Living with Rheumatoid Arthritis

Presented by:

Lauren Kennish, MD

Rheumatologist

May 6, 2015

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: 0.5-1% population, about 1.5 million

• 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, Symptoms, Exam

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

Medscape.com

How is RA Diagnosed?

• Imaging Xray MRI Ultrasound

Copyright ACR, 2013

What are the Symptoms of RA?

• Joint pain and swelling Small joints, symmetric

• Morning stiffness > 1 hour

• Difficulty with activities

Copyright ACR, 12/2013

Arthritis.org, 12/2013

What are the Symptoms of RA?

• Joint Damage

Copyright ACR, 12/2013

What are the Symptoms of RA?

• Fatigue

• Anemia

• Skin nodules

• Inflammation – Eyes Blood vessels Lungs Heart

Copyright ACR, 12/2013

Associated Autoimmune Diseases

• Sjogren’s Syndrome

• Hashimoto’s Thyroiditis (Hypothyroidism)

Webmd.com

Associated Conditions• Osteoarthritis

• FibromyalgiaWebmd.com, 2013Copyright ACR, 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

Copyright ACR, 2013

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, complications Prevent joint damage, 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

How is RA Treated?

• Use: Temporary relief of pain and stiffness

• Mechanism: Anti-inflammatory

• 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• Oral, Injection• Requires close

monitoring

Immunosuppressive Therapy

How is RA Treated?

• Use: Joint pain and swelling

• Mechanism: Anti-inflammatory, Immune suppressing

• 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?

• Use: Joint pain Swelling, Stiffness Reduce risk of progression and joint damage Prevent flares

• Mechanism: Immune suppressing, Disease modifying

• 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?

• Use: Joint pain, swelling, stiffness Reduces risk of progression and joint damage Prevents flares

• Mechanism: Specifically targets molecules of the immune system, Immunesuppressing

• 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)• Rituximab (Rituxan)• Anakinra (Kineret)

Biologics

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 and Selfcare:• Exercise • Don’t smoke

• Heat/Cold therapy• Topical therapies• Modify activities

How to Live Well with RA?Healthy Lifestyle:• Manage fatigue

Get enough sleep Rest during the day Plan your time effectively Medications Exercise

• Treat depression Reduce stress Social support Positive attitude Arthritis.org.

How to Live Well with RA?

Healthy Lifestyle:• Healthy well balanced diet• Mediterranean diet• Weight loss • Calcium, Vitamin D• 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• Higher risk of preterm birth • Usually symptoms improve during

pregnancy

What’s New with RA?• Tofacitinib (Xeljanz) – JAK inhibitor

Use: Similar to biologics in effectiveness and side effects

Mechanism:• Oral disease modifying medication• Targets inflammation signaling

pathway

• Biosimilars• Blood tests

14-3-3 ETA test for early diagnosis Vectra-DA test for RA activity

Nature.com

cell

What’s New with RA?

• 65+ new medications in development for RA!

http://www.ahdbonline.com/issues/2014

• Barcitinib – JAK1/2 inhibitor – Phase IIb trial

• Decernotinib – JAK 3 inhibitor – Phase II trial

• Mavrilimumab – anti-GM-CSF receptor – Phase II trial

• Sarilumab – Il-6 inhibitor – Phase III

• Secukinumab – Il-17 inhibitor – Phase III

What’s New with RA?

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

response to medication Curative treatments

What’s New at SMG?

• Best Practices in Managing Patients with Rheumatoid Arthritis Learning Collaborative

American Medical Group Foundation Advance the care of those with rheumatoid

arthritis for better diagnosis, treatment and monitoring

For More Information

• Arthritis Foundation www.arthritis.org

• National Institute of Arthritis and Musculoskeletal and Skin Diseases

www.niams.nih.gov

• American College of Rheumatology www.rheumatology.org

• Patient Perspectives

• Questions?

Thank you!

Lauren Kennish, MD

Summit Medical Group

Rheumatology

908-277-8640

www.summitmedicalgroup.com

Facebook/SummitMedicalNJ

Twitter: @SummitMedicalNJ