Living with Rheumatoid Arthritis

Presented by:

Lauren Kennish, MD

Rheumatology

January 15, 2014

Lecture Outline

• What is Rheumatoid Arthritis (RA)?

• How is it diagnosed?

• What are the symptoms of RA?

• What are the treatment options?

• How do we live well with RA?

• What is new on the horizon?

What is Rheumatoid Arthritis?• RA is an autoimmune disease

• Autoimmune disease:Immune system incorrectly targets your own

tissues and organs

Antibodies form and attack cells

Inflammation/Swelling

Damage/Disease

What is Rheumatoid Arthritis?• Type of inflammatory arthritis = pain,

swelling and stiffness in the joints

• Systemic – can affect whole body

• Chronic condition

• Can damage cartilage,

bone• Mild Severe

Arthritis.org, 12/2013

flare relapse

remission

What is RA?

• Prevalence: 1.5 million people (0.6% population)

• Diagnosis age: Average

30-60 years old

• Females (3x) > Males

Helmick et al. A&R, 2008.

What Causes RA?

• Largely unknown• Theories:

Genetics +

Environment

• Possible Triggers Infection

• Gut/Gum bacteria Smoking Obesity Stress Female hormones

How is RA Diagnosed?

• History and Symptoms

• Blood tests Rheumatoid factor, anti-CCP, anti-MCV Inflammatory markers – ESR, CRP

How is RA Diagnosed?

• Imaging Xray MRI Ultrasound

What are the Symptoms of RA?

• Joint pain and swelling Small joints, symmetric

• Morning stiffness > 1 hour

• Difficulty with activities

• Joint DamageArthritis.org, 12/2013

What are the Symptoms of RA?

• Fatigue

• Anemia

• Skin nodules

• Inflammation – Eyes Blood vessels Lungs Heart

Associated Autoimmune Diseases

• Sjogren’s Syndrome

• Hashimoto’s Thyroiditis (Hypothyroidism)

Associated Conditions• Osteoarthritis

• FibromyalgiaWebmd.com, 2013

Associated Conditions• Osteoporosis

• Heart Disease Atherosclerosis -> high cholesterol, heart attack

• Increased risk of: Infections Cancer

Related Types of Arthritis

• Spondyloarthritis Psoriatic Arthritis Ankylosing Spondylitis Reactive Arthritis

How is RA Treated?

• There is no cure yet

• BUT…

• Many treatment options to decrease symptoms and associated conditions

• Can lead active, healthy lives

How is RA Treated?• Goal:

Reduce symptoms Maintain remission Prevent flares Prevent complications Prevent joint damage Prevent disability Maintain quality of life

• Treatment is tailored to individual Based on symptoms, concurrent conditions, lifestyle Treatment is usually continuous Combination of medication and non-medical therapy

• EARLY treatment is KEY to successful course

How is RA Treated?

• Over-the-counter or prescription

• Treats: Temporary relief of pain

and stiffness

• Side effects: Stomach ulcers, kidney/liver problems,

high blood pressure, heart disease

NSAIDs: Non-Steroidal Anti-Inflammatory Drugs

How is RA Treated?

• Suppresses immune system cells from forming and making antibodies to tissues

• Modifies disease

• Slow acting

• Oral, Injection

• Requires close monitoring

Immunosuppressive Therapy

How is RA Treated?

• Anti-inflammatory / Immune suppressing• Works rapidly• Oral or injection• Treats:

Joint pain Swelling

• Potential side effects: Weight gain, mood change, infections,

diabetes, high blood pressure, osteoporosis, cataracts

Steroids / Prednisone

How is RA Treated?

• Widely used, first-line medications

• Methotrexate• Leflunomide (Arava)• Sulfasalazine• Hydroxychloroquine (Plaquenil)

Disease Modifying Anti-Rheumatic Drugs

How is RA Treated?

• Treat: Joint pain Swelling, stiffness Reduces risk of progression and joint damage Prevents flares

• Potential side effects: Stomach upset, infection, hair loss, oral ulcers,

rash, low blood counts, inflammation of liver or lungs, vision problems

DMARDs

How is RA Treated?

• Second line therapies for more severe symptoms

• Have revolutionized treatment• Injectable or oral (new)• Mechanism of action

Bind to cells/molecules to stop inflammation, autoimmune signaling

• Potential side effects: Infection, rash, allergy, low blood counts, heart

failure, neurologic condition, skin cancer

Biologics

How is RA Treated?

• TNF inhibitors: Etanercept (Enbrel) Adalimumab (Humira) Infliximab (Remicade) Certolizumab (Cimzia) Golimumab (Simponi)

• Abatacept (Orencia)• Tocilizumab (Actemra)

Biologics

• Rituximab (Rituxan)• Tofacitinib (Xeljanz)

Nature.com, 2013

How is RA Treated?

• Arthrocentesis = joint injections Steroids Hyaluronic Acid

• Surgery: Joint replacement Joint fusion Tendon repair

Interventional Treatment

How is RA Treated?

• Exercise Low-moderate activities Stretching, strengthening Yoga, Pilates, Tai Chi

• Physical Therapy

• Bracing

• Acupuncture

Additional Treatment

How to Live Well with RA?

• How to: Maintain control of disease to prevent flares Avoid complications and associated risks Cope with the disease Feel healthy

• To lead an active, high quality life

How to Live Well with RA?

Follow-up with Rheumatologist Regularly:

• 2-6 months for monitoring

• Even if feeling well

• Recognize symptoms of flares

• Get treated early

• Take medications consistently

Follow-up with Your Doctors:

• Follow regularly for preventative care Internist/Primary care

• Follow with Specialists Ophthalmologist, Orthopedist, Cardiologist

• Planned surgery Best when low activity

How to Live Well with RA?

How to Live Well with RA?

Reduce Risk of Infections:

• Increased risk of infection

• Up to date with vaccines Influenza, Pneumonia, Shingles

• Wash hands frequently

• Stay away from people who are sick

• Get evaluated sooner rather than later

How to Live Well with RA?

Healthy lifestyle:

• Exercise

• Modify activities

• Don’t smoke

How to Live Well with RA?

Healthy Lifestyle:

• Manage fatigue Get enough sleep Rest during the day Plan your time effectively Medications

• Treat depression Reduce stress Social support

Arthritis.org.

How to Live Well with RA?

Healthy Lifestyle:• Eat well balanced diet• Weight loss • Vitamin D, Calcium• Omega-3 fatty acids• ? Avoid certain foods

• Alternative treatments/supplements – not well studied

How to Live Well with RA?

Planned Pregnancy:

• Ideally when in remission

• Many medications have to be stopped before pregnancy

• Usually symptoms improve during pregnancy

What’s New with RA?

• Tofacitinib (Xeljanz) Similar to biologics in effectiveness and side effects Targets inflammation pathway But, it’s oral

• Vectra-DA test for RA activity

• In development…

What’s New with RA?

• 65+ new medications in development for RA!

What’s New with RA?

• Ongoing research: Why RA develops Genetics of RA Biomarkers to better diagnose and predict

response to medication

For More Information

• Arthritis Foundation

• National Institute of Arthritis and Musculoskeletal and Skin Diseases

www.niams.nih.gov

• American College of Rheumatology www.rheumatology.org

Questions?Thank you!

Lauren Kennish, MD

Summit Medical Group

Rheumatology

908-273-4300

www.summitmedicalgroup.com

Facebook/SummitMedicalNJ

Twitter: @SummitMedicalNJ