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The Early arthritis clinic
Dr Fahim Khan.MD,MRCP,FRCP,FACP.
Consultant Rheumatologist
Aut Even Hospital Kilkenny.
Early RA hands
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.
The Synovium in RA
Normal Synovium
Rheumatoid Synovium
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.
Early arthritis clinic--synovitis
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 nonsteroidal
antiinflammatory 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
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.
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 Clin Rheumatol 2009;23:93–102
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.
Rheumatoid factor and
Anti 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.
Rheumatoid factor and
Anti citrullinated peptide antibodies
•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 early oligo- or
polyarthritis, anti-CCP testing appears to be of
predictive value in the IgM-RF negative
subgroup.10
10Jansen LM; van Schaardenburg D; van der Horst-Bruinsma I; van der Stadt 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
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
Conventional DMARDs: Currently
available therapies
• General anti-inflammatory and/or antiproliferative 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
Biological agents: The additional
dimension in RA treatment
Symptomatic relief only
•
•
•
•
Traditional NSAIDs
COX-2 inhibitors
Corticosteroids
Analgesics
Some retardation of joint
damage AND alleviation of
disease signs and symptoms
BIOLOGICS:
cytokine-targeted therapies
• anti-TNF agents
• IL-6R inhibitor
• IL-1 inhibitor
DMARDs
• Disease-modifying anti-rheumatic
drugs (e.g. methotrexate)
cell-targeted therapies
• T-cell co-stimulation modulator
• B-cell depleting agent
P06/03/09
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
Early arthritis clinic(EAC)
Aut Even Hospital Kilkenny
A 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
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.
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
EAC Framework (New Referrals)
General Practitioner, Other Speciality
referred to rheumatology clinics.
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.
THANK YOU
QUESTIONS ?
DR FAHIM KHAN