improving early diagnosis and treatment of rheumatoid arthritis
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IMPROVING EARLY DIAGNOSIS AND TREATMENT OF RHEUMATOID ARTHRITIS. Michael Lockwood, MD, FACP, FACR Rheumatology Indiana University Health Arnett. Presentation of Case. March 1994: 48 yo w F smoker, joint pain and swelling, RF 74 June 1994 started hydroxychloroquin - PowerPoint PPT PresentationTRANSCRIPT
IMPROVING EARLY DIAGNOSIS AND TREATMENT OF RHEUMATOID
ARTHRITISMichael Lockwood, MD, FACP, FACR
RheumatologyIndiana University Health
Arnett
Presentation of Case• March 1994: 48 yo w F smoker, joint pain and swelling, RF 74• June 1994 started hydroxychloroquin• September 1994 feeling much better• May 1998 started methotrexate• April 2002 found benefit with COX 2 Selective NSAIDs• August 2002 deformity and nodulosis• 2005 methotrexate was increased• May 2006: DAS 4.02, Hand films• January 2007: Infliximab started• Could a different outcome have been achieved?
11/25/1996 8/19/2006
Rheumatoid Arthritis CureWhy is it important?
• Severe disability after 20 year: 19%• Lifetime Costs: $225,000 - $370, 000• Excess Deaths: Mortality Ratio = 2.26• Excess Cardiovascular events = 4x• Increases risk of coronary artery disease = Type 2 diabetes
Wolfe, A&R 37(4), p. 481
Rheumatoid ArthritisApproach to Therapy
Timing
Korpela, A&R vol. 50, pp 2072-81
Before 4 months:
Combination 42%
Single Drug 35%
After 4 months
Combination 42%
Single Drug 11%Mottonen, A&R, vol. 46, pp.894-98
Rheumatoid ArthritisAdvantage of Early Assessment
Timing
Van der Linden, A&R Vol. 62 pp 3537-3547
Rheumatoid Arthritis History
• Onset: Weeks to Months– Can be Palindromic onset– Can have pauciarticular onset
• Constitutional features– Morning stiffness lasting for hours
• Functional Questions
Rheumatoid Arthritis Epidemiology
• Women:Men 3:1• Peak onset age 30-55• Incidence 30/100,000• Prevalence
– 1% Caucasians– 0.1% rural Africans
Rheumatoid Arthritis Physical
Rheumatoid Arthritis Physical
Rheumatoid Arthritis Deformities
Ulnar Deviation
Swan neck deformities
Boutenaire deformities
Rheumatoid Arthritis Deformities
Bayonet Deformities
MTP Subluxation
Rheumatoid Arthritis Deformities
Atlantoaxial Instability
MRI
Rheumatoid Arthritis Extraarticular Involvement
Rheumatoid Nodules
Rheumatoid Arthritis Extraarticular Involvement
Rheumatoid Vasculitis
Rheumatoid Arthritis Extraarticular Involvement
Pulmonary
•Pleurasy
Rheumatoid Factor
Antibodies to Fc portion of IgG
75-80% of Patients have during course of disease
Useful for prognosis
Cyclic Citrullinated PeptideAntibodies (anti CCP)
Schellekens, A&R, Vol 43, pp. 155-163
Rheumatoid Arthritis X-Ray
Rheumatoid Arthritis X-Ray
Rheumatoid ArthritisClassification 1987 Criteria
Arnett, A&R, Vol 31, pp. 315-324
Rheumatoid ArthritisClassification 2010 Criteria
Aletaha, A&R, Vol 62, pp. 2569-2581
Rheumatoid ArthritisPathology
Choy, E. H.S. et al. N Engl J Med 2001;344:907-916
Pathogenesis of Rheumatoid Arthritis
Rheumatoid ArthritisPannus
Rheumatoid ArthritisApproach to Therapy
Triple Drug Therapy
O’Dell, NEJM vol. 334, pp 1287-1291
Triple Drug: 77% get 50 % improvement
Methotrexate: 33%
Plaquenil/Sulfasalazine: 40%
Choy, E. H.S. et al. N Engl J Med 2001;344:907-916
Cytokine Signaling Pathways Involved in Inflammatory Arthritis
Rheumatoid Arthritis How do we proceed?
• Aggressive approach, <5 yr disease, monthy followup• DAS calculated monthly• Aggressively escalating therapy• Goal: DAS remission or low disease activity• Results: ACR 50 = 84% vs 40% standard tx.
– Decrease erosions– Total Costs less
Grigor, Lancet, Vol. 364, pp. 263-269
Rheumatoid Arthritis
Implementation DAS scoring &
aggressive approach in a
community rheumatology
practice
Arnett #
Pain Count
Swelling Count
VAS Patient
WSR
DAS
Comment
Date
I________________________________________________________________INot Active
at allExtremely
Active
Physician Assessment
PainSwelling
Patient Assessment of Disease Activity
DAS28 < 2.6 Remission
DAS28 2.6 to < 3.2 Low Disease Activity
DAS28 3.2 to 5.1 Moderate disease Activity
DAS28 >5.1 High Disease Activity
Last Name First Name Birth Date
Problem 1A 32 year old man presents with fatigue, low back pain and
morning stiffness lasting 15 minutes. He notes that the back pain seems to get worse as he works through his day. He is a machinist at a local factory. What should you do next?
A. Start a Medrol (methylprednisolone) dose packB. Check a rheumatoid factor (RF), cyclic citrullinated
peptide antibody (CCP), and an antinuclear antibody (ANA)
C. Refer to physical therapy for back strengthening and instruction in back protection
D. Get a lumbar sacral xray 3 viewsE. Get a MRI of the back.
Problem 2A 26 year old women presents with a 4 week history of
swelling and tenderness of all of the MCPs, PIPs and the MTPs of the feet. This is confirmed on physical examination. There are no other stigmata on examination. Her labs are remarkable for a sed rate of 35 but a negative rheumatoid factor (RF), CCP, and ANA. Her hand a feet xrays are normal. Her most likely diagnosis is:
A. Systemic lupus erythematosusB. Rheumatoid arthritisC. Psoriatic arthritisD. Fibromyalgia
Problem 3What treatment would you initiate for the above patient?
A. Monotherapy with methotrexate, hydroxychloroquin, or sulfasalazine but follow serial DAS (disease activity score) and treat to target.
B. Combination therapy with methotrexate, hydroxychloroquin, and sulfasalazine but follow serial DAS (disease activity score) and treat to target.
C. Combination therapy with methotrexate and a TNF blocker but follow serial DAS and treat to target.
Problem 4A 45 year old women presents with swelling and pain in the joints of 8
months duration, morning stiffness lasting several hours, and she finds it difficult to do her work. She has swelling and tenderness in most of the MCPs, PIPs, and MTPs. There is also swelling of the wrist, ankles, elbows, and one knee. Her sed rate is 60, and she has a high titre positive rheumatoid factor and cyclic citrullinated peptic (CCP). The ANA is 1:160. Her hand films do show joint space narrowing in one of the MCP and there is an erosion of a couple of the PIP. What treatment would you initiate for the patient?
A. Monotherapy with methotrexate, hydroxychloroquin, or sulfasalazine but follow serial DAS (disease activity score) and treat to target
B. Combination therapy with methotrexate, hydroxychloroquin, and sulfasalazine but follow serial DAS (disease activity score) and treat to target.
C. Combination therapy with methotrexate and a TNF blocker but follow serial DAS and treat to target