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Rheumatoid Arthritis/Osteoarthritis

Rheumatoid Arthritis/Osteoarthritis. Sarah Daoud Florida A&M University College of Pharmacy and Pharmaceutical Sciences 10/02/13 Seminar: Disease Presentation. Objectives. Discuss the prevalence, epidemiology, risk factors, and pathophysiology of RA/OA.

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Rheumatoid Arthritis/Osteoarthritis

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  1. Rheumatoid Arthritis/Osteoarthritis Sarah Daoud Florida A&M University College of Pharmacy and Pharmaceutical Sciences 10/02/13 Seminar: Disease Presentation

  2. Objectives • Discuss the prevalence, epidemiology, risk factors, and pathophysiology of RA/OA. • Discuss the signs and symptoms, diagnosis, and treatment of RA/OA. • Assess treatment of disease states in special populations. • Evaluate the role of the pharmacist in the overall approach of these conditions. • Discuss key components of RA/OA which would serve as educational points for patients and healthcare practitioners.

  3. RHEUMATOID ARTHRITIS

  4. Prevalence • RA is the most common form of autoimmune arthritis affecting more than 1.3 million Americans. • Women encompass 75% of individuals diagnosed with this disease. • 1-3% of women may get RA in their lifetime. • Usual occurrence is in individuals between 40-60 years of age.

  5. Epidemiology • RA does not have any racial inclination and can occur at any age. • Research has shown, this disease has a genetic predisposition and diagnosis may be necessitated by certain unknown environmental exposures. • Major histocompatibility complex (MHC) molecules located on T-lymphocytes play a major role in patients with RA. • Human lymphocyte antigen (HLA) typing can characterize these molecules and assess the risk of RA in those with presence of antigens on MHC molecules.

  6. Risk Factors • Sex (Female) • Family history • Older age • Silicate exposure • Smoking • Consuming 3 or more cups of coffee/day (esp. decaffeinated coffee)

  7. Pathophysiology

  8. Signs and Symptoms • Morning stiffness lasting hours (sometimes whole day) • Fatigue • Weakness • Low-grade fever • Loss of appetite • Joint pain • Firm lumps ***Joint involvement tends to be symmetrical

  9. Diagnosis

  10. Non-pharmacological Treatment • Rest • Occupational therapy • Physical therapy • Use of assistive devices • Weight reduction • Surgery

  11. Pharmacological Treatment

  12. Pharmacological Treatment • Agents used for pain and inflammation

  13. Pharmacological Treatment • Non-biologic Disease-modifying anti-rheumatic drugs (DMARDS)

  14. Pharmacological Treatment • Non-biologic DMARDS cont.

  15. Pharmacological Treatment • Biologic agents- TNFalpha inhibitors • BBW: serious infxs; lymphomas; malignancies; perform test for latent TB before initial therapy. • Contraindication: sepsis • Can cause worsening or new onset Heart Failure; hep. B reactivation; demyelinating disease. • Do not give with other biologics or live vaccines • SE: infections and injection site reactions • Administration: do not shake; require refrigeration; allow to reach room temp. before injecting • These agents are usually add-on therapy to methotrexate

  16. Pharmacological Treatment • Biologic DMARD agents- TNFalpha inhibitors

  17. Pharmacological Treatment • Biologic response modifiers

  18. Pharmacological Treatment Kinase Inhibitors

  19. OSTEOARTHRITIS(AKA: Degenerative Joint Disease)

  20. Prevalence • An estimated 15.8 million adults display symptoms of OA • Prevalence increased with age • E.g. Those aged 75-79 years, 85% have OA of the hands, whereas those 45 year and younger, only 1/5th have OA of the hands. • Severity also increases with age • Women are more affected • Knee OA twice as prevalent in black opposed to white women

  21. Epidemiology • Most prevalent of the rheumatic diseases • Responsible for disability and loss of productivity • OA at some skeletal sites occurs in nearly everyone 75 years and older • ½ million symptomatic cases of idiopathic OA occur yearly in the US white population

  22. Risk Factors • Obesity • Repetitive motion (constant stress on hand, knee, etc.) • Joint injury • Genetics • Type and intensity of physical activity

  23. Pathophysiology

  24. Signs and Symptoms • Pain with motion • Joint stiffness lasting <30min (usually in the morning) • Joint: • Tenderness • Crepitus • Enlargement

  25. Diagnosis • 3 Goals: • Differentiate between primary or secondary OA • Clarify joints involved • Assess prior therapies • Diagnostic Parameters: • OA of knee- • Refer to signs and symptoms • Age >50yo • OA of hand- • Heberden’s node (2 or more out of 10) • OA of hip- • Normal ESR • Osteophytes and joint space narrowing on on X-ray

  26. Non-pharmacological Treatment • Exercise programs (aquatic) • Weight loss • Patient education for self-management • Wedged shoe insoles • Rest • Braces (symptomatic relief)

  27. Pharmacological Treatment • Pain Relief (primary indication for pharmacological treatment)

  28. Pharmacological Treatment Opioid Analgesics

  29. Pharmacological Treatment NSAIDS

  30. Pharmacological Treatment Topical NSAIDS (preferred over oral NSAIDs for pts >75 yoa) Topical Analgesics

  31. Pharmacological Treatment Intra-acrticular Glucocorticoids (knee or hip)

  32. Pharmacist Role • Be aware of certain labs to order for particular agents • Understand patient populations, which certain medications should be avoided in • Counsel patients on the disease state , SE, possible treatments • Assess progression of disease and appropriate measures to take • Make recommendations to physicians regarding drug regimen

  33. Clinical Pearls- Based on Guidelines • RA • Etanercept recommended for use in patients with hepatitis C. • No biologics for hepatitis B • Rituxibam recommended for pts with malignancy <5yrs, treated skin melanoma, treated lymphoproliferative disease • TNF inhibitor recommended for patients with CHF • OA • Knee • Acetaminophen • Oral NSAIDs • Topical NSAIDs • Tramadol • Intraarticular corticosteroid injections • Hip • Same as above without topical NSAIDs • Hand • Topical NSAIDs • Topical capsaicin • Oral NSAIDs

  34. Reference • American College of Rheumatology 2012 Recommendations for the Use of Nonpharmacologicand Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee. American College of Rheumatology. vol. 64, No. 4, April 2012, pp 465–474 • 2012 Update of the 2008 American College of Rheumatology Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid ArthritisAmerican College ofRheumatology. vol. 64, No. 5, May 2012, pp 625–639 • Kenneth C Kalunian, MD. Patient information: Osteoarthritis symptoms and diagnosis (Beyond the Basics). UpToDateAugust 2013. • Peter H. Schur, MD. General principles of management of rheumatoid arthritis in adults. UpToDateAugust 2013 • Micromedex

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