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Rheumatoid Arthritis. Acknowledgements Dr. Andrew Thompson, rheumatologist at SJHC and developer of the UWO rheumatology medical school program.

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Presentation on theme: "Rheumatoid Arthritis. Acknowledgements Dr. Andrew Thompson, rheumatologist at SJHC and developer of the UWO rheumatology medical school program."— Presentation transcript:

1 Rheumatoid Arthritis

2 Acknowledgements Dr. Andrew Thompson, rheumatologist at SJHC and developer of the UWO rheumatology medical school program

3 Objectives Gain a basic understanding of Rheumatoid Arthritis Understand the presentation of Rheumatoid Arthritis (Inflammatory Arthritis) Understand the current treatment paradigm and medications used

4 Case Presentation 43 yo woman, has been healthy apart from: –C-Section for –Mild depression Her current medications are –Sertraline 100 mg per day (depression) –Naproxen 500 mg twice a day (recent joint pain)

5 Case Presentation 4 months ago developed pain in the left knee with some mild swelling. –The episode lasted a few days and then went away.

6 Case Presentation About a week later the right knee began to swell and become sore Then both wrists began to swell and become sore. She also noticed some soreness in her feet. About two weeks later her hands started to stiffen up and she couldn’t get her rings on.

7

8 Case Presentation She feels stiff when she wakes up in the morning and this stiffness lasts for at least 3 hours She has no energy and has missed the last week of work Her sleep is difficult because she is uncomfortable She isn’t running because it “hurts too much”

9 Differential Diagnosis INFLAMMATORY POLYARTHRITIS 1.Infection 2.Rheumatoid Arthritis 3.Seronegative Arthritis (Psoriatic) 4.Connective Tissue Disease (SLE etc) 5.Associated with another Systemic Disease

10 Who gets RA? ANYONE CAN GET RA –From babies to the very old Common Age to Start: 20’s to 50’s Sex: Females more common than males 3:1

11 How does RA start? RA usually starts off slowly (insidious) over weeks to months and progresses (70%) It can come on overnight (acute) but this is rare (10%) It can come on over a few weeks (subacute – 20%) Palindromic Presentation –RACECAR, RADAR, MOM, DAD

12 How does RA start? Initially, most patients notice stiffness of the joints which seems more pronounced in the morning Some fatigue Some pain

13 What Joints are affected? RA usually begins as an oligoarticular process (<5 joints) and progresses to polyarticular involvmement Has a predilection for the small joints of the hands and feet!

14 Small Joints of the Hand

15 What Joints are affected?

16 How are the Joints Affected Joints are usually –Swollen –Warm –NOT RED (might be a bit purple)

17 NO REDNESS!

18 Morning Stiffness Prominent Feature Greater than 60 minutes of morning stiffness (Patients minimize) Some patients have difficulty answering the question because they are stiff all day “How long does it take until you are the best you are going to be?”

19 Morning Stiffness Inflammatory fluid increases in and around the joint As patients get moving the fluid gets resorbed Stiffness can occur after rest “gelling”

20 Constitutional Features Fever – Unusual Weight Loss – Can be seen with severe polyarticular disease (again not common) Anorexia – Unusual Fatigue – VERY COMMON Sleep Disturbance – VERY COMMON –Musculoskeletal Reasons –Neurologic Reasons – Carpal Tunnel –Psychological Reasons – Worry about illness, finances, job, family etc.

21 Functional Status In the Rheumatology Clinic we use a Health Assessment Questionnaire (HAQ) –Dressing, Bathing, Grooming –Cooking, Cleaning, Shopping –Mobility – Walking and Standing –Working –Social Activities & Sports Rank the Functional Status (IMPORTANT) –Mild, Moderate, or Severe

22 Pleasure Work Cooking Cleaning Shopping Dressing Bathing Grooming

23 Rheumatoid Arthritis is … 1.Usually insidious in onset 2.Adds joints over time 3.Has a predilection for the small joints of the hands and feet 4.Joints become warm and swollen but not red 5.Morning stiffness is greater than 1 hour 6.Patients are often tired and don’t sleep properly 7.Can result in significant disability very quickly

