Dr Jeremy McNally
BSc, MB BS, USMLE Part 1 and 2, FRCP
Practices at: Circle Reading Hospital
He has a special interest in inflammatory rheumatic diseases and biologic therapies developed during a 3 year Rheumatology Fellowship at The Hospital for Special Surgery at Cornell University in New York, USA. He was asked to return to New York as visiting Professor to The Hospital for Special Surgery and Cornell University in 2005.
Jeremy has been principal investigator in clinical trials of new treatments (biologics) for rheumatic diseases. He has presented research findings at national and international conferences. He has authored a number of scientific publications in peer-reviewed journals and written review articles and book chapters. In 2010 he appeared on the BBC TV evening News to discuss recent advances in arthritis treatment.
He is Clinical lead for Osteoporosis and Biologic Therapies for West Berkshire.
New Biologic therapies for the treatment of Inflammatory Rheumatic Diseases, early arthritis and osteoporosis.
- Fellow Royal College of Physicians, London
- Member British Society of Rheumatology
- Fellow of The American College of Rheumatology
What is ankylosing spondylitis?
Ankylosing spondylitis can affect anyone but is more common in young men. It usually starts in the late teens or early 20s. It should be considered when there is new onset back pain below the age of 40.
The back pain can be anywhere in the spine, but commonly it occurs in the sacroiliac joints. It tends to affect the base, or the bottom part of the spine.
The characteristics of inflammatory back pain are that it causes morning stiffness. It tends to wake you in the second half of the night and there is sometimes a family history of spondylitis.
By diagnosing the condition early, we can prevent damage and often put you on a very effective treatment, which will significantly improve your pain and allow resolution. Early diagnosis is therefore extremely important.
People who see me complain of new onset back pain, neck pain, fatigue, waking in the second half of the night; they sometimes have associated large joint arthritis and they may have other conditions, such as psoriasis or inflammatory bowel disease.
About 30% of people with psoriasis will develop inflammation in their joints at some point in their life. Inflammatory spinal pain can incur as a result of several conditions, one of them being ankylosing spondylitis, but psoriasis and inflammatory bowel disease can also lead to inflammation in the spine.
Ankylosing spondylitis: what happens at your first appointment?
When patients visit the clinic with ankylosing spondylitis, we take a history and perform a thorough physical examination. We sometimes test for a particular gene, called HLA B27. This is a risk factor for the development of the condition and can be associated with disease severity in men.
We’ll examine you and often start off with some plain X-Rays; you may require MRI imaging of your spine and sacroiliac joints. That will often allow us to confirm the diagnosis.
During your first appointment, you would have a clinical examination, blood tests, some X-Rays and possibly some imaging with MRI.
Ankylosing spondylitis: what treatment modalities can you expect?
At our first appointment, we might start you on treatment and refer you for physiotherapy. You’d then return to see us for the results of those tests in around two weeks, to assess whether you’ve responded to the treatment you’ve been given. If not, we’ll then decide a more longer-term treatment plan for you.
The treatment is always tailored to you and your wants and needs.
Ankylosing spondylitis: what happens after your treatment?
We would follow up with you until you’re in remission, making sure the inflammation and pain is controlled. We’d usually see you at baseline, so we’d take some measurements and tests, and see you again in three months’ time if you’re feeling better.
We’ll then see you again in six months, and then again at 12 months.
What is gout?
Gout affects about 4% of the UK population. It’s a condition that usually affects men. It causes short lived ‘attacks’ of very intense pain, which affect the lower limbs, especially the big toe joint, but it can also affect the mid-foot, the ankle and the knees.
Common Symptoms of Gout
Gout can mean unbelievable pain for the patient – pain that can last anything from a couple of days to a couple of weeks and it’s often recurrent. Gout can cause long-term severe and irreversible damage to joints and kidneys and is associated with an increased risk of heart attack.
How is gout diagnosed?
When we see a patient with suspected gout, we’re looking to confirm the diagnosis. This is usually done by taking a thorough history and performing a physical examination to look at the affected joints. We will then try to decide, with blood tests, if it’s primary or secondary gout.
There is often a family history of gout. Blood tests, X-Rays or imaging can be performed at your first appointment.We can give you treatment on the same day that will get rid of your pain, too. If you’re someone who experiences ‘excruciating pain, exacerbated by even the bedclothes touching the joint’ and someone says they can take that pain away for you today, that’s a very reassuring and helpful thing!
How is gout treated?
In 100% of cases, we can get rid of gout pain on the same day. We’ll then decide on a longer-term management plan. Certain foods can precipitate the condition, so we may give you information about diet and lifestyle.
We’ll listen to your history, perform a physical examination and arrange blood tests and an X-Ray.
