Joint effort: arthritis awareness and action

old persons arthritic hands

Arthritis is one of the most prevalent, disabling and costly diseases in Australia and yet community pharmacy can play a key role in the lives of those suffering from this chronic condition, Leanne Philpott reports.

Key points:

  • Osteoarthritis is a disease and not an inevitable part of the ageing process;
  • 58% of people with OA are of working age;
  • OA is one of the leading causes of chronic pain;
  • Up to 70% of OA is preventable by reducing overweight and obesity and preventing joint injuries;
  • Early diagnosis and appropriate treatment of rheumatoid arthritis is critical and can prevent much of the associated joint damage, deformity and disability; and
  • Without effective management, up to one-in-five Australians diagnosed with RA is likely to be out of the workforce within five years because of their condition.

AFFECTING MORE THAN three million people and costing the health and welfare system more than $5.6bn annually, arthritis is a serious problem. While there are more than 100 different types of arthritis, the most common forms are osteoarthritis, rheumatoid arthritis and also juvenile idiopathic arthritis—affecting children.

“It’s important that people are aware of the signs and symptoms of arthritis and that it can occur at any age, including childhood,” says Franca Marine, national policy and government relations manager at Arthritis Australia.

“Pharmacists can also raise awareness that obesity, inactivity, joint injury and smoking can increase a person’s risk of developing arthritis and encourage those at risk to adopt preventive strategies.

“Pharmacists are in a position to be able to provide support and referral to effective programs to help people at risk of arthritis to lose weight, be physically active and stop smoking,” she says.

Early diagnosis and intervention plays an important part in all forms of arthritis. Arthritis Australia says that prevention strategies and enhanced care for people with arthritis could help reduce the pain and immobility of arthritis, increase quality of life for those living with the disease, while also having a positive impact on the cost and burden of arthritis.

Marine says: “Pharmacists can help identify people who may present to the pharmacy with inflammatory forms of arthritis such as rheumatoid arthritis, as opposed to osteoarthritis, and ensure they seek prompt medical attention.

“Rheumatoid arthritis is a serious autoimmune condition, which can cause irreversible joint damage, deformity and disability if it is not treated quickly and appropriately. People with symptoms of inflammatory arthritis—joint swelling, redness and prolonged morning stiffness—require early referral to a rheumatologist, ideally within 12 weeks of symptom onset, for appropriate treatment. It is important to recognise that rheumatoid arthritis and other forms of inflammatory arthritis, including juvenile arthritis, can occur at any age, so symptoms in a young person or child should not be ignored or dismissed,” says Marine.

Earlier this year (2014) Arthritis Australia launched ‘Time to Move: Arthritis’, which promotes improved care for people with arthritis to help keep them in the workforce and living life to the fullest.

“The ‘Time to Move’ strategy recommends improved education and awareness raising activities, resources and tools to support all primary health care professionals, including pharmacists, to promote early diagnosis and appropriate intervention for people with arthritis,” Marine says.

“One of the biggest myths is that arthritis is an inevitable part of ageing. Firstly, arthritis affects people of all ages; in the case of osteoarthritis, the most common form of arthritis, 58% of people are of working age. Secondly, much can be done to prevent osteoarthritis. In fact, about 70% of osteoarthritis can be prevented.

“Supporting people with healthy lifestyle management programs, such as physical activity and weight loss, are important in the prevention of osteoarthritis and the management of all forms of arthritis,” says Marine.

Eloise Milthorpe, head of community health services, Arthritis and Osteoporosis NSW, says, “We also know that obesity and being overweight are inextricably linked to the development of osteoarthritis and the worsening of pain levels.

Therefore any kind of support or coaching that a pharmacist is able to provide in the maintenance of a healthy weight will go a long way to improving the effects of arthritis and, often, the efficacy of the medications they are dispensing”.

Medication management

“Any additional time that a community pharmacist can spend with patients explaining the best way to maximise the efficacy of prescribed medication is a benefit. The dose-response and timing of prescribed medication is information that, as a team, our office tries to impart to the community; however, we do not reach everyone living with arthritis. The provision of medicine management services, such as MedCheck, help educate patients on the effective use of their medicines,” says Milthorpe.

Community pharmacist and medical herbalist, Gerald Quigley says customers want information and reassurance, and that the reason they come to the pharmacy and not the doctor is for advice.

“There should never be a nonsteroidal anti-inflammatory drug (NSAID) leave a pharmacy—either on prescription or over-the-counter (OTC)—without a clear, detailed written set of adverse effect possibilities,” he says.

“Pharmacists are medication managers, but that’s only part of our responsibility. We need to help guide a person whose life is dominated by arthritic pain to understand what inflammation is, to understand what food choices are and what they might mean to their perception of pain, what exercise means—for someone with arthritis it might just be a quite slow walk around the block, or a trip to the local pool to sit in a warm hydrotherapy spa for 15 minutes. It often doesn’t take a lot but they need encouragement to do it,” Quigley says.

Quigley tells the AJP that if a person gets to a stage where they can’t take a NSAID, then they are often given high-dose analgesics, which—he points out—his patients say don’t help their pain.

“We must listen to the patient. Understand their frustrations. Assess their current treatment. What’s working? What’s not working? Learn about every factor that can affect the level of inflammation,” he says.

“Pharmacists might not get paid for this but offering this type of service to those suffering from arthritic pain will help change the perception that pharmacy is only interested in a sale: this perception is destroying us,” he says.
Quigley also highlights that there are many herbs and supplements available that have shown to be helpful in relation to the pain of inflammation.

