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“The management of inflammatory arthritis in adults and children”
Update from the Irish Society for Rheumatology Annual Scientific Meeting

Dr David Kane, Consultant Rheumatologist, Adelaide and Meath Hospital (incorporating the
National Children’ s Hospital), Dublin.

The Irish Society for Rheumatology Winter Meeting was held at Killiney Castle on 23 - 24 of September.
The theme of the meeting was “The management of inflammatory arthritis in adults and children”. The
meeting highlighted the major advances that have been made in the care of adults and children with
inflammatory arthritis particularly as a result of novel developments in Biological Therapy.
Table 1: New Paradigm of Managing Rheumatoid arthritis in Children and Adults
1. Patient is diagnosed and commenced on treatment within three months of symptom 2. Immediate introduction of single or combination disease modifying anti-rheumatic drug 3. Early use of Corticosteroid to obtain restoration of normal joint function 4. Establish a standardised protocol and treat according to the disease activity score 5. Perform disease activity score at each assessment 6. Monthly visits in the first stages of disease until disease activity score has been reduced to less then 2.6 in early disease and 3.2 in established disease 7. Consider biologic therapy early in non-responders and patients with poor prognostic signs
Rheumatoid Arthritis in Ireland – the case for treating in the first 3 months of disease
Rheumatoid arthritis is estimated to affect 45,000 people in Ireland with 2250 new cases of rheumatoid
arthritis diagnosed each year. 75% of these patients are at a working age; 30% of patients stop work
within one year due to the effects of rheumatoid arthritis with this increasing to 50% at three years.
Dr Patrick Kiely of St George's Hospital in London outlined the new paradigm of early aggressive
therapy in rheumatoid arthritis. Two pivotal studies published by Lard and Nell confirmed that there is an
early window of opportunity to treat patients within the first three months of symptoms. These patients
should be commenced at the earliest opportunity on immunomodulatory therapy (disease modifying anti-
rheumatic drugs) and or steroids to obtain control of joint inflammation.
The benefits of early control of joint inflammation in preventing joint damage will persist for many years.
However, in patients who have a delay in obtaining treatment for rheumatoid arthritis, there is clear
evidence that they will have worse outcomes in terms of function, disability and radiological damage.
Factors causing delays in treating patients with Rheumatoid Arthritis
There are three factors in the delay in obtaining treatment for rheumatoid arthritis. In the early rheumatoid
arthritis network in the United Kingdom, patients waited an average of four months before they sought a
GP opinion for their joint pains. There was a second delay from the initial consultation with their GP
before a referral to a rheumatologist was made. There was a third delay from referral to achieving the
appointment with a rheumatologist.
Clearly if strategies can be implemented to make patients aware to consult their GPs earlier and if GPs
can access the early arthritis referral pathways present in most Irish hospitals then the possibility of
treating people within the first three months of symptoms could be attainable. Most Irish hospitals now
have Early Inflammatory Arthritis referral criteria and designated rapid access clinics or appointments.
The FinRACo study showed the treatment of rheumatoid arthritis within the first four months of
treatment led to remission of 40% but treatment after four months led to remission of just 10%. With
remission, the new target of rheumatoid arthritis therapy, the consensus was that more work must be
focussed not just on earlier rheumatology appointments but also on patient education.
The choice of treatment is also critical. Immunomodulatory treatment with disease modifying anti-
rheumatic drugs should be started immediately on making the diagnosis of rheumatoid arthritis. EULAR
guidelines suggest the use Methotrexate while recent NICE guidelines recommend combination of
Methotrexate and Sulfasalazine or another DMARDs. Both EULAR and NICE guidelines recommend
initial use of corticosteroids either oral or intramuscular to obtain rapid symptom control and to maintain
patients at their usual level of social function.
Treat to Target – Target Remission: The Gold Standards of RA therapy!
In addition to early treatment with immunomodulatory drugs, there is clear evidence that patients should
be seen very frequently at the early stages of the disease and treated according to standardised protocols
to obtain remission of joint symptoms. This requires practice change whereby formal disease activity
scores are recorded in patients at each visit with therapy escalated until the disease activity score is less
than 2.6 in early disease and 3.2 in established disease. The optimal frequency in the TICORA study was
one monthly review of patients until they had obtained remission.
