard to help assess his mood?
You might try the following approach, asking if Richard has:

n h
ad difficulty thinking clearly, concentrating or carrying out normal activities because of any worries
or concerns
n had poor or disturbed sleep night after night – due to symptoms such as pain disrupting his sleep
n had difficulty falling asleep, or waking up in the early hours, because of worrying?
What questions could you ask Richard to help assess his level of fatigue?

n got ready to go out, but felt too exhausted to go
n gone hungry, because he did not have the energy to prepare food for himself
n fallen asleep on the sofa, because he could not get himself upstairs to bed?
What questions could you ask Richard to help assess the impact of his condition on his
ability to work?

n missed work due to tiredness or his RA
n had difficulty thinking clearly, concentrating or carrying out normal activities such as driving
n felt stressed, worried or low at work due to his health?
improve his mental health?
n F
atigue beyond tiredness is a useful booklet from the National Rheumatoid Arthritis Society
(NRAS), available at
www.nras.org.uk/data/files/Publications/Fatigue%20Beyond%20Tiredness.pdf
n The
guidance includes: Pace yourself, Know your limitations, Listen to your body, Adapt your lifestyle,
Don’t beat yourself up because you can’t do something, Ask for help if you need it, Manage RA, so it does
not manage you, Prioritise your activities, Think positive, Remember, tomorrow is another day.
n E
xercise and relaxation are important – an exercise regimen can improve wellbeing, strength,
energy levels and sleeping patterns.
n A physiotherapist could help Richard with exercise and posture advice.
n Relaxation techniques can help the body recharge itself and may also improve sleep.
38
What guidance could you share with Richard that will support him to remain healthier and
maintain his job?
n Continuing with his job is an important consideration for Richard.

n Whilst Richard’s knees are more painful helping him to improve symptom control is a priority.
n A
desk job will further reduce his mobility and worsen Richard’s situation – he will benefit more
from increased exercise and activity to ensure that he remains mobile and independent.
n B
oth NRAS and Versus Arthritis have guidance that Richard could find useful regarding his work
(www.versusarthritis.org/about-arthritis/living-with-arthritis/work/).
n Both NRAS and Versus Arthritis also produce advice and guidance for employers.
Part six – Agreeing medicines optimisation options with Richard

What advice could you share with Richard regarding medicines optimisation measures that will support
him to maintain effective control of his inflammatory arthritis condition?
Medicines optimisation advice and support for Richard.
n Establish Richard’s understanding of each of his medicines and his routine for taking them.
n E
nsure that Richard has adequate quantities of paracetamol on his prescription if he decides to take
this more frequently.
n I f the rheumatology team recommend that Richard takes a course of NSAIDs or corticosteroids,
ensure that Richard understands when these should be stopped.
n I f Richard’s DMARD therapy changes, be available to support him with further information and
advice.
Part seven – Exploring Richard’s concerns, eg, need for referral or

surgery
Richard has stated that he would not be happy to consider surgery. However, his RA is less well controlled
at present and he would benefit from an early review with the rheumatology team – how would you
approach a discussion about the options or benefits of referral with Richard?
What questions could you ask Richard to help understand his expectations, or concerns,
about referral to the rheumatology team?
n L
(ICE)F – has Richard found the team supportive or is he concerned that they may suggest
surgery?
n V
ersus Arthritis produce guidance about joint surgery – should Richard want to know more in the
future (www.versusarthritis.org/about-arthritis/treatments/surgery/knee-replacement-
surgery/).
How could you summarise your recommendations about referral to Richard?
n R
ichard would benefit from an early review with the rheumatology team to assess his knees for joint
damage and determine whether a course of NSAIDs, or corticosteroids, could help to control his
symptoms quickly – this could be helpful for work.
n T
he team would decide with Richard if his current DMARD regimen is optimal for him or if
treatment escalation should be considered.
ichard could access physiotherapy, hydrotherapy, or occupational therapy which will help with
n R
symptom relief.
n If Richard prefers, telephone advice could be initially sought from the team.
2
39
Part eight – Lifestyle changes to support Richard to live well with his
inflammatory arthritis condition

During the annual review, you have discussed several lifestyle measures with Richard that will support
him to live well with his inflammatory arthritis condition.
How could you summarise the overall benefits of lifestyle change for Richard?
n L
ifestyle modification would enable Richard to manage his RA symptoms, maintain his mobility,
work and keep his independence – improving his mental health and wellbeing. It would also help
him to reduce his risks of cardiovascular disease, diabetes and fractures and improve his physical
health and wellbeing in the future.
What lifestyle changes would be most beneficial for Richard?
n S
topping smoking and making progress with regular exercise and healthy eating/weight reduction
would be most beneficial.
Summary – establishing an action plan with Richard

