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C L I N I C I A N E D U C A T O R V O L U M E 4

Rheumatoid Arthrit is: Primary care Initiative for improved D iagnosis and outcomes

Co-sponsored by

SIDE A is for clinicians FREE CME

See panel 2A

SIDE B is for patients

RHEUMATOID ARTHRITIS FACTSRA is a chronic, progressive, systemic inflammatory disease •Characterizedby: – Progressive destruction of synovial joints with bony erosions and

loss of cartilage – Symptoms usually begin in the small joints of the fingers, wrists, and

feet – Swollen, tender joints are painful and difficult to move – Loss of physical function and quality of life – Decreased work productivity and increased disability and job loss •1.3millionadultAmericanshavebeendiagnosedwithRA •Peakageofonset:30to60years •2to4timesmorecommoninwomenthanmen •RApatients7timesaslikelytohavegreater-than-moderatedisability

than age- or sex-matched individuals •Ifundertreated,lifeexpectancyisreducedby5to15years –RAaccountsfor22%ofalldeathsfromarthritisandother

rheumatic conditions

It is never too late to stop further damage.

HochbergMC,SilmanAJ,SmolenJS,etal.eds.Rheumatology.3rded.NewYork,NY:Mosby;2003.AmericanCollegeofRheumatology.Factsheet.Availableat:http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/ra.asp.AccessedOctober1,2010.MacLeanCH,LouieR,LeakeB,etal.Qualityofcareforpatientswithrheumatoidarthritis.JAMA.2000;284:984-992.

RA IS A DISEASE OF THE ENTIRE BODYHeart:Cardiovasculardisease(CVD)occursonaverage10yearsearlierinRA patients than in the general population •AcceleratedatherosclerosisLungs:Increasedriskofmultiplepulmonarycomorbidities •Pleuritismayoccur • InterstitiallungdiseasesGastrointestinal (GI):RApatientshaveahighincidenceofGIbleeding,which may be attributable to use of nonsteroidal anti-inflammatory drugs (NSAIDs)andsteroidsduringtherapyNervous system: The deformity and damage to joints in RA may lead to entrapment of nerves •PatientmaypresentwithcarpaltunnelsyndromeOsteoporosis: Generalizedbonelossmayresultfromimmobility,theinflammatoryprocess,and/ortreatmentssuchassteroids • PeriarticulardemineralizationmayresultfrommediatorsofinflammationInfections:RApatientshavea6-to9-foldincreaseintherateofseriousinfections, including tuberculosis (TB) Malignancy: RA doubles the risk of some malignancies, particularly lymphoma

DeaneK.ManagingcomorbiditiesinRA.J Musculoskel Med.2006;23(suppl):S24-S31.BöttcherJ,PfeilA.DiagnosisofperiarticularosteoporosisinrheumatoidarthritisusingdigitalX-rayradiogrammetry.Arthritis Res Ther.2008;10:103.

PRIMARY CARE: EARLY DETECTION IS CRITICALTo prevent the progressive destruction of synovial joints and improve long-termoutcomes,RAmustbedetectedandtreatedearly. •Jointdamagecanberapid;withouttreatment,bonyerosionsmaybe

detectablebymagneticresonanceimaging(MRI)within4monthsofdisease onset

•Rateofx-rayprogressionismorerapidinthefirstyearthaninthesecond and third

•Withoutoptimaltreatment,mostpatientsdevelopbonyerosionswithin2years,and~80%ofthesepatientsdeveloplong-termdisability

•Successfullong-termmanagementrequiresapartnershipbetweenthe PCP and the rheumatologist, the patient, and other health care team members

Benefits of early detection: •DecreasedRAseverity,disability,andmortalitywitheffectivetreat-

ments, such as disease-modifying antirheumatic drugs (DMARDs) •LowerratesofRAcomplications •Lowerratesoflower-extremityorthopedicsurgicalprocedures •Decreasedcardiacriskswithcontrolofinflammation

McQueenFM,StewartN,CrabbeJ,etal.Magneticresonanceimagingofthewristinearlyrheumatoidarthritisrevealsahighprevalenceoferosionsatfourmonthsaftersymptomonset.Ann Rheum Dis.1998;57:350-356.BykerkVP,KeystoneEC.RAinprimarycare:20clinicalpearls.J Musculoskelet Med.2004;21:133-146.