Recent data from the RAISE study in Ireland suggests that most patients get an appointment on average
of every six months, probably due to issues of capacity within the current system. The consensus was
that any service reconfiguration in the future needs to accommodate frequent visits for patients with new
or unstable rheumatoid arthritis until therapeutic target has been obtained. The gains highlighted were
clear with a change from previous remission rates of approximately 10% to a potential remission rate of
70% using these.
Biologic Therapy in Rheumatoid Arthritis
Dr Andrew Oster of Addenbrooke’s Hospital Cambridge reviewed the data on anti-TNF therapy. There
are now five licensed anti-TNF therapies, Adalimumab, Etanercept, Infliximab, Golimumab, and
Certolizumab. All have proven efficacy in not just rheumatoid arthritis but also in psoriatic arthritis,
ankylosing spondylitis and other inflammatory conditions. Dr Oster reviewed data from the ATTRACT,
PREMIER and ARMADA studies all of which demonstrates superiority to traditional disease modifying
anti-rheumatic drugs. The Quinn study also suggests that the earlier these are introduced, the greater the
potential to induce remission in patients with rheumatoid arthritis. Further data from the Irish RAISE
study demonstrated the beneficial effects of these drugs in Irish patients.
In addition to the anti-TNF therapies, rheumatologists have the option to use anti-IL6 therapy
(Tocilizumab), anti-B cell therapy (Rituximab) and anti-T cell therapy (Abatacept). Dr Oster reviewed
the data from the REFLEX, ATTAIN, and RADIATE studies demonstrating that all of these agents were
effective when used in rheumatoid arthritis, with equivalent efficacies. Selection of optimal therapy for
the patient depends on specific features of their disease activity and co-morbidities. There has been a
revolutionary change in the management of rheumatoid arthritis now that eight novel extremely
efficacious biologic agents exist.
Managing Co-morbidity and Preventing Premature Mortality in Rheumatoid arthritis
Rheumatoid arthritis causes inflammation and damage of the joints. Most doctors however, are unaware
that most patients with rheumatoid arthritis will have a reduced life expectancy if the disease is
inadequately controlled. It is expected with the newer therapeutic approaches that the standard of
treatment will improve and the frequency of comorbidities of osteoporosis and coronary disease will
diminish. At present however, established rheumatoid arthritis patients must be viewed as being as at
significantly increased risk of coronary artery disease and osteoporotic fractures.
Advances in Osteoporosis Therapy
Professor Eugene McCloskey of the University of Sheffield reviewed the treatment of rheumatoid
arthritis-related osteoporosis fractures. It is essential that doctors now recognised that patients with
rheumatoid arthritis have an increased risk for osteoporotic fractures. The FRAX score has been
developed for clinical diagnosis of osteoporosis within a primary care setting. It is available from
By entering clinical data, the 10 year risk of all fractures and the 10 years of hip
fracture can be calculated allowing a decision on osteoporosis treatment. Rheumatoid arthritis is an
independent risk in the FRAX model highlighting the strong association between rheumatoid arthritis and
osteoporotic fractures.
Table 2: Treatment for Rheumatoid Arthritis-Related Osteoporosis
2. Calcium/vitamin D/Calcitriol 3. RANK Ligand Targeted therapy 4. Anabolic therapy
Professor McCloskey outlined all of the available therapies for osteoporosis, particularly in the setting of
rheumatoid arthritis. Currently bisphosphonates, calcium and vitamin D are the mainstay of therapy.
However, he presented data on a novel agent Denosumab which acts by inhibiting osteoclast formation.
Data in the FREEDOM trial demonstrated that three years of Denosumab therapy produced a reduced risk
of vertebral fracture (68%), non-vertebral fracture (20%) and hip fracture 40%. The therapy is
administered by two six-monthly subcutaneous injections which were felt to improve patient’s
compliance. Added benefits may exist in rheumatoid arthritis where inhibition of osteoclast function has
been shown to reduce the development of bone erosion, a key feature of rheumatoid joint damage.
