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CRA e-Newsletter October 2012 Treating Rheumatoid Arthritis to Target Inside this issue: Patient Profile Treating Rheumatoid Arthritis to Target References Patient profile Helen is a 45-year old woman diagnosed with rheumatoid arthritis (RA) 2 months ago. On physical exam she has 9/28 swollen joints and 12 /28 tender joints; she also complains of pain in her feet with evidence of synovitis in 5 MTP joints. She rates her overall disease activity at 7/10; she is RF positive and anti-CCP positive and her ESR is at 45 and her CRP at 2.2 mg/dL. She had to miss several days of work in the last 6 weeks. Her GP prescribed naproxen 500 mg BID and some codeine. Treating Rheumatoid Arthritis to Target Rheumatoid arthritis (RA) is a chronic disease that is estimated to affect approximately 1% of Canadians. 1 Articular and non-articular manifestations of RA lead to reduced functional capacity and disability. 2 As a result, patients with RA experience significant productivity losses, impaired psychological well being, and poorer health-related quality of life. 3-5 Traditionally, the pharmacological management of RA involved a symptomalleviating approach with changes in dosage or the addition of medications only if symptoms progressed. 6 However, dramatic strides in RA management have now made long-term remission and prevention of irreversible joint damage a realistic goal. Important developments over the last two decades have included the advent of biologic therapies that can alter the clinical course of RA, together with significant advances in the availability of tools to help guide clinical decisions toward optimal outcomes. 7-9 Current guidelines recommend a targeted approach to RA management. 10,11 Aiming at specific predefined therapeutic targets in diseases such as diabetes and hypertension has been associated with a reduced risk of organ failure, but in the past, such targets had not been defined for RA management. In 2010, an international Treat to Target (T2T) task force formulated consensus recommendations aimed at improving the management of RA in clinical practice, thus providing guidance for treatment to target. 11 The T2T task force, and also the European League Against Rheumatism (EULAR) 2010 guidelines, 12 refer to evidence from various randomized controlled studies and observational studies showing that RA patients who attain remission have better outcomes than patients who have residual disease activity. The T2T initiative resulted in 10 recommendations (see table below). Faculty Boulos Haraoui MD FRCPC References 1. Canada; 2006. View source [Accessed September 6, 2012]. 2. 2. Clinical remission is defined as the absence of signs and symptoms of significant inflammatory disease activity. 3. While remission should be a clear target, based on available evidence, low Doeglas D, Suurmeijer T, Krol B, et al. Work disability in early rheumatoid arthritis. Ann Rheum Dis 1995;54(6):455-60. 3. Puolakka K, Kautiainen H, Möttönen T, et al. Predictors of productivity loss in early rheumatoid arthritis: a 5 year follow up study. Ann Rheum Dis 2005;64(1):130-133. 4. Gettings L. Psychological well-being in rheumatoid arthritis: a review of the literature. Musculoskeletal Care 2010;8(2):99-106. 5. Whalley D, McKenna SP, de Jong Z, et al. Quality of life in rheumatoid arthritis. Rheumatology 1997;36(8):884-888. 6. Rindfleisch JA, Muller D. Diagnosis and management of rheumatoid arthritis. Am Fam Physician 2005;72(6):1037-47. 7. Fransen J, Stucki G, van Riel PL. Rheumatoid arthritis measures: Disease Activity Score (DAS), Disease Activity Score-28 (DAS28), Rapid Assessment Table. Treating rheumatoid arthritis to target: recommendations of an international task force 11 1. The primary target for treatment of rheumatoid arthritis should be a state of clinical remission. Rheumatoid arthritis. Ottawa: Statistics of Disease Activity in Rheumatology (RADAR), and Rheumatoid Arthritis Disease Activity Index (RADAI). Arthritis Rheum 2003;49 Suppl 9:S214-24. 8. Fransen J, Häuselmann H, Michel BA, Caravatti M, Stucki G. Responsiveness of the self-assessed Rheumatoid Arthritis Disease Activity Index to a flare disease activity may be an acceptable alternative therapeutic goal, particularly in established longstanding disease. of disease activity. Arthritis Rheum 2001;44:53-60. 4. Until the desired treatment target is reached, drug therapy should be adjusted at least every 3 months. 