PROVISIONAL DIAGNOSIS OF RAPatientswhohaveatleast1jointwithdefinitiveclinicalsynovitis(swelling)and in whom the synovitis is not better explained by another disease shouldbeexaminedforRA.MAkE THE DIAGNOSIS Does your patient have: 3 Swollen or tender joints –Either>1largeor≥1smalljointofthehandsorfeet,or –Positivesqueezetest(painwhengentlysqueezingacrossthe

metacarpophalangeal/metatarsophalangealjoints) 3 Symptoms lasting ≥6weeks

If patient has swollen joints or a positive squeeze test as above for ≥6 weeks, refer to a rheumatologist for provisional RA.

If the patient does not meet these criteria but has at least 1 swollen or tender joint and a positive RF or anti-CCP test, he or she should be referred to a rheumatologist.

A rheumatologist will make a definitive diagnosis of RA based on the followingcriteria: 1.Clinicalsignsandsymptoms 2.Patternandnumbersofjointsinvolved 3.Laboratorymeasures(RFandanti-CCPantibody) 4.Radiographicfindings 5.Rulingoutothercausesofinflammatoryarthritis

AletahaD,NeogiT,SilmanAJ.2010rheumatoidarthritisclassificationcriteria:anAmericanCollegeofRheumatology/ EuropeanLeagueAgainstRheumatismcollaborativeinitiative.Arthritis Rheum.2010Sept;62:2569-2581.

COLLABORATION BETwEEN PRIMARY CARE AND RHEUMATOLOGY ENSURES OPTIMAL CARESuccessfulmanagementofRArequireslong-termteaminvolvement.Inthe first stages, the PCP is responsible for identifying possible cases of RA,providingearlyreferraltoarheumatologistandearlypaincontrol.TherheumatologistconfirmsthediagnosisandinitiatesDMARDtherapy. •EarlyreferraltoarheumatologistiscriticaltoearlyinitiationofDMARD

therapy and to stop joint damage •Tofacilitatetheevaluationofthepatientbytherheumatologist,itis

advisabletoobtain: –Rheumatoidfactor(RF) n30%–70%ofRApatientsarepositive,althoughpositiveRFcan

be caused by many conditions – Anti-CCP antibody n40%–60%ofRApatientsarepositive(maybeyearsbefore

clinical manifestation) nMaybedetectableearlierthanRF n Extremely high specificity for RA – C-reactive protein, erythrocyte sedimentation rate –Completebloodcount(CBC),liverfunctiontests(LFTs) –Optionalx-raysofthehands,wrists,andfeet •Monitorforalarmsigns(infection,dyspnea,neckpain,rheumatoideye

disease, painful red eye) •EarlytreatmentbythePCPisintendedtorelievepainandenhance

mobility –NSAIDs,shortcourseoflow-doseprednisone;rarely,opioidsfor

severe pain

A patient who is RF and anti-CCP negative may still have RA.

BridgesSL.SpottingaggressiveRAearly:thephysicalexamination,testing,andimaging.J Musculoskelet Med.2006;23(supplNov):S10-S14.

LONG-TERM MANAGEMENT OF RA PATIENTSCVD: Patients with RA and persistent inflammation may have additional risk for CVD and require more aggressive cholesterol lowering •MinimizeCVDriskfactors(eg,smoking,lipids,bloodpressure) •MaintainhighindexofsuspicionforCVDFever and infections:RApatientsonsteroids,methotrexate(MTX),leflunomide,orbiologic agents are at increased risk of serious infection •AssessRApatientswithfever,suspectedinfection – Prompt and thorough evaluation of symptoms, antibiotics if warranted – Biologics may need to be held until infection is resolved – Prompt initiation of antibiotics (especially for patients on biologics) nAvoiduseoftrimethoprim/sulfamethoxazoleinpatientsonMTX •Ifpatientsonimmunosuppressiveagentsandbiologicsdonotrespondrapidlytoinitial

treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc) •Considersepticarthritiswhenthereis –Isolatedmonoarthritiswhenallotherjointsstable – Swelling and tenderness in a patient with total joint replacement n RA patients may not mount a febrile response and the white blood cell count

may not be elevated in this setting •AcutedyspneaandcoughinapatientonMTXmayrepresentpneumonitis

