The Early arthritis clinic Dr Fahim Khan. MD,MRCP,FRCP,FACP . Consultant Rheumatologist Aut Even Hospital Kilkenny .

1. The Early arthritis clinic Dr FahimKhan.MD,MRCP,FRCP,FACP.Consultant RheumatologistAut Even Hospital Kilkenny.

2. Early RA hands

3. Aims and ambitions • 1. Rapid and easy access (< 2 weeks) • 2. Patient education • 3. A comprehensive assessment to make an optimal diagnosis • 4. Initiate EARLY optimal therapy • 5. Prevention of joint damage.

5. The Synovium in RA Normal Synovium Rheumatoid Synovium

6. Early arthritis clinic • The Early Arthritis Clinic represents a structured environment for patients to be investigated, reviewed and treated using the latest technology (such as US imaging with Power Doppler assessment of synovitis). • This will provide patients with the opportunity for rapid symptom control and improved long term functional outcome based on an evidence based approach to therapy and management of their condition.

7. Early arthritis clinic--synovitis

8. THE MOVEMENT TOWARD EARLY ARTHRITIS CLINICS Emery and Gough2 pointed out that RA is the most common cause of potentially treatable disability in Western countries, based on recognition of longterm severity of clinical RA. At that time, general practitioners were advised to give patients a nonsteroidalantiinflammatory drug for up to 2 years before the use of disease modifying antirheumatic drugs (DMARD)3​. 2.Emery P, Gough A. Why early arthritis clinics? Br J Rheumatol 1991;30:241–2. McCarty DJ 3.Lightfoot RW, Jr. Treatment of rheumatoid arthritis. In: McCarty DJ, editor. Arthritis and allied conditions. 10th ed. Philadelphia: Lea & Febiger; 1985:668–76

9. EARLY ARTHRITIS IN POPULATION STUDIES Research concerning early arthritis and early rheumatoid arthritis (RA) may be thought to have begun in population-based studies in the late 1950s to late 1960s. These studies indicated that the majority of people who had clinical findings of RA had no evidence of disease 3–5 years later., and that only about 25%–30% of people in a population who met criteria for RA had rheumatoid factor4. 4.Sokka T, Pincus T.A historical perspective concerning population-based and clinical studies of early arthritis and early rheumatoid arthritis. Clin Exp Rheumatol 2003;21:S5–S14.

10. EARLY TREATMENT IS BENEFICIAL IN RANDOMIZED CLINICAL TRIALS Observations from randomized clinical trials (RCT) support early versus delayed drug treatment in RA. The benefits of early versus delayed treatment have been documented in studies of intramuscular gold, auranofin, sulfasalazine, and hydroxychloroquine (as reviewed5). 5.Sokka T, Makinen H. Drug management of early rheumatoid arthritis — 2008. Best Pract Res ClinRheumatol 2009;23:93–102

11. IMPROVED LONGTERM OUTCOMES OF RA REFLECT EARLY AND ACTIVE TREATMENT STRATEGIES Data from clinical cohorts and observational studies indicate that status and outcomes of RA patients have improved over the past decades concomitantly with implementation of early and active treatment strategies6-7. 6.Pincus T, Sokka T, Kautiainen H. Patients seen for standard rheumatoid arthritis care have significantly better articular, radiographic, laboratory, and functional status in 2000 than in 1985. Arthritis Rheum 2005;52:1009–19. 7.Sokka T, Kautiainen H, Mottonen T, Hannonen P. Erosions develop rarely in joints without clinically detectable inflammation in patients with early rheumatoid arthritis. J Rheumatol 2003;30:2580–4.

12. Rheumatoid factor andAnti citrullinated peptide antibodies • Assays for autoantibodies and acute phase reactants are helpful in the early diagnosis of RA. The most reliable early predictors of both chronic and erosive disease are the presence of RF and anti-CCP antibodies.8 • 8,Schellekens GA; Visser H; de Jong BA; van den Hoogen FH; Hazes JM; Breedveld FC; van Venrooij WJ The diagnostic properties of rheumatoid arthritis antibodies recognizing a cyclic citrullinated peptide Arthritis Rheum 2000 Jan;43(1):155-63.

