1 / 23

Rheumatoid Arthritis Treatment for the non rheumatologist

Rheumatoid Arthritis Treatment for the non rheumatologist. Catherine Gerrish, MD, FACP Brown Clinic, PLLP SWAN meeting, Jackson Hole Wyoming 9-2011. Rheumatoid Arthritis. Cathy Gerrish Brown Clinic SWAN ACP Meeting September 2011. Rheumatoid Arthritis. A lifelong disease, chronic

ekram
Download Presentation

Rheumatoid Arthritis Treatment for the non rheumatologist

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Rheumatoid Arthritis Treatment for the non rheumatologist Catherine Gerrish, MD, FACP Brown Clinic, PLLP SWAN meeting, Jackson Hole Wyoming 9-2011

  2. Rheumatoid Arthritis Cathy Gerrish Brown Clinic SWAN ACP Meeting September 2011

  3. Rheumatoid Arthritis • A lifelong disease, chronic • 0.8-1.0% prevalence worldwide • Female predominance 2:1 • Disability common if left untreated, 20-30% become disabled inn 2-3 years • Increasing evidence that it is a risk factor for ASCVD similar to diabetes, hypertension and high cholesterol.

  4. RA characteristics • A chronic lifelong inflammatory disease • Characterized by uncontrolled proliferation of synovial tissue • Untreated RA—20-30% become disabled within 2-3 years of diagnosis • Remains primarily a clinical diagnosis, although lab and x-ray markers help confirm diagnosis and help track response to disease.

  5. Why should IM doctors treat this disease? • These are high risk patients • Disability is common if untreated • Morbidity (pain and suffering) is common, but treatable • Rheumatologists are scarce and busy treating more complicated and sicker patients • Often long waits to get patients in to see rheumatologists

  6. Diagnosis of RA • Diagnosis is made primarily on clinical finding (history and physical exam), lab markers and x-rays can help confirm diagnosis and track disease • CC arthralgia, pain in joints, symmetry, stiffness, weakness, fever, weight loss, dry eyes, mouth, Raynaud’s • PE symmetrical swelling of joints, effusions, MCP, PIP etc. • GALS screen (gait, arms, legs, spine)

  7. Lab in Rheumatoid Arthritis • Lab findings: • acute phase reactants--CRP, ESR most commonly used • Autoantibodies—rheumatoid factor anti-CCP antibody • For other rheumatic disease—check FANA, p-ANCA, c-ANCA, serum complement levels, HLA-B27 • SYNOVIAL FLUID?—viscosity, mucin clot, protein, WBC’s ?

  8. Rheumatoid Arthritis • Radiologic findings: • Conventional radiology: inexpensive, widely available, low radiation load • Use peripheral extremities, most involved joints—look for cysts, erosions, osteopenia • Computerized Radiography/Tomography • Higher in cost, can be digitized easily for consultation, more sensitive for soft tissue

  9. RA Radiology • MRI • Frequently the second imaging study but must be correlated with plain films • Best for soft tissue • No ionizing radiation

  10. Treatment of RA • First goal of treatment is to relieve pain, decrease swelling so using NSAID, APAP, steroids should be started as soon as possible • Prevention of joint destruction and disability is paramount, so institution of DMARD (Disease modifying anti-rheumatic drugs) should be done quickly

  11. RA Treatment • Evaluation prior to initiation or therapy • CBC, ESR, CRP, creatinine, liver panel • PPD screen, chest x-ray? to screen for TB for biologics • Immunization update (influenza, pneumovax, ? Shingles vaccine)

  12. RA Treatment DMARD • DMARD therapy • Gold standard methotrexate 7.5 mg to 25 mg oral or inj per week • Sulfasalazine oral • Hydroxychloroquine 200 mg qd-bid • Minocycline • (gold injections, oral gold have fallen into disuse)

  13. RA Treatment--Biologics • TNF-alpha inhibitors • Enbrel (SQ)2x per wk • Humira (SQ) q 2 wks • Simponi (SQ), monthly • Remicade (IV) q 6-8 wks after load • Cimzia • Rituximab • Orencia (IV)q 4 wks

  14. RA Treatment---Nonbiolobics • Arava (leflunomide) oral

  15. Rheumatoid Arthritis—Goals of treatment • Remission—can be achieved • Lowest disease activity possible • Best functional ability possible • These are the primary goals of therapy

  16. Highlights • The most common inflammatory arthritis • Chronic disease, erosive Requires early AND aggressive treatment

  17. History & Exam Key Points • Symptoms: active arthritis, symmetric, lasting over 6 weeks, age 20-50, predominately female • Joints: painful, swollen, possibly nodules • Morning stiffness, fatigue • Vasculitis

  18. Diagnostic tests • First tests to order: • Inflammatory markers (ESR, CRP) • Rheumatoid factor (RF) • Anticyclic citrulllinated peptide (anti-CCP) • Radiographs of affected joints (baseline to follow disease, check for erosions, bony changes)

  19. Treatments • Acute treatment goals • Relief of pain and stop progression of disease • For mild to moderate disease, non pregnant: • NSAID, corticosteroids • DMARD

  20. Treatment • Mild-moderate disease, pregnant or planning pregnancy: • Corticosteroids, sulfasalazine, hydroxychoroquine are options

  21. Treatment Options • High disease activity at presentation (not pregnant or planning pregnancy) • Aggressive treatment should be considered with methotrexate, biological agents, with pain relief from NSAID/corticosteroids

  22. Treatment Options • Ongoing treatment: • Goal is to reach lowest disease activity possible • Consider combination DMARDs, biologic agents • Wean NSAIDs, steroids as possible to avoid long term side effects of these drugs

  23. Guidelines for the management of Rheumatoid Arthritis • Summary: • American College of Rheumatology2008 • Patients with mild to moderate disease activity are to be started on methotrexate, leflunomide, sulfasalazine or hydroxychloroquine. • Patients with severe disease activity, poor prognostic factors can be started on mtx, plus TNF inhibitor (etanercept, infliximab, adalimumac, Abatacept, • If TNF fails, consider rituximab (B cell inhibitor) • Reference ACR Subcommittee of Rheumatoid Arthritis • http://www.ncbi.nlm.nih.gov/pubmed/1184035 • http://onlinelibrary.wiley.com/dol/10.1002/art.10148/full

More Related