2. Emily Iseman Intern Mentor Program Mount Hebron High School Arthritis Care Specialists of Maryland Mentor: Kathleen Skolnik

3. Upcoming Information  Rheumatoid Arthritis  Treatment Options  Biologic Drugs  Arthritis Care Specialists of Maryland  Surveying the Patients  Conclusions Drawn

4. Rheumatoid Arthritis  Autoimmune  Pain, swelling, stiffness  Medications: Oral Subdermal Injections Intravenous  ACR 20 20% decrease in swelling 20% decrease in pain & disability

5. Methotrexate  Liver toxicity  Immune suppressant  Disease Modifying Antirheumatic Drug

6. Biologic Drugs  Attack the immune system  Animal proteins

7. Remicade  TNF-inhibitor (TNF attacks healthy tissue)  1 st line of infusions used

8. Orencia  T cell inhibitor (reduces inflammation, swelling & pain)  2 nd line of infusions used

9. Actemra  Blocks interleukin 6 (reduces inflammation  3 rd line of infusions used

10. Arthritis Care Specialists of Maryland  Mentor: Kathleen Skolnik  Priming IV Tubing  Setting up Trays  Monitoring Patient Vitals  Developing Relationships with Patients

11. Surveying Patients  Gender  Age  Current Biologic  Past Biologics  Methotrexate?  Pain and Mobility  HAQ 20-item Disability Scale

13. Results - Remicade  Remicade and Methotrexate (18) Average HAQ-.885 HAQ = 0 – 3 Pain improved w/ MTX? - 3 Mobility Improved w/ MTX? - 10  Remicade (12) Average HAQ-.139 HAQ = 0 – 4 Pain improved w/ MTX? - 0 Mobility Improved w/ MTX? - 0

14. Results - Orencia  Orencia and Methotrexate (4) Average HAQ-.25 HAQ = 0 – 1 Pain improved w/ MTX? - 1 Mobility Improved w/ MTX? - 2  Orencia (1) Average HAQ- n/a HAQ = 0 – n/a Pain improved w/ MTX? – no difference Mobility Improved w/ MTX? – no difference

15. Results - Actemra  Actemra and Methotrexate (3) Average HAQ- 1.25 HAQ = 0 – 1 Pain improved w/ MTX? - 0 Mobility Improved w/ MTX? - 0  Actemra (2) Average HAQ- 1.875 HAQ = 0 – 0 Pain improved w/ MTX? – no difference (2) Mobility Improved w/ MTX? – no difference (2)

16. What am I doing with this?  Pamphlet!  Presenting Pamphlet to doctors/nurses at my internship

17. Conclusion  Methotrexate does not need to be paired with Remicade or Actemra (no difference or better feelings and HAQ), and there was not enough information collected to determine the difference with Orencia

19. Works Cited  Arthritis Foundation. "Treatment Guides." Arthritis Today. Arthritis Foundation, 2013. Web. 11 Dec. 2013.  Arthritis Foundation. "What Is Rheumatoid Arthritis?" Arthritis Today. Arthritis Foundation, 2013. Web. 11 Dec. 2013.  American College of Rheumatology. "Tocilizumab (Actemra)." American College of Rheumatology. American College of Rheumatology, Mar. 2013. Web. 21 Nov. 2013.  Arnett, DK, Bridges, SL, Brown, EE, Danila, MI, Halilova, KI, Hwang, MH, and Morgan, SL. "Markers of Treatment Response to Methotrexate in Rheumatoid Arthritis: Where Do We Stand?" International Journal of Rheumatology 2012 (n.d.): n. pag.EBSCOhost. Medline, 9 July 2012. Web. 23 Sept. 2013.  Bingham, Clifton. "Remicade without Methotrexate?" Johns Hopkins Arthritis Center. Johns Hopkins, 26 Sept. 2011. Web. 18 Dec. 2013.  Bristol-Myers Squibb. "Indications and Important Safety Information for ORENCIA® (abatacept)." ORENCIA® (abatacept) Official Site. Bristol-Myers Squibb, Sept. 2013. Web. 13 Nov. 2013.  "C-Reactive Protein (CRP)." WebMD. WebMD, 18 Mar. 2010. Web. 16 Oct. 2013.  Dowshen, Steven. "Blood Test: Comprehensive Metabolic Panel." Kids Health. Nemours, Feb. 2011. Web. 2 Oct. 2013.  "Drug-Induced Hepatotoxicity." Drug-Induced Hepatotoxicity. WebMD, n.d. Web. 24 Mar. 2014.  Genentech. "Proven to Help Relieve Symptoms." ACTEMRA (tocilizumab). Genentech, 2013. Web. 06 Nov. 2013.  George, Stephen W. "Methotrexate at Arthritis Care Specialists of Maryland." Personal interview. 22 Oct. 2013.  Healthwise. "Complete Blood Count (CBC): Results and Interpretation." WebMD. WebMD, 03 Aug. 2010. Web. 23 Oct. 2013.  Jones, G., A. Sebba, J. Gu, M. Lowenstein, A. Calvo, J. Gomez-Reino, D. Siri, M. Tomsic, E. Alecock, T. Woodworth, and M. Genovese. "Comparison of Tocilizumab Monotherapy versus Methotrexate Monotherapy in Patients with Moderate to Severe Rheumatoid Arthritis: The AMBITION Study." Ann Rheum Dis 69.01 (2010): 69+. Http://ard.bmj.com/. BMJ Publishing Group Ltd & European League Against Rheumatism, 19 Feb. 2009. Web.  Jones, Kelly W., and Supen R. Patel. "A Family Physician's Guide to Monitoring Methotrexate." A Family Physicians' Guide to Monitoring Methotrexate. American Family Physician, 1 Oct. 2000. Web. 25 Sept. 2013.  Kavanagh, Ronan. "Methotrexate." YouTube. Western Rheumatology, 17 Feb. 2012. Web. 28 Oct. 2013.  "Methotrexate (Anti-Rheumatic) Oral." WebMD. WebMD, 2013. Web. 09 Oct. 2013.  "Methotrexate." Livertox. National Library of Medicine, 18 July 2013. Web. 25 Sept. 2013.  "Remicade Medication Guide." Remicade.com. Janssen Biotech, Inc., 29 July 2013. Web. 12 Sept. 2013  Skolnik, Kate. Personal interview. 2 Oct. 2013.  Walsh, Nancy. "Methotrexate Not Needed with Actemra in RA." MedPage Today. MedPage Today, 18 Nov. 2011. Web. 04 Dec. 2013.