“There’s lots of research now on the benefits of particular herbs like turmeric, curcumin olive leaf extract and rose hip. Pharmacists need to be on top of this to be able to supply their patients with the options out there.

“Not many people are given the explanation that 1,000mg of fish oil capsule in some instances only contains a third of the 1,000mg as it’s the actual omega-3 fats that are of benefit. So if you’re using a standard strength fish oil capsule containing 180mg and 120mg of the two main types of omega-3 fats (EPA and DHA) you’ve got to have at least nine capsules to make any difference that’s clinically proven to make an impact on the pain of arthritis.

“A pharmacist that says here’s the fish oil, it’s ultra clean and explains the source, and the amounts of EPA and DHA contained and advises that the required dose, for example, is two twice a day because the capsules contain a higher content than the standard strength is taking responsibility and supplying the patient with evidence-based information that pharmacists should know,” says Quigley.

Pain management beyond medicine

“Many health practitioners, including pharmacists, look at arthritis as something that can be fixed with a pill or with something simple, but it can’t,” Quigley says.

“This shows a misunderstanding of what the problem is and what we can offer to a person whose quality of life is dominated by pain. They will often wake up in the morning with pain, this is with them all day, they go to bed at night in pain and will often wake in the night in pain; this is the cycle day after day.

“Research has shown that people who have poor quality sleep have an increased risk of wide quality pain, so we’re going around in circles.

“As pharmacy staff we need to make a stand and say ‘come to us and let us guide you to a better quality of life’. Even though we can’t fix the problem, we can certainly play a part in helping, alongside the other healthcare professionals, make a positive difference to a person’s quality of life,” says Quigley.

In cases where medications aren’t working effectively Milthorpe says pharmacists can look for other referral options and pro-actively work with their health professional colleagues to look for the best outcome for the patient.

“This could mean referral back to the GP for medication review, possible change of medication or specialist referral. Alternatively, it could be to a physiotherapist or exercise physiologist for exercise prescription; a podiatrist for shoe or orthotic prescription; or to a pain clinic if there is one in the area. Communication is the key in these referrals, though, so that all professionals are working towards a common goal,” she says.

Quigley believes that while pharmacists have a role as medication managers, “it’s fundamental that pharmacists also promote non-pharmacological strategies for dealing with arthritis associated pain.”

For example, he says pharmacies can promote the correct and safe use of heat packs, which might involve advising the customer to make sure the heat pack they’re about to use is on the register of therapeutic goods.

Quigley explains that non-pharmacological strategies also include social contact. “People who are riddled with pain and arthritis can feel quite isolated and social isolation doesn’t help your health.”

He says a local pharmacist could get together 10 or so people and call it a ‘pain information group’, where he chats to them on a weekly basis about their pain. He urges pharmacists not to wait for people to come into your store and compare your advice to someone else’s.

Supporting self-management

“Self-management is a key part of managing a chronic disease like arthritis,” says Marine. “Effective self-management requires access to information, education and support from health professionals.

“Given that only a third of people with arthritis discuss self-management with their GP, pharmacists—among other healthcare practitioners—could help support people to self-manage their condition,” she says.

“One of the key messages that pharmacists can promote to help people is that being physically active and maintaining a healthy weight are important in the prevention of osteoarthritis and in the management of all forms of arthritis.

“Every kilogram of excess weight that someone carries adds around four kilograms of extra loading on weight-bearing joints, so even losing a small amount of weight can make a big difference. The benefits of exercise in relation to pain and physical function in osteoarthritis are similar to those attained with analgesics and non-steroidal anti-inflammatory medications (NSAIDs), but with fewer side effects,” Marine says.

“Any encouragement that the pharmacist can provide to people to exercise and try and maintain a healthy weight is incredibly beneficial. We know that gentle exercise, such as Tai Chi, walking or warm water exercise, is one of the best things that people with arthritis can do to manage their pain and joint stiffness,” says Milthorpe.

“Work with your patients to set small, achievable goals. Confidence is the key to effective self-management so it is important to build that. I would also advise to work on those areas that matter to the patient. In our experience, the person who doesn’t want to lose weight, regardless of how much they may need to, will not do so and focusing on this will only detract from other areas of self-management that may be more successful. Patient education will also provide support and encouragement, and promote informed decision-making,” Milthorpe adds.

“Pharmacists must offer empathy and understanding and remain nonjudgmental. My favourite phrase is ‘tell me how you feel’ or ‘what affect is this problem having on your quality of life?’” says Quigley.

Case study : Listening can be the difference

Community pharmacist Gerald Quigley explains that one of his patients—a 50-year-old woman who takes a range of prescribed medicines for her rheumatoid arthritis—has struggled with persistent infections and constant fatigue.

“She sought guidance, asking ‘what can I do to regain vitality and combat fatigue?’ and dietary advice was given to avoid the foods that encouraged her inflammatory state. She started to enjoy fresh, organic fruits and vegetables from her local Farmer’s Market.

“Olive leaf exact was recommended—a dose of 10ml every morning and night with her meals—and it seemed to settle her digestive issues, and reduce the incidence and impact of the viral infections, which had plagued her in the past.

“Probiotics and one teaspoonful of liquid fish oil each day have helped her gut integrity.

“You’ll notice that this integrative treatment isn’t complicated. These were simple suggestions, based on the ability to be empathetic and to listen, but they made an important impact on the health of the patient.”

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