Rheumatoid Arthritis Treatment for the non rheumatologist Catherine Gerrish, MD, FACP Brown Clinic, PLLP SWAN meeting, Jackson Hole Wyoming 9-2011
Rheumatoid Arthritis Cathy Gerrish Brown Clinic SWAN ACP Meeting September 2011
Rheumatoid Arthritis • A lifelong disease, chronic • 0.8-1.0% prevalence worldwide • Female predominance 2:1 • Disability common if left untreated, 20-30% become disabled inn 2-3 years • Increasing evidence that it is a risk factor for ASCVD similar to diabetes, hypertension and high cholesterol.
RA characteristics • A chronic lifelong inflammatory disease • Characterized by uncontrolled proliferation of synovial tissue • Untreated RA—20-30% become disabled within 2-3 years of diagnosis • Remains primarily a clinical diagnosis, although lab and x-ray markers help confirm diagnosis and help track response to disease.
Why should IM doctors treat this disease? • These are high risk patients • Disability is common if untreated • Morbidity (pain and suffering) is common, but treatable • Rheumatologists are scarce and busy treating more complicated and sicker patients • Often long waits to get patients in to see rheumatologists
Diagnosis of RA • Diagnosis is made primarily on clinical finding (history and physical exam), lab markers and x-rays can help confirm diagnosis and track disease • CC arthralgia, pain in joints, symmetry, stiffness, weakness, fever, weight loss, dry eyes, mouth, Raynaud’s • PE symmetrical swelling of joints, effusions, MCP, PIP etc. • GALS screen (gait, arms, legs, spine)
Lab in Rheumatoid Arthritis • Lab findings: • acute phase reactants--CRP, ESR most commonly used • Autoantibodies—rheumatoid factor anti-CCP antibody • For other rheumatic disease—check FANA, p-ANCA, c-ANCA, serum complement levels, HLA-B27 • SYNOVIAL FLUID?—viscosity, mucin clot, protein, WBC’s ?
Rheumatoid Arthritis • Radiologic findings: • Conventional radiology: inexpensive, widely available, low radiation load • Use peripheral extremities, most involved joints—look for cysts, erosions, osteopenia • Computerized Radiography/Tomography • Higher in cost, can be digitized easily for consultation, more sensitive for soft tissue
RA Radiology • MRI • Frequently the second imaging study but must be correlated with plain films • Best for soft tissue • No ionizing radiation
Treatment of RA • First goal of treatment is to relieve pain, decrease swelling so using NSAID, APAP, steroids should be started as soon as possible • Prevention of joint destruction and disability is paramount, so institution of DMARD (Disease modifying anti-rheumatic drugs) should be done quickly
RA Treatment • Evaluation prior to initiation or therapy • CBC, ESR, CRP, creatinine, liver panel • PPD screen, chest x-ray? to screen for TB for biologics • Immunization update (influenza, pneumovax, ? Shingles vaccine)
RA Treatment DMARD • DMARD therapy • Gold standard methotrexate 7.5 mg to 25 mg oral or inj per week • Sulfasalazine oral • Hydroxychloroquine 200 mg qd-bid • Minocycline • (gold injections, oral gold have fallen into disuse)
RA Treatment--Biologics • TNF-alpha inhibitors • Enbrel (SQ)2x per wk • Humira (SQ) q 2 wks • Simponi (SQ), monthly • Remicade (IV) q 6-8 wks after load • Cimzia • Rituximab • Orencia (IV)q 4 wks
RA Treatment---Nonbiolobics • Arava (leflunomide) oral
Rheumatoid Arthritis—Goals of treatment • Remission—can be achieved • Lowest disease activity possible • Best functional ability possible • These are the primary goals of therapy
Highlights • The most common inflammatory arthritis • Chronic disease, erosive Requires early AND aggressive treatment
History & Exam Key Points • Symptoms: active arthritis, symmetric, lasting over 6 weeks, age 20-50, predominately female • Joints: painful, swollen, possibly nodules • Morning stiffness, fatigue • Vasculitis
Diagnostic tests • First tests to order: • Inflammatory markers (ESR, CRP) • Rheumatoid factor (RF) • Anticyclic citrulllinated peptide (anti-CCP) • Radiographs of affected joints (baseline to follow disease, check for erosions, bony changes)
Treatments • Acute treatment goals • Relief of pain and stop progression of disease • For mild to moderate disease, non pregnant: • NSAID, corticosteroids • DMARD
Treatment • Mild-moderate disease, pregnant or planning pregnancy: • Corticosteroids, sulfasalazine, hydroxychoroquine are options
Treatment Options • High disease activity at presentation (not pregnant or planning pregnancy) • Aggressive treatment should be considered with methotrexate, biological agents, with pain relief from NSAID/corticosteroids
Treatment Options • Ongoing treatment: • Goal is to reach lowest disease activity possible • Consider combination DMARDs, biologic agents • Wean NSAIDs, steroids as possible to avoid long term side effects of these drugs
Guidelines for the management of Rheumatoid Arthritis • Summary: • American College of Rheumatology2008 • Patients with mild to moderate disease activity are to be started on methotrexate, leflunomide, sulfasalazine or hydroxychloroquine. • Patients with severe disease activity, poor prognostic factors can be started on mtx, plus TNF inhibitor (etanercept, infliximab, adalimumac, Abatacept, • If TNF fails, consider rituximab (B cell inhibitor) • Reference ACR Subcommittee of Rheumatoid Arthritis • http://www.ncbi.nlm.nih.gov/pubmed/1184035 • http://onlinelibrary.wiley.com/dol/10.1002/art.10148/full