Managing Cardiovascular Disease in Rheumatoid Arthritis
Dr Vincent Maher of the Adelaide and Meath Hospital, Dublin reviewed the increased risk of coronary
heart disease and sudden death that exists in rheumatoid arthritis. Patients with rheumatoid arthritis have
had a threefold increase in the incidence of acute myocardial infarction and a twofold increase in the
incidence of sudden death. This appears to be related to therapy in the pre-biologic age and there is much
hope from initial studies that more effective biological therapy may reduce the risk of coronary artery
disease. This remains to be proven.
At present, rheumatoid arthritis patients must be viewed at a high risk for coronary artery disease and
should have regular cardiovascular assessment including lipid profile and blood pressure. Dr Maher
pointed out that the patient with rheumatoid arthritis may not present with the usual angina pectoris
symptoms due to their reduced capacity for exercise. Thus traditional tests such as stress ECG may be
limited while newer modalities such CT coronary angiography are likely to become more widely
available given the combination of high accuracy and the non-invasive nature of the test.
The economic and social impact of Rheumatoid Arthritis
Professor Carol Black, the National Director for Health and Work (UK) presented an overview of work
and musculoskeletal diseases. Musculoskeletal disease is the second, leading cause of sickness absence
and long term incapacity in Ireland with an estimated 14,000,000 working days lost last year due to ill-
health overall. It is estimated that the direct cost of musculoskeletal disease due to sickness absence and
disability is € 750,000,000 per annum in Ireland.
Rheumatoid arthritis in particular is a serious concern to rheumatologist as only 22% of rheumatoid
arthritis patients in Ireland remain in full time employment. There is now clear evidence that intervention
in the first few months of disease has a major impact in maintaining rheumatoid arthritis patients in the
workforce. While there are obvious economic benefits to this, it is important to realise that work is also a
strong social determinant of health. It is imperative that the patients with all musculoskeletal disorders
have early intervention to maintain them in the workforce.
Fit for Work – Replacing the Sick Note with the “Fit Note”
In the UK this has resulted in the Fit for Work Services which provide early interventions to actively
manage the return of patients with musculoskeletal disorders back to work. The longstanding Sick Note
has now been replaced by a Fit Note which was designed to create a management plan for a return to
work rather than an all or nothing scenario practised under the old Sick Note system. The Fit Note
outlines directions for a graded return to work in addition to guidance on hours of work, change of duties
and adaptations that the employer needs to engage in. The role out of this new scheme has been
underpinned with planned changes within undergraduate and postgraduate training so that GPs can play a
more active role in managing work disabilities.
Professor Black advocated a fit for work programme for Ireland which would involve a national plan for
musculoskeletal disorders led by a national clinical director. She recommended a change from our current
Sick Note system to a Fit Note with early diagnosis and management of sickness absence due to
musculoskeletal disorders.
Arthritis in Children – the Irish situation
Professor Helen Foster outlined the current state of managing inflammatory arthritis in children. The
commonest condition is juvenile inflammatory arthritis which like many adult diseases was previously
thought to be relatively benign. It is estimated there are 1000 juvenile inflammatory arthritis patients in
paediatric services in Ireland and 700 adult patients with juvenile inflammatory arthritis.
It is now clear that the juvenile inflammatory arthritis is a chronic disorder which is not benign. Joint
damage occurs early and it is recognised that early aggressive treatment provides a window of
opportunity to obtain tight control and better outcome in terms of overall health and functioning for
children with inflammatory arthritis.
Methotrexate is the drug of choice in juvenile inflammatory arthritis but all of the biologic agents used in
adults are currently been used in juvenile inflammatory arthritis with good results. There are many
challenges for these children as they grow up with 1/3 continuing to have active disease and 1/3 having
disability problems despite eventually going into remission of inflammation.
Adults patient with JRA are best managed by a transition model run by paediatric and adult
rheumatologist. It was highlighted that there is only one paediatric rheumatologist through the whole of
Ireland which make provision of these services extremely difficult. The lack of services for children
prevents implementation of modern standards of therapy, thus exposing paediatric patients to irreversible
loss of joint damage and function with consequent high risk of permanent disability.

Source: http://www.isr.ie/images/stories/docs/winter-meeting-report.pdf