Now consider how you would summarise and close the annual review consultation with Richard. What
strategies could you use that would help Richard to make an action plan?
What questions and strategies would help Richard to make an action plan?
n Good rapport, engagement and empathy with Richard is crucial.

n R
ichard hasn’t been feeling well – improving his pain management and symptom control are
immediate priorities.
(ICE)F – understanding Richard’s thoughts about the information you have shared during the
n L
review will help to establish his priorities and next steps.
n Using a health coaching/motivational interviewing approach will also help.
n Signpost Richard to resources and services that are appropriate for him.
n Enable Richard to make decisions at his own pace.
40
Reference

1. N
ational Institute for Health and Care Excellence. QS33 Rheumatoid arthritis in over 16s. 2013.
www.nice.org.uk/guidance/qs33/chapter/Quality-statement-7-Annual-review
41
Notes
42
43
2
Notes
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CENTRE FOR PHARMACY

A CPPE workshop Workshop book

Cate Dawes, education supervisor

© Copyright controller HMSO 2019

Supporting people to live well with inflammatory arthritis – Workshop book

About this CPPE workshop resource 5

Activity 1 – Clinical decision-making scenarios – Emma Partridge’s journey 7

Activity 2 – Patient safety incidents with DMARDs 14

Activity 3 – Rheumatoid arthritis – Richard Arnold’s annual review 15

1 Core learning (limited expectation of prior knowledge)

2 Application of knowledge (assumes prior learning)

Supporting people to live well with inflammatory arthritis – Workshop book

This has the potential to improve patient outcomes by:

n reducing disease and treatment burden

The workshop will last two hours.

A note about web links

Supporting people to live well with inflammatory arthritis – Workshop book

Only old people get rheumatoid arthritis – true or false?

Activity 1 – Clinical decision-making scenarios – Emma Partridge’s

Supporting people to live well with inflammatory arthritis – Workshop book

What additional actions should you take to ensure Emma’s safety?

How would you respond to Emma’s question about Gedarel 30/150?

How would you respond to Emma’s question about stopping methotrexate?

Supporting people to live well with inflammatory arthritis – Workshop book

What does a DAS28 score of 4.51 mean for Emma?

Patient factors Communication factors

Prescribing factors Monitoring factors

Opportunities for me to support and improve DMARD monitoring in my practice.

Supporting people to live well with inflammatory arthritis – Workshop book

A comprehensive annual review includes:

Richard’s recent measurements

eGFR 80 mL/min/1.73 m2 (60-89 mL/min/1.73 m2)

Supporting people to live well with inflammatory arthritis – Workshop book

Calculate Richard’s current DAS28 score

What does this DAS28 score indicate?

What non-pharmacological approaches to pain management could you discuss with

Supporting people to live well with inflammatory arthritis – Workshop book

Supporting people to live well with inflammatory arthritis – Workshop book

Calculate Richard’s FRAX* score

The NICE recommended questions are:

Supporting people to live well with inflammatory arthritis – Workshop book

Part seven – Exploring Richard’s concerns, eg, need for referral or

How could you summarise your recommendations about referral to Richard?

inflammatory arthritis condition

What lifestyle changes would be most beneficial for Richard?

Summary – agreeing an action plan with Richard

Supporting people to live well with inflammatory arthritis – Workshop book

2. Familiarise yourself with the RCGP/BSR Inflammatory arthritis toolkit (www.rcgp.org.uk/clinical-

False – current British Society for Rheumatology/British Health Professionals in Rheumatology

Continuation of DMARD therapy is appropriate during episodes of minor infections, eg,

Supporting people to live well with inflammatory arthritis – Workshop book

What additional actions should you take to ensure Emma’s safety?

How would you respond to Emma’s question about Gedarel 30/150?

How would you respond to Emma’s question about stopping methotrexate?

What does a DAS28 score of 4.51 mean for Emma?

n Emphasise the importance of adherence to treatment with Emma.

Activity 2 – Patient safety incidents with DMARDs

Supporting people to live well with inflammatory arthritis – Workshop book

Richard’s recent measurements

eGFR 80 mL/min/1.73 m2 (60-89 mL/min/1.73 m2)

Calculate Richard’s current DAS28 score

What does this DAS28 score indicate?

Supporting people to live well with inflammatory arthritis – Workshop book

n reducing disease and treatment burden

2. Familiarise yourself with the RCGP/BSR Inflammatory arthritis toolkit (www.rcgp.org.uk/clinical-

n Emphasise the importance of adherence to treatment with Emma.

n Richard’s risk of diabetes score is 24.

n Richard has a moderate risk of developing type 2 diabetes.

n Richard’s ten-year probability (risk) of major osteoporotic fracture is 5.2 percent.

n The Royal Osteoporosis Society (https://theros.org.uk/) produce a range of useful guidance

n Continuing with his job is an important consideration for Richard.

n Good rapport, engagement and empathy with Richard is crucial.