13. Rheumatoid factor andAnti citrullinated peptide antibodies • 10Jansen LM; van Schaardenburg D; van der Horst-Bruinsma I; van derStadt RJ; de Koning MH; Dijkmans BA The predictive value of peptide antibodies in early arthritis. J Rheumatol 2003 Aug; 30(8):1691-5. Listing J; Rau R; Muller B; Alten R; Gromnica-Ihle E; Hagemann D; Zink A J Rheumatol 2000 Sep; 27(9):2100-9 • Testing for the combination of anti-CCP antibodies and IgM RF may be better for excluding the diagnosis of RA than is achievable by testing for either antibody alone 9. • Among patients with earlyoligo- orpolyarthritis, anti-CCP testing appears to be of predictive value in the IgM-RF negative subgroup.10 • 9.Bas S; Genevay S; Meyer O; Gabay Anti-cyclic citrullinated peptide antibodies, IgM and IgA rheumatoid factors in the diagnosis and prognosis of rheumatoid arthritis. Rheumatology (Oxford) 2003 May; 42(5):677-80

15. Conventional DMARDs: Currently available therapies • General anti-inflammatory and/or anti-proliferative activity • DMARDs have the potential to slow or prevent joint damage • Lack a direct analgesic effect • Have a slow onset of action (weeks to several months) • Most common conventional DMARDs1 • Methotrexate • Leflunomide • Sulfasalazine • Hydroxychloroquine

16. Biological agents: The additional dimension in RA treatment Symptomatic relief only Some retardation of joint damage AND alleviation ofdisease signs and symptoms • Traditional NSAIDs • COX-2 inhibitors • Corticosteroids • Analgesics • BIOLOGICS: • cytokine-targeted therapies • anti-TNF agents • IL-6R inhibitor • IL-1 inhibitor • cell-targeted therapies • T-cell co-stimulation modulator • B-cell depleting agent • DMARDs • Disease-modifying anti-rheumatic drugs (e.g. methotrexate) P06/03/09

20. Referral Criteria for EAC: • Symptoms present for at least 4 weeks but less than 1 year • Early morning stiffness of > 30 mins AND ANY ONE OF THE FOLLOWING: • 3 or more swollen joints • Tender/involved metacarpophalangeal joints • Tender/involved metatarsophalangeal joints

21. Early arthritis clinic(EAC)Aut Even Hospital KilkennyA Review of 44 patients Data • In the early arthritis clinic( EAC)at Aut Even Hospital Kilkenny, we looked at total of 44 patients who were referred to the EAC with an average time at : • Minimum 1 DAY TO Maximum 10 DAYS after referral. • Symptom classification: 39/44 patients presented with joint pains,swelling of hands(metacarpo-phalangeal joints) and feet (Metatarso-phalangeal joints) and stiffness lasting over 30 minutes. • 2-3 synovial swelling of hands/feet at presentation on clinical examination in 27 out of 44 patients

22. EAC—AUT EVEN HOSPITAL • FBS, LFTS, Renal profile on referral were normal. • ESR/CRP--- Raised in 39/44 patients • Rheumatoid Factor(R.F): positive in 38/44 patients • Anti Cyclic Citrullinted Peptide Antibody Test (Anti CCP Ab) performed in 26/44 , positive in 26/26 patients. • Anti Nuclear Antibody Test(ANA ) Performed in 15/44 patients, weakly positive in 13/15 patients.

23. EAC—AUT EVEN HOSPITAL • Diagnosis: Rheumatoid arthritis in 44/44 patients • DMARD STARTED AFTER REFERRAL:23 DAYS (3WEEKS 2 DAYS) • InitialDMARD used Methotrexate in 41/44 patients. Hydroxychloroquine used in 3/44 patients. • Biologics added to Methotrexate: Enbrel, Humira in 7/44 patients. • Follow up at 8 weeks after DMARD/Biologics prescribed with improvement in DAS 28 SCORE of 2.97

24. 1,Initial NEW patient assessment in E.A.C. 2, Early diagnosis of Rheumatoid Arthritis. 3,Decision taken to initiate earlier use of DMARD therapy to prevent long term joint damage. EAC Framework (New Referrals) General Practitioner, Other Speciality referred to rheumatology clinics.

25. THANK YOU QUESTIONS ? DR FAHIM KHAN