treatment of rheumatoid arthritis then and now
DESCRIPTION
Treatment of Rheumatoid Arthritis Then and Now. Objectives:. Outline the diagnostic criteria for Rheumatoid Arthritis, its systemic manifestation, and the complication of untreated RA. Identify and discuss laboratory tests that aid in the diagnosis of RA. - PowerPoint PPT PresentationTRANSCRIPT
Treatment of Rheumatoid ArthritisTreatment of Rheumatoid ArthritisThen and NowThen and Now
Objectives:Objectives:
1. Outline the diagnostic criteria for Rheumatoid Arthritis, its systemic manifestation, and the complication of untreated RA.
2. Identify and discuss laboratory tests that aid in the diagnosis of RA.
3. Explain the differences between oral disease modifying anti-rheumatic medications and biologic medications, including medication risks and safety profiles.
Pathophysiology
Rheumatology Nurse Newsletter Volume2:2
Cytokines
Rheumatology Nurse NewsletterVolume 2:2 Summer 2009
Paradigm shift in the treatment Paradigm shift in the treatment of rheumatoid and of rheumatoid and
inflammatory Arthritisinflammatory Arthritis
THEN…THEN…
Mary’s StoryMary’s Story31 year old female who presents to the
Beals Institute in 1982 with five year history of RA
Disability at age 27First joint replacement surgery at age
29
Mary’s treatments: Tried and Mary’s treatments: Tried and Failed Failed
• 24 aspirin daily• Cyclosporin (Neoral)• Plaquenil
(Hydroxychloroquine)• Injectable Gold• Methotrexate• Azulfidine
• Enbrel (Etanercept)• D-penicillamine• Prednisone• NSAIDs• Plasmaphoresis• Arava (Leflunomide)
Mary’s NumbersMary’s Numbers3 reconstructive hand surgeries last one 20071 wrist fusion2 hip replacements2 total knee replacements1 elbow replacement1 ulnar fracture repair and prosthetic repair> 10 hospitalizations for flares of uncontrolled
disease process
AND NOW…AND NOW…
Initiate Therapy• Patient Education• Start DMARD(s) Within 3 Months (Table 2)• Consider NSAID• Consider Local or Low-Dose Systemic Steroids• Physical Therapy/Occupational Therapy
Periodically Assess Disease Activity (Table 3)
Inadequate Response (i.e., ongoing active disease after
3 months of maximal therapy)
Adequate Responsewith Decreased Disease
Activity
• Establish Diagnosis of Rheumatoid Arthritis Early• Document Baseline Disease Activity and Damage (Table 1)• Estimate Prognosis (See Text)
Change/Add DMARDs (Tables 2, 4, and 5)
MTX Naive Suboptimal MTX Response
MTX Other CombinationMono Rx Rx
CombinationMono RxRx
Other Biologics
Mono Combination
Rx Rx
Multiple DMARD Failure
SymptomaticAnd/or Structural
Joint Damage
Surgery
Figure 1. Outline of the management of rheumatoid arthritis. Each step is detailed in the text. Boxes with heavy borders represent major decision points in management. A suboptimum response to methotrexate (MTX) is defined as intolerance, lack of satisfactory efficacy with a dosage of up to 25 mg/week, or a contraindication to the drug. DMARD = disease-modifying antirheumatic drug; NSAID = nonsteroidal antiinflammatory drug; mono Rx = monotherapy; combination Rx = combination therapy.
Prim
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Car
e P
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Rhe
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ist
…Now
Abigail’s StoryAbigail’s Story
34 year old presents in 2005 with shoulder, wrist and hand pain for 2 months
Started on combination therapy using Arava and Enbrel
Due to diarrhea and weight loss, changed to Methotrexate and Enbrel
Abigail’s NumbersAbigail’s Numbers0 days missed work due to disability0 hospitalizations, surgeries and joint
replacements due to RA5K - the length of the races she runs
regularly
Why Is Early Diagnosis and Why Is Early Diagnosis and Treatment Imperative?Treatment Imperative?
•Rheumatoid arthritis progression is the most rapid in the first two years of disease onset •75% of joint damage will occur within the first five years of disease onset.•Rheumatoid Arthritis is as lethal as lymphoma if left untreated!
Diagnostic Criteria for RADiagnostic Criteria for RA>4 of the following must be present Morning stiffness > 1 hour > 3 joints involved Symmetrical swelling; usually in hands,
wrists and MTP joints in feet Rotating joint pain Positive Rheumatoid Factor
(Note: 20% of patients with RA
will not test positive) Positive CCP Erosive joint changes on x-ray RA nodules
Complications of Untreated RAComplications of Untreated RA
Pulmonary fibrosis Disability Deformity ↓ QOL ↑ morbidity and
mortality
All Slides (c) Current Medicine
Clinical PearlClinical Pearl
Hepatitis C presents with identical symptomatology and will cause the Rheumatoid Factor to be positive..
Labs Eval: ArthritisLabs Eval: Arthritis SPEP Sed rate CBC CCP RF HLA-B27
CRP Hepatic panel ANA, ENA, DNA Hepatitis panel Vitamin D
Treatment: NSAIDsTreatment: NSAIDs Celebrex Relafen Lodine Arthrotec Feldene
Voltaren Mobic Indocin Daypro Colchicine
Treatment: DMARDsTreatment: DMARDs
Methotrexate Arava (Leflunomide) Plaquenil
(hydroxychloroquine) Azulfidine (sulfasalazine)
Imuran (azathioprine) Minocin (minocycline) Gold (myochrysine) Neoral (cyclosporine)
Treatment: Biologic AgentsTreatment: Biologic Agents
IL-1 antagonist– Kineret: sc daily
TNF inhibitor– Enbrel: sc 1-2 times/week– Humira: sc 2 times a month– Remicade: IV q 6 to 8 weeks– Simponi: sc q month– Cimzia: sc q month
T-cell inhibitor– Orencia: IV q month
B-cell inhibitor– Rituximab: IV load, 2 weeks then PRN
Contraindications of Biologic Agents
Active Lupus Tuberculosis Active infection Hypogammaglobulinemia Hepatitis B / C CHF III & IV Demyelinating Disorder
A Happy Ending?A Happy Ending?
In January 2004 Mary started Humira Continued Methotrexate, Gold, and
episodic prednisone for flaresSince that time, she has avoided
hospitalization and disease has been more consistently in remission.
SummarySummaryRefer to rheumatology early and treat
aggressivelyRheumatoid arthritis and inflammatory
arthritis shorten the patient’s life expectancy if left untreated
Many treatment options exist and treatment can be tailored to the patient’s needs.