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Rheumatology Update 2008

Rheumatology Update 2008. R.W.Jackson,D.O.,F.A.C.O.I. Kirksville, MO. rheumdr@hotmail.com. Rheumatology Three Major Risks. >Heart< >Head< >Bugs< These represent the major Causes of death & lawsuits . ‘HEART’.

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Rheumatology Update 2008

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  1. Rheumatology Update 2008 R.W.Jackson,D.O.,F.A.C.O.I. Kirksville, MO. rheumdr@hotmail.com

  2. Rheumatology Three Major Risks • >Heart< • >Head< • >Bugs< These represent the major Causes of death & lawsuits

  3. ‘HEART’ • Rheumatology patients have a major increase risk in CAD due more to ‘inflammation’ then atherosclerosis Dr. Sherine Gabriel ACR Winter Conf. • Rheum pts. Have 2 X greater risk for CHF • Anti-TNF therapy contra-indicated in patients who have advanced CHF • Rheum pts. Have 10yrs reduced life-span

  4. ‘HEART’ • Aggressively evaluate patients with CP, SOB, atypical CP & Pre-op. presentations • Stress to Cardiology consultants the need for added attention to Rheum pts. • Control the ‘inflammation’ with goals to normalize the ESR (sed rate) and CRP (C-reactive protein)

  5. ‘HEAD’ • SLE, Temporary arteritis, Sjogrens, and Vasculopathies all associated with CNS ds. • CNS vasculopathies very difficult to dx. • Rheum diseases can result in CVA sx, MS, seizures, dementia and neuropathies. • Rheum diseases are potentially preventable and quiet treatable causes of these conditions.

  6. ‘BUGS’ • Rheumatology patients are inherently prone to ‘infections’. (Pneumonia is the number cause of death in RA patients) • Therapy with prednisone and immunosuppressive agents obviously increase this risk. By as much as 2X! • Treat all patients with autoimmune diseases as ‘high risk’

  7. ‘BUDS’ • Any fever in Rheum patients is significant and treat a temp of 100F = 104F • Start antimicrobial therapy earlier and more aggressively • Withhold DMARDs (ie. MTX and Biologics) during the treatment if infections • IMMUNIZE!!!! (avoid attenuated live virus vaccinations in patients on Biologics!)

  8. Osteoarthritis Update • ‘SINGLE” injection viscosupplementation • Oral hyaluronates (Membrell NEM) • Glucosamine/chondroitin sulfate helpful • Traditional NSAIDs causing ‘havoc’ the only UGI protection is from PPIs & misoprotol • Topical ketoprofen now available

  9. Rheumatoid Arthritis Update • Anti-TNF + MTX ‘best hope’ of DMARDs • Certolizumab (Cimzia) fully human monoclonal antibody; Golimumab (SQ monthly);Ocrelizumab & Atumumab deplete B-cells • Orencia (abataxcept) – AG presenting process • Rituxan (rituximab: anti CD-20 B-cells) • IL-6 inhibitor tocilizumab (Actemra) • Kenerit (IL-1 ihibitor) remains disappointing

  10. Fibromyalgia Update • Lyrica (pregabalin) first FDA approved medication for fibromyalgia (FM) • Cymbalta (duloxetine) soon to be approved for FM • Mirapex (pramipexole) has showen new promise in the treatment of FM

  11. Systemic Lupus Erythematosus Update • Biologics now show promise in the treatment of Lupus nephritis with both rituxan and atacicept • Lower dose cyclosporine (European minipulse) 500mg/2 weeks x 12weeks; instead of USA 1g/m2 per month for 6 to 12 months.(*) • CellCept (mycophenolate) now less exciting for SLE nephritis in Caucasians (*) Dr. David Wofsy reports at ACR Winter Conf.

  12. GOUT Update • Febuxostat (Adenuric/Puricase) first new medication in 40 years (1964) for gout! -more twice as effective than allopurinol -less adverse side-effects than allopurinol -useful in patients with advance renal ds. • New goal : reduce the uric acid <4.5mg%

  13. Scleroderma with Pulmonary Artery Hypertension (PAH) Update • PAH now treatable! (Past Mortalities <2yr) -epoprostenol -bosentan -inhaled treprostinil -tadafil Very expensive & requires Sub-specialists

  14. Juvenile Ideopathic Arthritis Update • JIR ‘New title’ for Juvenile Rheumatoid Arthritis • JIR probably represents 5 different conditions • More common overlap of RA/SLE/Spondylitis features • Arthralgias during the daytime not“growing pains” • Don’t forget about Rheumatic Fever

  15. Osteoporosis Update • “Best Calcium” > Membrell EggshellCalcium for Bone Health – 3 caps/day • “Best Vitamin D” 25-hydroxyvitamin (D3) Maxium D3 10000 iu / week • Vit D3 treatment goal >40ng/ml • New FDA guidelines will increase Vit D suggested supplementation to 1000iu/d

  16. Questions? Comments. Thank you! R.W.Jackson,D.O.,F.A.C.O.I. Kirksville, MO rheumdr@hotmail.com

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