9. Pincus T, Yazici Y, Bergman M. A practical guide to scoring a Multi- 5. 6. Measures of disease activity must be obtained and documented regularly, as frequently as monthly for patients with high/moderate disease activity or less frequently (such as every 3 to 6 months) for patients in sustained low disease activity or remission. Dimensional Health Assessment use in standard clinical care, without Questionnaire (MDHAQ) and Routine Assessment of Patient Index Data (RAPID) scores in 10-20 seconds for The use of validated composite measures of disease activity, which include joint assessments, is needed in routine clinical practice to guide treatment decisions. rulers, calculators, websites or computers. Best Pract Res Clin Rheumatol 2007;21:755-87. 7. Structural changes and functional impairment should be considered when making clinical decisions, in addition to assessing composite measures of disease activity. 10. Bykerk VP, Akhavan P, Hazlewood GS, et al. Canadian Rheumatology Association Recommendations for 8. The desired treatment target should be maintained throughout the remaining course of the disease. Pharmacological Management of Rheumatoid Arthritis with Traditional and 9. The choice of the (composite) measure of disease activity and the level of the target value may be influenced by consideration of comorbidities, patient factors, and drug-related risks. Biologic Disease-modifying Antirheumatic Drugs. J Rheumatol 2011. 11. Smolen JS, Aletaha D, Bijlsma JW, et al. 10. The patient has to be appropriately informed about the treatment target and the strategy planned to reach this target under the supervision of the rheumatologist. Clinical remission is defined as the absence of signs and symptoms of significant inflammatory disease activity. In some patients, e.g., those with long-standing disease, complete remission may not be realistic or achievable; for such patients, low disease activity may be an acceptable alternative goal. For these patients, some residual joint tenderness or a single swollen joint may be compatible with a state of remission. 11 The Canadian Rheumatology Association 2011 guidelines 10 also recommend that remission should be the goal of RA treatment; when this is not possible, treatment should aim for minimal disease activity while controlling symptoms, halting damage, preventing disability, and improving quality of life. Maximal clinical benefit with drug therapy in RA is usually not achieved before 3 months of treatment. By this time, if at least a state of low disease activity is not attained, treatment should be amended. A change of drugs is not always necessary, because dosage adjustment of an existing medication may be sufficient for achieving further benefit. 11 Methotrexate (MTX) is the preferred and most frequently used first line therapy for RA, and remains an anchor drug to enhance or maintain the efficacy of biologic agents. Patients who respond inadequately to MTX may be treated sequentially with another DMARD, combination of DMARDs, or a biologic agent. 13 Treatment decisions should be guided by using composite measures of disease activity; these may include the disease activity score (DAS) or the DAS employing 28 joint counts (DAS28), the simplified disease activity index (SDAI) and the clinical disease activity index (CDAI). X-rays should be obtained 6-12 monthly to estimate progression of joint damage. Intensification of treatment may be warranted if joint damage appears to be progressing despite achieving the desired target such as low disease activity. 10,11 A treatment algorithm as recommended by the T2T task force is provided in the figure below. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis 2010;69(4):631-7. 12. Smolen JS, Landewe R, Breedveld FC, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological diseasemodifying antirheumatic drugs. Ann Rheum Dis 2010;69(6):964-75. 13. Haraoui B., for the CRA sub-committee on biologic agents. Canadian Rheumatology Association Position on the use of Biologic Agents for the Treatment of Rheumatoid Arthritis. View source [Accessed September 7, 2012]. Figure. Algorithm for treating RA 11 Patient profile (contd.) With her regimen of daily naproxen and codeine as needed, Helen complains that the relief from her symptoms is unsatisfactory. Therapy with MTX is initiated, with the MTX dosage being escalated to 25 mg/week over 2 weeks. Helen’s treatment is adjusted as needed to achieve a target of clinical remission. This eNewsletter is provided by an educational grant from Pfizer.