Taking charge of arthritis – Dr James Bluett speaks to Arthritis Digest
Arthritis Digest is a magazine for people with arthritis that highlights the latest relevant research and reviews topical issues.
BRC Researcher Dr James Bluett is Senior Lecturer at The University of Manchester and Honorary Consultant Rheumatology at Manchester Royal Infirmary. Continuing regular contributions from our BRC Musculoskeletal (MSK) theme, he discusses how new tests will support patients with rheumatoid arthritis to regain control of their health.
Rheumatoid arthritis is a chronic condition that causes joint swelling and pain, and affects up to one per cent of adults in the UK – more than 400,000 people.
Although rheumatoid arthritis can occur at any age, it peaks between those aged 30 to 50-years-old. We cannot yet cure rheumatoid arthritis, so we aim to keep the condition under control with drugs. Excitingly, people with rheumatoid arthritis now have access to much more effective medication. However, it remains difficult to know which patients will experience the best response with which drugs.
Treatments
Methotrexate is one of our first-choice tablets for people living with rheumatoid arthritis. It is effective in around 50 per cent of those with early rheumatoid arthritis and works well in combination with other treatments.
Unfortunately, methotrexate does not work in everyone.
We also know that it can be difficult to take medication on time, and this can cause a poor response to treatment.
In fact, research has shown that up to 40 per cent of patients may struggle to take their methotrexate tablets on time, or can forget to take their medication altogether.
For some people for whom methotrexate does not work (or is not suitable) other medications may be available to help control rheumatoid arthritis. Biologic medications, for example, target the immune system to reduce inflammation and are given as injections. A number of different biologic medications are available, but it is not always clear which is the best drug for each individual patient.
Improved support
At Manchester Royal Infirmary – which is part of Manchester University NHS Foundation Trust (MFT)) – we therefore started an ambitious project that aimed to change the way we support people who take methotrexate tablets. Several support tools were provided including:
- improved staff training
- bookmark reminders for patients
- smartphone apps to help patients manage medication.
We measured levels of methotrexate in the blood and found that there was an improvement in people taking methotrexate on time from 44 per cent to 83 per cent.
We are now working to see if measuring methotrexate drug levels in the blood could help support patients taking their medication on time.
New testing regimes
Measuring blood levels of other rheumatoid arthritis drugs, such as biologic medications, may help us make early decisions about if the medication is more or less likely to work. That is why we are studying whether measuring drug levels and suggesting changes to biologic medication in patients with rheumatoid arthritis may be of benefit in the future.
Working with people with rheumatoid arthritis and engaging them in research will improve the management of what used to be an extremely debilitating condition. The end goal is to enable people diagnosed with the disease to live full and active lives.
Living with arthritis – Golda, 80, from Cheshire
“I was 70-years-old when I was diagnosed with rheumatoid arthritis. For years I had noticed that the middle joint of my index finger was very sore if I wrote for any length of time. I put this down to keeping the finger stiff when holding a pen or pencil.
When I visited my GP, it was with a completely different problem, and I only mentioned my painful joints in passing.
To my surprise – and disappointment – a blood test came back that confirmed a high rheumatoid factor. My disappointment reflected my belief that having kept reasonably fit throughout my life I might avoid an illness that would never get better.
I armed myself with as much knowledge as I could, buying numerous academic books and delving into reliable websites.
My initial consultation with a rheumatologist confirmed some of the things I had read about – that rheumatoid arthritis is an autoimmune illness which cannot be cured, and can only controlled with medication. Put simply, my immune system saw the body it lived in as an enemy (like an infection or a virus) and needed to control and destroy it!
I was started on tablet medication which I was told would be lifelong.
Side effects
Except for nausea, I didn’t notice for a while that this medication was having an adverse effect on my system. But slowly, I started to lose weight.
When this became noticeable to others, alarm bells started to ring, and I was eventually sent to see a gastroenterologist.
In the minds of the hospital clinicians, they were considering I might have cancer, yet I knew this wasn’t the case. My nausea had not been considered a major problem, but now the weight loss changed that view.
The usual tests confirmed there was no cancer, so everyone relaxed and my medication remained unchanged. But my rheumatoid arthritis was still very active. I had swollen and tender joints, huge fatigue and found walking a struggle.
My GP arranged an urgent appointment to the hospital. This appointment did not resolve anything so my GP and I agreed a second opinion might be worthwhile. On a recent holiday, I had met a rheumatologist who had said she would be happy to give me a second opinion. I took up this offer and my GP sent the referral letter.
A new beginning
My new consultant initially ordered a barrage of tests, starting again really. One of the lung tests confirmed I had lung scarring, and I was given the new diagnoses of rheumatoid arthritis interstitial lung disease. Again, I reminded myself that this was my immune system attacking my body and had nothing to do with any external agent, i.e. there was no infection or virus.
With a new drug regime, I started to regain weight. Although better in many ways, my joint pain and swelling remained, thus requiring extra visits for joint injections.
A few months later it was decided that I should start on biologics. At this point I needed a further chest X-ray, which to my surprise confirmed latent tuberculosis (TB). At this point, all my rheumatoid arthritis drugs had to be stopped and I was started on three months of TB medication.
It was explained to me that without doing this there was a potential for the biologics to reactivate the TB. I couldn’t help reflecting that there was a point in my past when my immune system had protected me, not like now.
Once the TB treatment was complete, I restarted my tablet rheumatoid arthritis treatment, which now included a biologic drug.
For the new treatment it was necessary to go into hospital as a day case. The treatment was given in two doses, two weeks apart, with a repeat as and when necessary. This was initially six to eight months apart. In the days, weeks and months that followed, I continued to improve, and to date I am still on these drugs.
Making a difference
Had there been the knowledge, awareness and facility to measure drug levels when I was first diagnosed, it is quite possible that I would not have continued to suffer so much. My life could have been easier to manage.
My memories are of going to a rheumatoid arthritis clinic, full of hope that tomorrow I would feel better, only to find there was no change, and it would be months before I would see anyone again. That was a time of struggle, despair and hopelessness.
My guess is that I speak for many people with rheumatoid arthritis.
There is no question that rheumatoid arthritis is a debilitating illness, dismissed in society as ‘arthritis’.
We need research that helps to alleviate this burden on the individual, and that is why I am so intent in doing all I can while I am still here, to reduce this suffering.
If it is our intention to relieve pain, and reduce suffering through research and any other means, then we owe it to patients to seek and explore all possibilities. If a blood test could be developed that can do that, then it is our duty to research that possibility and make it available.”