VACCINATIONS AND DMARD THERAPY •Recommendedbeforetherapybegins –Influenzaandpneumococcalvaccinations –HepatitisBimmunizationifappropriate •Safe –Influenza(injection),tetanus,pneumococcus,meningococcus,hepatitisA,

hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV) •Avoid – Live virus vaccines such as intranasalinfluenza,mumps/measles/rubella(MMR),

yellow fever, and typhoid should be avoided in patients on immunomodulators –Waitatleast2weeksaftergivingthesevaccinesbeforeinitiatingimmunomodulators – Zoster vaccine, should be avoided in patients on biologic agents, but can be

giventopatientstakingMTXandprednisone<20mg/day

DeaneK.J Musculoskel Med.2006;23(supplNov):S24-S31.RavikumarR,etal.Curr Rheumatol Rep.2007;9:407-415;CDC.MMWR.2004;53:Q1-Q4;AveryRK.Rheum Dis Clin North Am.1999;25:567-584;ChalmersA,etal.J Rheumatol.1994;21:1203-1206;HarpazR,etal.MMWR Recomm Rep.2008;57 (RR-5):1-30;ACR.Herpeszoster(shingles)vaccineguidelinesforimmunocompromisedpatients.Availableat:http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp.AccessedOctober1,2010.

Issue date: February 2011 • Expiration date: February 29, 2012

OVERVIEwThispocketeducatorisdesignedtoaidprimarycareproviders(PCPs)inrecognizingtheearly signs of rheumatoid arthritis (RA) and determining when to refer a patient to a rheumatologist.SideAdiscussestheroleofthePCPintheearlydiagnosisofRAanddescribes how the PCP can work in tandem with the patient’s rheumatologist to effectively managethisdisease.SideBisdesignedtohelppatientsunderstandRA.LEARNING OBjECTIVES•IdentifypatientswhohaveprobableearlyRAandshouldbereferredtoarheumatologist•EmploythesqueezetesttoassistwithdiagnosisofRA•OrderappropriatelaboratorytestswhenRAissuspectedINTENDED AUDIENCEThistoolisintendedforPCPs.FACULTYClifton O. Bingham III, MD Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, Johns Hopkins University, Baltimore, MarylandJoyce P. Carlone, MN, RN, FNP-BC, CCRC NursePractitioner,DivisionofRheumatology,EmoryUniversity,Atlanta,GeorgiaMary Suzanne Cleveland, JD (Patient/Patient Educator) SeniorAnalyst,KansasHealthInstitute,Topeka,KansasLauren G. Collins, MD AssistantProfessorofFamilyandCommunityMedicine,JeffersonMedicalCollegeofThomas Jefferson University, Philadelphia, PennsylvaniaSTEERING COMMITTEE Michael E. Weinblatt, MD–Co-Chair JohnR.andEileenK.RiedmanProfessorofMedicine,HarvardMedicalSchool,Co-Director,ClinicalRheumatology,DivisionofRheumatology,Immunology,andAllergy,BrighamandWomen’sHospital,Boston,MassachusettsLauren G. Collins, MD–Co-ChairClifton O. Bingham III, MDJoyce P. Carlone, MN, RN, FNP-BC, CCRC Mary Suzanne Cleveland, JD (Patient/Patient Educator)Jeanne G. Cole, MS Director,OfficeofCME,JeffersonMedicalCollegeofThomasJeffersonUniversity,Philadelphia, PennsylvaniaKaren H. Costenbader, MD, MPH AssociatePhysician,DivisionofRheumatology,ImmunologyandAllergy,BrighamandWomen’sHospital, Assistant Professor of Medicine, Harvard Medical School, Boston, MassachusettsPaul P. Doghramji, MD, FAAFP MedicalDirectorforHealthServicesatUrsinusCollege,FamilyPhysician,CollegevilleFamilyPractice,Collegeville,PennsylvaniaDaniel Duch, PhD MedicalDirector,CuratioCMEInstitute,Exton,PennsylvaniaDavid S. Kountz, MD, MBA, FACP Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical Center,AssociateProfessorofMedicine,RobertWoodJohnsonMedicalSchool,NewBrunswick,NewJersey

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PCP:• Suspect diagnosis• “Immediate” referral• Baseline labs

PCP:• Surveillance• Comorbidity management• CVD risk reduction

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Rheumatologist• Confirm diagnosis• Initiate early, aggressive DMARD therapy• Monitor for toxicities and disease progression

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Squeeze test

Participation in this activity includes reviewing the clinician educator and completing a posttest and evaluation. For additional information,

and to obtain 0.5 CME credits for participating in this activity, please visit http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.

