Download The Primary Care Provider`s Role in the Treatment of Rheumatoid

Treatment of Rheumatoid Arthritis
Then and Now
Objectives:
1.
2.
3.
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.
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 Newsletter
Volume 2:2 Summer 2009
Paradigm shift in the treatment
of rheumatoid and
inflammatory Arthritis
THEN…
Mary’s Story
31 year old female who presents to the
Beals Institute in 1982 with five year
history of RA
 Disability at age 27
 First joint replacement surgery at age
29

Mary’s treatments: Tried and
Failed
•
•
•
•
•
•
24 aspirin daily
Cyclosporin (Neoral)
Plaquenil
(Hydroxychloroquine)
Injectable Gold
Methotrexate
Azulfidine
•
•
•
•
•
•
Enbrel (Etanercept)
D-penicillamine
Prednisone
NSAIDs
Plasmaphoresis
Arava (Leflunomide)
Mary’s Numbers

3 reconstructive hand surgeries last one 2007
 1 wrist fusion
 2 hip replacements
 2 total knee replacements
 1 elbow replacement
 1 ulnar fracture repair and prosthetic repair
 > 10 hospitalizations for flares of uncontrolled
disease process
Rheumatologist
Primary Care Physician
• Establish Diagnosis of Rheumatoid Arthritis Early
• Document Baseline Disease Activity and Damage (Table 1)
• Estimate Prognosis (See Text)
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
AND NOW…
Periodically Assess Disease Activity (Table 3)
Inadequate Response
(i.e., ongoing active disease after
3 months of maximal therapy)
Adequate Response
with Decreased Disease
Activity
Change/Add DMARDs (Tables 2, 4, and 5)
MTX Naive
MTX
Other
Mono Rx
Combination
Rx
Suboptimal MTX Response
Combination
Rx
Other
Mono Rx
Biologics
Mono
Rx
Combination
Rx
Multiple DMARD Failure
Symptomatic
And/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.
…Now
Abigail’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 Numbers
0 days missed work due to disability
 0 hospitalizations, surgeries and joint
replacements due to RA
 5K - the length of the races she runs
regularly

Why Is Early Diagnosis and
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 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 RA





Pulmonary fibrosis
Disability
Deformity
↓ QOL
↑ morbidity and
mortality
All Slides (c) Current Medicine
Clinical Pearl
Hepatitis C presents with identical
symptomatology and will cause the
Rheumatoid Factor to be positive..
Labs Eval: Arthritis
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SPEP
Sed rate
CBC
CCP
RF
HLA-B27




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CRP
Hepatic panel
ANA, ENA, DNA
Hepatitis panel
Vitamin D
Treatment: NSAIDs





Celebrex
Relafen
Lodine
Arthrotec
Feldene





Voltaren
Mobic
Indocin
Daypro
Colchicine
Treatment: DMARDs

Methotrexate
 Arava (Leflunomide)
 Plaquenil
(hydroxychloroquine)
 Azulfidine (sulfasalazine)

Imuran (azathioprine)
 Minocin (minocycline)
 Gold (myochrysine)
 Neoral (cyclosporine)
Treatment: 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

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Active Lupus
Tuberculosis
Active infection
Hypogammaglobulinemia
Hepatitis B / C
CHF III & IV
Demyelinating Disorder
A Happy Ending?
In January 2004 Mary started Humira
 Continued Methotrexate, Gold, and
episodic prednisone for flares
 Since that time, she has avoided
hospitalization and disease has been
more consistently in remission.

Summary
Refer to rheumatology early and treat
aggressively
 Rheumatoid 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.