A steroid injection on the same day, or some tablets, will get rid of your pain. You will then be followed up a couple of weeks later to make sure the pain has gone and to allow us to create a longer-term management plan. We can make sure there are no secondary causes of gout and you are happy with your treatment plan.
There are drugs that can get rid of the condition and there are also drugs that lower uric acid in the blood, which can prevent it coming back.
Often gout symptoms can be sorted out with a couple of appointments. There’s treatment for an acute attack of gout and then there’s treatment to prevent it. It’s important not to take the preventative treatment when you’ve got acute gout, as it can make it much worse.
What happens after gout treatment?
When you have been started on treatment to keep gout away, we now adopt a ‘Treat to Target’ approach. We aim to lower your uric acid to below 300umol/L to prevent joint and kidney damage. We will recommend a blood test to check the level of uric acid at three months and perhaps again at six months, if the dose of the drug to lower your uric acid needs to be increased. In the longer term, most patients remain on a single agent, which prevents any further attacks of gout for the long term.
What is inflammatory arthritis?
Patients come to see me with inflammatory arthritis; this is a condition that causes pain, morning stiffness and can also lead to joint damage, if not treated.
There are lots of different types of inflammatory arthritis. Probably the commonest type is rheumatoid arthritis, which affects about 1% of the population. Rheumatoid arthritis usually starts in your 30s or 50s and often starts in the small joints of the hands and the feet. The joint become stiff in the morning for more than one hour and become painful and swollen.
Depending on the distribution of the joints involved, we can usually decide what type of inflammatory arthritis is causing the pain and swelling.
It’s very important to treat these conditions as early as possible; if untreated, they can lead to permanent joint damage. Starting medication early can arrest progression and abrogate the need for joint replacement surgery.
With modern treatment, we can often put patients into remission. What that means is that patients take medicines to suppress the inflammation and in time, the condition goes away.
Other types of inflammatory arthritis
These include psoriatic arthritis, which is a type of arthritis that affects up to 30% of people who have a skin condition called psoriasis.
Psoriasis causes a scaling rash on the elbows, knees and trunk and can also cause flaking of the scalp. The inflammatory arthritis can either affect the spine and sacroiliac joints or can involve the peripheral joints. It tends to cause asymmetric joint involvement. It can also cause tendonitis and enthesitis.
This is a separate condition, where patients develop inflammation in the spine and it often involves the large joints rather than the small joints.
Patients may also get inflammation in their spine, specifically the sacroiliac joints, which are the joints where the pelvis joins onto the base of the spine. Ankylosing spondylitis can also affect other joints in the spine. It usually starts with back pain below the age of 40 and is associated with significant morning stiffness in the spine. It often wakes patients in the middle of the night with stiffness or pain in the buttocks.
Inflammatory arthritis: what happens at your first appointment?
There are different ways to differentiate between these conditions. Patients come to visit me, and they will often sit and have a chat for 20 minutes; your medical history is quite important in soliciting what is actually the cause of your symptoms.
I’ll listen to you to ensure that you can get across what is causing your problem. I will then examine you. This usually involves you getting undressed to have all your joints and skin examined. A thorough physical examination is carried out including listening to your heart and lungs, as autoimmune disease can involve organs other that the joints. Conditions that cause arthritis can often cause systemic manifestations which may give a clue to the diagnosis.
After your appointment, you may also have blood tests, X-rays and scans on the same day.
If you require an MRI scan to look at a joint that is particularly inflamed, this can usually be organised very quickly; sometimes you’ll come back for some additional investigations depending on your preference.
If one joint is particularly swollen, I can aspirate that and take some fluid from the joint for diagnostic purposes and inject it with some steroid and anaesthetic on the same day. This simple procedure will often give enormous almost immediate relief. The benefits of the injection can often last for several months.
We’ll give around 95% of patients some form of treatment on the same day. The treatment that we offer in rheumatology is often medication; we have a pharmacist on site, too, so you can pick up your medication on the same day.
If you require a steroid injection into the joint, or an intramuscular injection, which is an injection which gives benefit to many joints, these can be done at your first appointment. These short treatments can settle the condition that is causing your joint pain while we’re working out what is causing the problem.
Inflammatory arthritis: what treatment modalities can you expect?
In some cases, it’s quite obvious from the first appointment that it’s rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis. In those cases, we might start you on a drug called a disease modifying drug to control your condition until it’s in remission.
We would look at reducing the dose of the drug you’re taking to maintain the improvement and in some cases to stop the drug completely.
Inflammatory Arthritis: what happens after your appointment?
In terms of aftercare, you would usually return to see us between one and two weeks after the initial appointment. This is to allow time to see how things settle or have improved. We’ll then decide at that point which other drugs you may require.
