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Australian Journal of Pharmacy : July 2005
RA public awareness campaign F disease activity criteria for RA that is unresponsive to other measures. ‘The rheumatoid factor test is more a diagnostic test than a disease activity test, given that more than 30 per cent of rheumatoids are sero-negative and did not have access to TNF inhibitors under earlier restrictions. ‘Initially there were very tight restric- tions, so there was no blow-out in usage. But the general experience with the use of TNF blockers has been positive and certainly seems to help those who have failed other treatments. ‘Accordingly, the broadening of indi- cations to capture other patients with RA is appropriate,’ Professor Cleland said. He said the main message to send to RA patients and the community was that treatment with combinations of conven- tional lower-cost RA disease-modifying drugs (for example methotrexate with sulphasalazine and hydroxychloroquine) was effective for most patients, especially when given early. ‘There is good evidence that this is bet- ter than monotherapy. People need to be referred to rheumatologists early, not late. Rheumatologists should have triage arrangements in place to access patients with recent onset polyarthritis as a mat- ter of priority.’ However, Professor Cleland pointed out that non-steroidal anti-inflammatory drugs (NSAIDs) were not the answer for RA even if they made symptoms tolera- ble, and could deflect from more appro- priate treatments with disease-modifying anti-rheumatic drugs (DMARDs). The less effectively that early arthritis is treated, the greater the likely ultimate recourse to TNF blockers. The effectiveness of com- bination standard anti-rheumatic drugs, when they are applied early, means only a small minority of people will need TNF blockers. ‘However if patients continue to have uncontrolled disease after using these combination therapies, and there is suffi- cient rheumatoid activity to qualify for a TNF blocker, then that is what we use. ‘In our hospital’s early arthritis clinic, most could be treated successfully with combination therapies and only a small proportion of patients may ultimately need TNF blockers. OR the first time the Arthritis Foundation of Australia will run a national direct awareness campaign later this year to promote early diagnosis of rheumatoid arthritis. The radio and community service announcements are expected to air during the period from July to September, said Arthritis Foundation of Australia chief executive Mark Franklin. He said posters to complement the community service announcements would be provided to pharmacy. He said a report from Access Economics released earlier this year showed that 2.5 per cent of the Australian population—or 500,000 people—are affected by RA. This is expected to increase to 3 per cent in 2020. Currently RA affects 2 per cent of men and 3 per cent of women in this country. The current cost of RA to the economy is estimated by Access Economics to be $1.9bn a year with direct health costs of nearly $300m a year including $56m in pharmaceutical costs. ‘We adjust doses and add drugs if dis- ease suppression is not achieved, based on an objective assessment of disease activity. If we don’t suppress disease activity then it is necessary to increase the dose.’ Professor Cleland said 50 per cent of patients could expect a remission with this approach and more than 80 per cent get a good response. ‘Really most people with RA can live normal lives now because treatment has changed enormously compared to 10 or 15 years ago.’ Treating stress in RA Stress associated with rheumatoid arthri- tis frequently goes unrecognised said Geoffrey Littlejohn, associate professor of medicine at Monash University. Educa- tion is the most potent and effective strat- egy in helping patients cope with the problem, he told the AJP. Professor Littlejohn said in many cases doctors and therapists overlook stress and other psychological aspects of RA when they see patients. He said: ‘Stress can amplify pain because patients with chronic RA are often worried about how the disease will impact on their lives, adding further stress into the system which in turn aggravates more pain. ‘Other ancillary issues may be impact- ing on the patient’s overall pain control, such as poor sleeping routines. Taking mildly sedating OTC medications, avoid- ing caffeine and heavy exercise and a quiet atmosphere can all help improve sleep quality.’ Professor Littlejohn said in many cases pharmacists are able to pick up on a patient’s concern and discuss the general nature of the problem with them and question issues that may be in the back- ground. ‘These problems are common. Coun- selling and reassurance are extremely important and advising patients to take paracetamol regularly three times a day instead of a dose in response to pain is a good place to start before considering more high powered medications.’ Exercise is a cornerstone of RA man- agement because regular exercise pro- grams have been shown to clearly improve the quality of life in RA patients, he said. ‘Keeping active improves muscle strength and keeps the joints flexible. There are different approaches to exer- cise programs, for instance pool therapy can be useful in cases where the knee is affected and it is not possible to do a lot of exercise. The exercise does not need to be strenuous but regular low-impact physical activity at least four times a week for at least 30 minutes is recommended. ‘Many people give up and become de- conditioned which leads to muscle wast- ing and even more trouble getting going.’ Overall treatment for stress manage- ment should not just be medication dri- ver, Professor Littlejohn said, but patients should be looking at the combined approach. ‘If the patient relies on medication alone to solve the problem they will not get the maximum benefit from treat- ment.’ Within a year another intravenous infusion therapy, abatacept—that acts by blocking the function of the immune T- cells—is expected to be available in Aus- tralia. It differs to existing TNF Inhibitors that intercept a protein the body pro- duces during the inflammatory response, Professor Littlejohn said. THE AUSTRALIAN JOURNAL OF PHARMACY VOL.86 JULY 2005 ? 531