ACCREDITATION AND DESIGNATIONThis activity has been planned and implemented in accordance with the Essential Areas andPoliciesoftheAccreditationCouncilforContinuingMedicalEducation(ACCME).Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to providecontinuingmedicaleducationforphysicians.JeffersonMedicalCollegeofThomasJeffersonUniversitydesignatesthisenduringmaterialforamaximumof0.5AMA PRA Category 1 Credit™.Physiciansshouldclaimonlythecreditcommensuratewiththeextentoftheirparticipationintheactivity.DISCLOSUREJefferson Medical College of Thomas Jefferson University endorses the Standards of the ACCMEandtheGuidelinesforCommercialSupport.Thefollowingindividualshavedeclarednofinancialinterestsand/oraffiliations:Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; Jonathan S. Simmons, ELSThefollowingindividualshavedeclaredfinancialinterestsand/oraffiliations:Clifton O. Bingham III, MD Grant/Research Support: BMS, Genentech, UCB, Roche Consultant: Genentech,Roche,CentocorOrthoBiotech,Merck,UCB,Flexion,CelgeneJoyce P. Carlone, MN, RN, FNP-BC, CCRC Consultant, Product/Speakers Bureau, Other: UCBDavid S. Kountz, MD, MBA, FACPConsultant:NiCox,NovartisMichael E. Weinblatt, MDGrant/Research Support: AbbottConsultant:Abbott,CentocorOrthoBiotech,Pfizer/WyethCONTENT DISCLAIMER The information presented in this enduring material is for continuing medical education purposes only and is not meant to substitute for the independent medical judgment of a physicianregardingdiagnosisandtreatmentofaspecificpatient’smedicalcondition.The views or opinions expressed in the resources provided do not necessarily reflect those of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson HealthSystemorstaff.

ThisprogramissupportedbyeducationalgrantsfromAbbott,CentocorOrthoBiotechInc.,andPfizer.

Youcandownloadafree barcode reader app for your smartphone by searchingforQRCODESCANNERin the iPhone App Store, Android Market,orBlackberryAppWorld.

QR Code

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what is rheumatoid arthritis (RA)?•RAisachronicconditionthatdamagesthejointsofthe

body.Chronicconditionsarelonglasting(greaterthan3months)anddonotgoawayeasilyorquickly.RAaffectswomenmorethantwiceasmuchasmen.Althoughitmayoccur at any age, it usually starts in patients when they arebetween30and60yearsold.RAcausescontinuingjointdamageandassociatedconditionsformanypatients.To reduce complications, RA should be diagnosed and treatedearlyandoptimallymanagedthroughoutlife.

what are the symptoms?EarlysignsofRAinclude:•Swelling,stiffness,aching,orpaininoneormorejoints•Morningstiffnessthatlastsforatleast30minutesand

often for several hours•Difficultygraspingobjectsasstronglyasyouusedto

RA commonly affects the small joints of the fingers, wrists, and feet, but it may also affect other joints as the disease progresses, includingtheankles,knees,hips,elbows,andshoulders.

1B 2B 3B 4B 5B 6B 7B 8B

what causes RA?•ItisnotknownwhatcausesRA,butitisanautoimmune

disease.Thismeansthatthebodyattacksitself

•Thebody’simmunesystemfightsoffinfectionscausedbyinvading bacteria and viruses

•InautoimmunediseaseslikeRA,thebodyrespondsasifitsnormal cells are foreign cells and attacks them

•GeneticsmayplayapartinthedevelopmentofRA,butmany people who get RA do not have any relatives with the condition

what happens when RA causes an autoimmune response? Whenanimmuneresponseistriggered,inflammationoccursintheareasthatareattackedbytheimmunesystem.

•Inflammationcausesrednessandwarmth,swelling,stiffness, and pain in the affected joints

•Iftheautoimmuneresponseisnotslowedorstopped,itcan permanently damage the affected joints and other tissues over time

Can RA be prevented?Because we do not know why RA happens, there is no known waytopreventthedisease.However, early diagnosis and early treatment are the best ways to fight RA.

