Presentation on theme: "Evidence-Informed Best Practices Rheumatoid Arthritis"— Presentation transcript:
1 Evidence-Informed Best Practices Rheumatoid Arthritis OsteoarthritisDr. Diane Lacaille
2 ObjectiveDescribe the rationale for key recommendations for best practice care for Rheumatoid Arthritis and Osteoarthritis according to the BC Guidelines.
3 Rationale for recommendations in guidelines Rheumatoid ArthritisEarly diagnosis and early treatment with DMARDsPrevention of joint damageManagement of co-morbiditiesMonitoring of disease activityOsteoarthritisReduction of painImprovement of functionOptimization of conservative careAppropriate and timely referral for surgical intervention
5 EARLY Treatment of RA with DMARDs EARLY DIAGNOSIS AND TREATMENT OF RAAGGRESSIVE USE OF DMARDS ALTERS THE COURSE OF RAREMISSION IS THE NEW TARGET OF RA TREATMENTLONG TERM USE OF DMARDSYES, DMARDS ARE SAFE WHEN MONITORED REGULARLYThis is the new standard of care.
6 RA is Not a Benign Disease If not controlled, RA inflammation leads to:joint damage and joint deformitiesprogressive loss of physical functionwork disability (32-50% after 10 years of RA)premature mortality, mainly from cardiovascular disease (50% increase in risk of death from CVD)All these outcomes are preventable.
7 Persistent Joint Swelling Leads to Joint Damage & Deformities =>If left untreated, swelling that persists over time leads to joint deformities
8 Early Diagnosis & Treatment of RA Recognizing signs of inflammation – clues pointing to RAEarly morning stiffness > 30 minutesWorse pain in the morning and post immobilitySwelling of small jointsPain or tenderness on squeezing the MTPs, MCPs or wristsSymmetrical involvementSystemic symptoms, such as fatigueRuling out other diagnosisSeptic arthritis, especially if monoarthritisCrystal arthritis, such as gout or pseudogoutJoint aspiration for acute monoarthritis to R/O infection or when crystal arthritis is suspectedTransient inflammatory arthritis (viral) < 6 weeksOther inflammatory arthritis, also Rx with DMARDsEARLY
9 E AR L Y Early Diagnosis & Treatment of RA Early treatment of RA Capture the window of opportunityEarly treatment with DMARDs alters the disease course.Joint damage occurs early (within months) and is irreversible.RA is more responsive to treatment early on.Early treatment increases the chances of remission.New onset RA requires urgent careDMARDs should be started within 2 months of symptoms.Referral to a rheumatologist for new onset RA should be seen within 4 weeks. State ‘new onset of RA’ on referral.Rheumatologists prefer early referrals.
10 Aggressive use of DMARDs Alters the course of RA YWhat are DMARDs?Disease Modifying Anti-Rheumatic DrugsThey improve symptoms and prevent joint damage.Methotrexate, Sulfasalazine, Hydroxychloroquine, Gold, Cyclosporine, Leflunomide and biologic agents.Think RA, think DMARDsAll RA patients with active inflammation should be on a DMARD.NSAIDs and prednisone are not enoughNSAIDs improve symptoms but fail to prevent joint damage.Prednisone should not be used alone because of long term toxicities
11 Role of steroids in RAMinimize steroids dose and duration, because of long term risks, esp. cardiovascular diseasesOral steroids do have a role:Small doses (< 10 mg daily), over short periodsBridging therapy, while waiting for DMARDsEarly on at time of RA onset, but avoid prior to rheumatologist referral for diagnosis bcse masks signs.To control flare-upsIntramuscular (40 mg depomedrol) and intra- articular are good alternatives to oral.If steroids are needed to control disease, then DMARDs need to be adjusted
12 E AR L Y Aggressive Use of DMARDs Alters the Course of RA DMARDs alter the course of RA by:Preventing joint damage and deformitiesReducing physical and work disabilityPreventing premature mortalityAggressive use of DMARDs means:Starting DMARDs earlyUsing DMARDs continuously, often in combinationEvaluating response every 1 to 3 monthsModifying DMARD therapy until the target is reachedAiming to eradicate inflammation
13 E AR L Y Remission is the new target of RA treatment The goal of RA treatment is no longer to simply control symptoms, but to eradicate inflammation.The target of DMARD therapy is no signs of activeinflammation i.e.,No swollen jointsNormal ESR or CRPLittle to no radiographic progressionAlthough remission is the target, minimal disease activity may be an acceptable alternative, when remission is not possible, especially in established long-standing disease, or when co-morbidities or other patient factors limit DMARD options.