We would carry on seeing you approximately every four to eight weeks, until your condition has either improved or you are in remission. In people with rheumatoid arthritis, a single appointment and a single follow-up is all that’s required, to reach your diagnosis.
A vast majority of patients with all of these conditions now enjoy a very good quality of life. We aim to try and put your disease into remission as quickly as possible.
What is osteoporosis?
Osteoporosis is common in the UK and affects nearly three million people. It is called the silent disease, as worryingly, most people don’t know they have it until they break a bone.
There are more than 300000 fractures a year in the UK; patients often come to see me after they’ve had a fracture, or they may be worried because someone else in their family has had a fracture. Another reason patients may visit me is if that they’ve had an early menopause.
Most patients are women over the age of 50, but patients with some chronic diseases like inflammatory bowel disease or rheumatoid arthritis may also visit me. People who have been on certain medications, such as steroids for severe asthma or polymyalgia rheumatica, might come for advice about their bones, because steroids can reduce bone density and lead to fracture.
What are the symptoms of osteoporosis?
There are two types of fractures: peripheral fractures – for example, fractures of ankle, wrists or hips. Some people can also fracture their spine. Spinal fractures can occur spontaneously and asymptomatically. They can lead to height loss and curvature of the spine.
Patients visit me for further evaluation or if they’re worried about osteoporosis. Often, they are referred by their GP or by an orthopaedic surgeon, if they’ve had a fracture.
Osteoporosis: what happens during your first appointment?
We will take a medical history and examine you to make sure there is not a secondary cause for osteoporosis. We may also go through your drug history, and we’d then usually arrange a bone density scan, or a DEXA scan. This is a non-invasive scan that involves you lying on a bed while an arm like scanner passes over you – it takes about 10 minutes. The scan is open, and you are not closed in. It can be done on the same day as the clinic appointment. We can then calculate your fracture risk, which will help us decide if you require treatment or diet and lifestyle advice.
Osteoporosis: what treatment modalities can you expect?
Following your initial appointment and DEXA scan, we can decide on what kind of treatment you need.
There are now several different oral therapies: an intravenous once yearly therapy, and a local subcutaneous injection, which is given once every six months. All the treatments are very effective. They reduce the risk of spinal fracture by up to 74% and reduce the risk of hip fracture by up to 40% over the following few years, so they’re worth trying.
Osteoporosis: what happens after treatment?
Once you have decided which treatment you wish to take, your GP can continue treating you with it for the next few years, if you decide on an oral treatment. If you decide to have an IV treatment, you will return once yearly for a 30-minute infusion for the next three years. This will protect your bones for up to six years in total (three years of treatment for six years of protection).
If you decide to have the six-monthly injection treatment, we will usually arrange the first injection and your GP could prescribe further treatments in the majority of cases after that. To make sure your bone density is improving, the option to have a repeat scan in two years’ time is available.
What is rheumatoid arthritis?
Rheumatoid arthritis is a condition that causes joint pain, swelling and morning stiffness. It affects women 3:1 times more often than men. If untreated, it can lead to permanent joint damage. The distribution of joints involved usually allows us to decide what type of inflammatory arthritis it is.
Rheumatoid arthritis is probably the commonest cause of inflammatory arthritis in the UK. It affects young people in their 30s and 50s. For those with the condition, the small joints of the hands and the feet become painful and swollen.
Early diagnosis is really important, as this allows us to get you on the right medication, which will get rid of the inflammation and prevent damage to your joints. The longer you have inflammation in the joints, the more damage occurs – and once this damage occurs, we cannot repair it. We’ll therefore get you on some medication that will prevent damage as quickly as possible, with our treatment goal being remission.
People with rheumatoid arthritis report stiffness in the morning, lasting up to an hour. It’s very important to treat this condition as early as possible. If it is untreated, it can lead to permanent joint damage. If it’s progressive and the joints are damaged, joint replacement surgery may be required.
With early identification and initiation of drug treatment, we can often put patients into remission. That means you can take medicines and drugs, and in time, the condition will be controlled.
Rheumatoid arthritis: what happens at your first appointment?
When I see patients, they will have a consultation with me. I’ll take a history, examine you and usually take some blood tests and X-Rays on the same day.
I may start you on some treatment, which will usually get rid of some of the inflammation on the same day. That’s either an injection or some tablets, and then you would come back in a week or two to make sure you’re tolerating the tablets.
Rheumatoid arthritis: what treatment modalities can you expect?
Most patients can expect a good response to medical treatment. Only a small percentage of patients are in a situation where the inflammation cannot be controlled; we can treat most people with synthetic disease modifying drugs.
If conventional treatments don’t work, we have biologic therapies. We probably now have a third of patients who have got progressive disease now who are on new drugs. For them, we can use biological targeted therapies that have been around since 2001.
Ways to pay
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