Search

Background: Despite increasing evidence for the optimal pharmacological management of early rheumatoid arthritis (RA), there remains uncertainty concerning the most effective treatment regimen and in particular the role of combination disease modifying anti-rheumatic drug (DMARDs) in early disease. Optimising medicines use will contribute to their effectiveness and community pharmacists (CP) are well placed to support this. However, little is known about the role CP play in managing RA. Aims: 1) Investigate DMARD utilisation in early RA and outcomes associated with various treatment approaches; 2) Explore the current role of community pharmacists in RA management. Methods: Data from the Rheumatoid Arthritis Medication Study (RAMS, 2008 to 2019), a large UK prospective study recruiting patients starting methotrexate (MTX) for the first time, were used in this thesis and included information on demographics, disease activity, and RA treatments captured at MTX start, and at 6 and 12 months thereafter. Patients were categorised as starting (1) MTX monotherapy or (2) MTX/other DMARD combination therapy. Patient characteristics at treatment start and outcomes after 6 months were compared. In parallel, a mixed methods study including a survey of UK based CP (n=84) and semi-structured interviews (n=9) was conducted. The survey was analysed using content analysis and simple proportions and thematic analysis was used to identify the key themes from the interviews. Results: Overall, most patients started MTX monotherapy (n=878, 72%), despite national guidelines recommending combination therapy. Hydroxychloroquine (HCQ) was used with MTX in most instances of combination therapy. Younger age, higher physician disease severity rating, and lower MTX dose were associated with use of combination therapy over monotherapy; however, there was no association between initial treatment regimen and outcome at 6 months. In general, the CP survey found almost half rated their RA knowledge as good and provided counselling on MTX, largely focussing on safety, but less commonly on other DMARDs such as HCQ. Many barriers to increasing their role in RA management were found in interviews (e.g. lack of information, lack of funding, and prioritising more common conditions) but most felt confident with to provide MURs despite lack of RA knowledge. Conclusion: Rheumatologists did not follow national guidance for pharmacological management of early RA, but there was no difference in outcomes when they did, suggesting no advantage to more complex treatment regimens, which has implications for guideline developers and policy makers. There is a clear current role that CP play in the pharmacological management of RA however, this is focused on side-effect counselling and reducing practical barriers to taking medicines. There may be significant barriers to both the current and future role of CP in the management of RA and these include: a lack of access to clinical information, a perceived lack of knowledge and the fact that pharmacists perceive patients with RA to be a low priority compared to patients with other long-term conditions, but this research has highlighted a potential future and even expanded role for CP in supporting people with RA, if these barriers can be addressed.

Across the human literature many successful attempts have been made to research how individual differences, such as; emotional predisposition, mood and personality both mediate and moderate how people express that they are in pain, cope with painful conditions and the impact painful conditions have on an individual's quality of life. As such, we have an understanding, albeit not full, of the ways in which pain can impact human life on many levels. We also know that individuals higher in positive affect cope better with compromised health. Despite there being pre-existing literature with nonhuman animals looking at both personality and pain independently, little research has attempted to look at the effect of one on the other. As such, it is unclear what impact, if any, emotional predisposition, mood or personality has on pain behaviour and coping in animals. Dogs are one of the most popular animals to be kept as domestic pets worldwide; further to this they play a crucial role in society in many working roles. There are several health conditions that affect dogs across their lifetime which are thought to cause pain, making them an ideal species to look at the impact of personality and mood on pain behaviour. Pain is exceptionally difficult to assess and monitor in animals, and as such further work in this area is needed. This PhD used a mixture of a systematic review, questionnaire data and biomechanical assessments of gait and pain to start to examine whether pain expression is associated with disease severity, or where other factors such as a dog's personality and mood moderates the relationship between disease severity and pain behaviour. In addition, accelerometers were piloted as an alternative to force plate assessment, to provide accurate, objective pain assessment in clinical settings. The findings suggest that as we see in humans, positive affect is a source of resilience in pain and dogs in pain can be differentiated from their healthy counterparts by lower levels of positive affect. Neuroticism also moderates the effects of severity on pain; higher levels of neuroticism are suggestive of higher levels of pain. Using the method employed in this thesis, accelerometers do not appear to be an alternative tool to assess gait changes related to pain. The implications from these findings are discussed in context with human literature on positive psychology to suggest a reconceptualization of how we view pain and its subsequent treatment in animals.