14 E AR L Y Long-term use of DMARDs DMARDs should be used continuously, throughout the disease.When sustained remission is achieved, DMARDs may be slowly decreased to find a lower dose that maintains remission.DMARD discontinuation is not recommended because of high risk of flare off DMARDs.All RA requires DMARD, the earlier the better, but even late RA requires DMARDs to reduce further damage.
15 E AR L Y Yes DMARDs are safe when monitored regularly RisksBenefitsreduce mortalityreduce disabilityprevent deformityimprove symptomscosttoxicityBenefits of early DMARDs outweigh their risks
17 EARLY is the new standard of care Family physicians play a critical role in early diagnosis and treatment of RA.DMARDs should be prescribed in all RA patients and should be started early.
18 Treatment of RA the standard of care has changed DMARDsNSAIDS
19 Management of Established RA Objective:Suppress inflammation, prevent joint damageTaskFamily DoctorRheumatologistMonitorQ 2-6 monthsQ 6-12 monthsAssess disease activity(Joint Count + Blood Work)Review Meds, S/E Adherence/ DosageRefer to PT/OTReview/adjust medsRating of Disease Activity for decision-makingAssess Joint DamagePain ReliefRefer PT/OT, surgerysameReview for Co-morbiditiesScreen and TreatReinforce monitoring processUse of Dosage chartsPatient may have combined active inflammation and joint damage
22 Osteoarthritis (OA) Features suggestive of OA: Absence of inflammatory features: morning stiffness < 30 min; gelling < 5 min; minimal swelling & heat; no redness.Pain worse with activity, better with restAdvanced OA => constant pain including at restAbsence of systemic symptomsGradual onsetHistory of prior injury (e.g. knee), prior deformity / malalignementJoint distribution: hips, knees, C & L spine, hands: DIP, PIP, 1st CMC, 1st MTP.Bony enlargement, crepitus, malalignementIf joint swelling, synovial fluid non-inflammatory, no crystals.
23 Joint Distribution Black= joints most commonly affected Grey= joints often affectedWhite= joints usually not affected
24 Other Diagnoses to Exclude Septic arthritis (acute monoarthritis requires joint aspiration)Crystal arthritis: gout, pseudogout (CPPD) (joint aspiration)Inflammatory arthritis: esp. psoriatic arthritisNon-articular : e.g. bursitis (trochanteric, pes anserine), tendonitis (shoulder, elbow)Bone pain (multiple myeloma, metastasis)Soft tissue pain syndromesReferred pain
25 Investigations X Rays Provide clinical information Can be normal in early OAOften don’t correlate with degree of painKnee Xrays must be ordered weight bearing (PA, lat, skyline)Hip (OA hip series: incl. lateral view and upper 1/3 femur)Absence of inflammatory markers (CBC, CRP normal)Labs can be useful to rule out other conditions (e.g. thyroid disease) or to assess for comorbidities prior to Rx (e.g. Cr, LFT)
26 Management - Considerations Severity of pain (with activity, at rest, interferes with sleep)Impact on function (ADLs, IADLs)Impact on participation (work, family obligations, social activities, leisure)Impact on independencePsychosocial issues (pain amplification, coping strategies, depression, adherence to treatment, social support)
27 Patient Education (OA and RA) GuidelinesPatient SupportFamily SupportCommunity SupportPatient Self Management (coping with pain and other arthritis symptoms, stress, lifestyle changes e.g. exercise).Arthritis Self Management Program (ASMP) and CDSMP.
28 Management – Non pharmacological Patient educationSelf-managementWeight management – support, dieticianExercise (ROM, strengthening, aerobic)Physiotherapy: prescribe specific therapeutic exercise programWalking aidsOccupational therapy: Orthotics, footwear, braces, splints, ADL aids, ergonomic modifications at work
29 Management - Pharmacological Acetaminophen:regular schedule vs. prnup to 4 gm/day, less if liver diseaseNSAIDs:Gastroprotection if high GI riskConsider cardiovascular risk factorsTopical NSAIDsGlucosamine and chondroitin sulfate:Not recommended, insufficient evidence of efficacyIntra-articular steroidsHyaluronic acid – limited benefit, can cause inflammatory reaction
31 Summary Differentiating inflammatory from non-inflammatory arthritis Importance of early diagnosis and DMARD treatment in RAMonitoring of disease activity to achieve treatment targetGoal of preventing joint damage, consequences of inflammationManagement of pain, improvement of function in OAWeight management, exercise and rehab in OAMultidisciplinary care of arthritisAppropriate and timely referral for surgeryManagement of co-morbidities, esp. cardiovascular diseasesNeed for shared approach to careImportance of patient education and self-management