•Treatmentisfirstfocusedonreducinginflammationandrelieving pain

•WhenadiagnosisofRAisconfirmed,treatmentalsoaimsatstopping or slowing joint damage and damage to other parts of the body

How can RA be controlled?TherehasbeengreatimprovementinthedrugsusedtotreatRA.

•Aclassofdrugsreferredtoas“DMARDs” acts to slow or stop the progression of RA to more advanced stages of the disease

•Ifyoulookatthegraphabove,youwillseethatwhenaDMARD is not used (the red line), the problems caused by RAincreaserapidly,especiallyinthefirst2years

•However,whentreatedwithDMARDs(theblueline),thedisease progresses much more slowly, and fewer problems occur

•DMARDssuchasmethotrexate,hydroxychloroquine,sulfasalazine,orbiologicDMARDsaremostoftenusedtocontrol RA

I have some pain in my joints. How can I tell if I have RA?•IfyouthinkyoumayhaveRA,youneedtotellyourhealthcare

provider.Heorshewillexamineyouandaskthefollowingquestions:

–Whathurtsasyougetoutofbedinthemorning? – How long does it take to feel as limber as you’re going to

feelfortheday? –Whenisyourpaintheworst(AMorPM)? –DoanymembersofyourfamilyhaveRA? –Isitdifficultforyouto: n Turnfaucethandles? n Holdahairbrush/toothbrush? n Dress/batheindependently? n Fixyourownbreakfast? n Walkoutdoorsonflatground? –Howisyourenergylevel? –Doyousmoke? –Signsthatmaysuggestotherreasonsforyourpain: n Fever n Nightsweats n Unexpected weight loss n Rash, tick exposure n Recent contact with sick children

Youmayalsofilloutthequestionnaireonpanel8B,whichwillhelpidentifythecauseofyourdiscomfort.

what happens next?•IfyourhealthcareproviderthinksyoumayhaveRA,he

or she will prescribe medication to reduce the pain and inflammationinthejoints.Heorshewillalsoreferyoutoarheumatologist,whichisadoctorwhospecializesinRAandrelateddiseases.

•The rheumatologist will confirm the diagnosis of RA and prescribe appropriate medication to slow or stop the autoimmuneprocessandjointdamage.

•Depending on the extent of injury caused by RA, you may be referred to a physical or occupational therapist, a podiatrist, orotherspecialists,suchasanorthopedicsurgeon.

Rheumatoid Arthritis Resources and InformationThe American College of Rheumatology http://www.rheumatology.org/The Arthritis Foundation http://www.arthritis.org/The National Library of Medicine/Medline Plus http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm

Healthy joint Damaged joint

Destruction of cartilage

Cutaway view

Joints affected:Jaw

Wrist,hand, fingers

Ankle, foot, toes

Shoulder

Other organs that may be affected if RA is not treated early:

Eyes: dryness and damage to delicate structures

Lungs: much greater risk of getting serious infections and other complications

Heart disease: may occurabout10years sooner than in people without RA

Stomach: high risk of bleeding

Double the risk of some types of cancer, so increased screening is advisable

Early diagnosis and treatment may prevent these complications.

Are other parts of the body affected besides the joints?

00 4321 5

Years of Disease

Without DMARDs, problems increase rapidly

With DMARDs, fewer problems

Treatment With Disease-Modifiying Antirheumatic Drugs(DMARDs) Improves Long-Term Outcomes

Immune cell

Target cell

ALSO AVAILABLE

An interactive version of this Rheumatoid Arthritis: Primary care Initiative for improved Diagnosis and outcomes (RAPID) clinician educator is now available as an iPhone app. The enhanced app version includes the following features:

• VideodemonstrationofthesqueezetestandprovisionalRAdiagnosis

• Videodiscussionofpatientpointofviewtowardsprimarycareproviders and the need for early diagnosis

• VideodiscussionofrecommendedvaccinationsforRApatientsand the presence of comorbid conditions

The free iPhone app is available in either of the following ways:

• Downloadtheappat http://www.curatiocme.com/RAPID/iphone

• UsingthecameraonyouriPhone,scantheQRcodebelow

Published in Rheumatology,3rded.GordonDA,HastingsDE.Clinicalfeaturesofrheumatoidarthritis,765-780.CopyrightElsevier2003.

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