Treatment of Rheumatoid ArthritisTreatment of Rheumatoid ArthritisThen and NowThen and Now

Objectives:Objectives:

1. Outline the diagnostic criteria for Rheumatoid Arthritis, its systemic manifestation, and the complication of untreated RA.

2. Identify and discuss laboratory tests that aid in the diagnosis of RA.

3. Explain the differences between oral disease modifying anti-rheumatic medications and biologic medications, including medication risks and safety profiles.

Pathophysiology

Rheumatology Nurse Newsletter Volume2:2

Cytokines

Rheumatology Nurse NewsletterVolume 2:2 Summer 2009

Paradigm shift in the treatment Paradigm shift in the treatment of rheumatoid and of rheumatoid and

inflammatory Arthritisinflammatory Arthritis

THEN…THEN…

Mary’s StoryMary’s Story31 year old female who presents to the

Beals Institute in 1982 with five year history of RA

Disability at age 27First joint replacement surgery at age

29

Mary’s treatments: Tried and Mary’s treatments: Tried and Failed Failed

• 24 aspirin daily• Cyclosporin (Neoral)• Plaquenil

(Hydroxychloroquine)• Injectable Gold• Methotrexate• Azulfidine

• Enbrel (Etanercept)• D-penicillamine• Prednisone• NSAIDs• Plasmaphoresis• Arava (Leflunomide)

Mary’s NumbersMary’s Numbers3 reconstructive hand surgeries last one 20071 wrist fusion2 hip replacements2 total knee replacements1 elbow replacement1 ulnar fracture repair and prosthetic repair> 10 hospitalizations for flares of uncontrolled

disease process

AND NOW…AND NOW…

Initiate Therapy• Patient Education• Start DMARD(s) Within 3 Months (Table 2)• Consider NSAID• Consider Local or Low-Dose Systemic Steroids• Physical Therapy/Occupational Therapy

Periodically Assess Disease Activity (Table 3)

Inadequate Response (i.e., ongoing active disease after

3 months of maximal therapy)

Adequate Responsewith Decreased Disease

Activity

• Establish Diagnosis of Rheumatoid Arthritis Early• Document Baseline Disease Activity and Damage (Table 1)• Estimate Prognosis (See Text)

Change/Add DMARDs (Tables 2, 4, and 5)

MTX Naive Suboptimal MTX Response

MTX Other CombinationMono Rx Rx

CombinationMono RxRx

Other Biologics

Mono Combination

Rx Rx

Multiple DMARD Failure

SymptomaticAnd/or Structural

Joint Damage

Surgery

Figure 1. Outline of the management of rheumatoid arthritis. Each step is detailed in the text. Boxes with heavy borders represent major decision points in management. A suboptimum response to methotrexate (MTX) is defined as intolerance, lack of satisfactory efficacy with a dosage of up to 25 mg/week, or a contraindication to the drug. DMARD = disease-modifying antirheumatic drug; NSAID = nonsteroidal antiinflammatory drug; mono Rx = monotherapy; combination Rx = combination therapy.

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…Now

Abigail’s StoryAbigail’s Story

34 year old presents in 2005 with shoulder, wrist and hand pain for 2 months

Started on combination therapy using Arava and Enbrel

Due to diarrhea and weight loss, changed to Methotrexate and Enbrel

Abigail’s NumbersAbigail’s Numbers0 days missed work due to disability0 hospitalizations, surgeries and joint

replacements due to RA5K - the length of the races she runs

regularly

Why Is Early Diagnosis and Why Is Early Diagnosis and Treatment Imperative?Treatment Imperative?

•Rheumatoid arthritis progression is the most rapid in the first two years of disease onset •75% of joint damage will occur within the first five years of disease onset.•Rheumatoid Arthritis is as lethal as lymphoma if left untreated!

Diagnostic Criteria for RADiagnostic Criteria for RA>4 of the following must be present Morning stiffness > 1 hour > 3 joints involved Symmetrical swelling; usually in hands,

wrists and MTP joints in feet Rotating joint pain Positive Rheumatoid Factor

(Note: 20% of patients with RA

will not test positive) Positive CCP Erosive joint changes on x-ray RA nodules

Complications of Untreated RAComplications of Untreated RA

Pulmonary fibrosis Disability Deformity ↓ QOL ↑ morbidity and

mortality

All Slides (c) Current Medicine

Clinical PearlClinical Pearl

Hepatitis C presents with identical symptomatology and will cause the Rheumatoid Factor to be positive..

Labs Eval: ArthritisLabs Eval: Arthritis SPEP Sed rate CBC CCP RF HLA-B27

CRP Hepatic panel ANA, ENA, DNA Hepatitis panel Vitamin D

Treatment: NSAIDsTreatment: NSAIDs Celebrex Relafen Lodine Arthrotec Feldene

Voltaren Mobic Indocin Daypro Colchicine

Treatment: DMARDsTreatment: DMARDs

Methotrexate Arava (Leflunomide) Plaquenil

(hydroxychloroquine) Azulfidine (sulfasalazine)

Imuran (azathioprine) Minocin (minocycline) Gold (myochrysine) Neoral (cyclosporine)

Treatment: Biologic AgentsTreatment: Biologic Agents

IL-1 antagonist– Kineret: sc daily

TNF inhibitor– Enbrel: sc 1-2 times/week– Humira: sc 2 times a month– Remicade: IV q 6 to 8 weeks– Simponi: sc q month– Cimzia: sc q month

T-cell inhibitor– Orencia: IV q month

B-cell inhibitor– Rituximab: IV load, 2 weeks then PRN

Contraindications of Biologic Agents

Active Lupus Tuberculosis Active infection Hypogammaglobulinemia Hepatitis B / C CHF III & IV Demyelinating Disorder

A Happy Ending?A Happy Ending?

In January 2004 Mary started Humira Continued Methotrexate, Gold, and

episodic prednisone for flaresSince that time, she has avoided

hospitalization and disease has been more consistently in remission.

SummarySummaryRefer to rheumatology early and treat

aggressivelyRheumatoid arthritis and inflammatory

arthritis shorten the patient’s life expectancy if left untreated

Many treatment options exist and treatment can be tailored to the patient’s needs.