24 Doesn’t just affect the joints EXTRA-ARTICULAR MANIFESTATIONS

25 Xerophthalmia (Dry Eyes)

26 Xerostomia (Dry Mouth)

27 Raynaud’s Phenomenon

28 Carpal Tunnel Syndrome

29 Pleural Effusion

30 Rheumatoid Nodules

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32 Rheumatoid Vasculitis

33 Extra-Articular Manifestations Sicca Features: Xerostomia & Xerophthalmia Raynaud’s Phenomenon Neuropathy: Carpal Tunnel Syndrome Rheumatoid Nodules Pleural Effusions Rheumatoid Vasculitis

34 Tests, Tests, Tests INVESTIGATING A PATIENT WITH SUSPECTED RA

35 CASE SUMMARY Has a 4 month history of an inflammatory polyarthritis Nothing else on history or physical examination to suggest an associated connective tissue disorder or seronegative spondyloarthropathy.

36 INFLAMMATION Complete Blood Count (CBC) –Hemoglobin: May be anemic (normocytic) –WBC: Should be normal –Platelets: May be normal to elevated Erythrocyte Sedimentation Rate (ESR) C-Reactive Protein (CRP)

37 ORGAN FUNCTION TO MAKE SURE MEDS WILL BE SAFE Renal Function –Creatinine + Urinalysis Liver Enzymes –AST, ALT, ALP, ALB –Hepatitis B & C Testing Consider baseline Chest X-Ray

38 ANTIBODIES Rheumatoid Factor Anti-Nuclear Antibody

39 Rheumatoid Factor IgG Molecule Fc Portion Antigen Binding Groove IgM Molecule Autoantibodies (IgM) directed against the Fc Fragment of IgG An Antibody to an Antibody Their Role in RA is not understood

40 Rheumatoid Factor Rheumatic Disease Sjogren’s syndrome Rheumatoid Arthritis SLE MCTD Myositis Cryoglobulinemia Non- Rheumatic Disease Normal Aging Infection –Hepatitis B & C –SBE –Tb –HIV Sarcoidosis Idiopathic Pulmonary Fibrosis

41 Rheumatoid Factor (RF) Question: What Percentage of New Onset RA will have a positive RF? Answer: 30-50% Question: What Percentage of Established RA will have a positive RF? Answer: 70-85% NOT USEFUL FOR DIAGNOSIS OF RA

42 Pearls about RF in RA 1.Asymptomatic people with a positive RF are unlikely to go on to develop RA 2.The higher the value the greater the likelihood of rheumatic disease 3.USEFUL for PROGNOSIS 1.Patients who are RF +ve are more likely to have aggressive disesase 4.NOT USEFUL to FOLLOW TITRES 1.Not predictive of flare 2.Not predictive of improvement

43 RADIOGRAPHIC FINDINGS IN RA

44 Periarticular Osteopenia Joint Space Narrowing Erosions Mal-Alignment

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46 SYNOVIAL FINDINGS IN RA

47 Rheumatoid Synovium A non-suppurative (no pus) inflammatory infiltrate in the synovium Due to the aggregation of lymphocytes and plasma cells

48 Rheumatoid Synovium

49 PRINCIPLES OF TREATMENT

50 The Big Bang 90% of the joints involved in RA are affected within the first year SO TREAT IT EARLY

51 Disability in Early RA Inflammation –Swollen –Stiff –Sore –Warm Fatigue Potentially Reversible

52 Disability in RA Most of the disability in RA is a result of the INITIAL burden of disease People get disabled because of: –Inadequate control –Lack of response –Compliance GOAL: control the disease early on!

53 A Fire in the Joints If there’s a fire in the kitchen do you wait until it spreads to the living room or do you try and put it out?

54 Clinical Course of RA Type 1 = Self-limited—5% to 20% Type 2 = Minimally progressive—5% to 20% Type 3 = Progressive—60% to 90% Years Severity of Arthritis Pincus. Rheum Dis Clin North Am. 1995;21:619.

55 Why is Early Treatment Important? Joint Damage Occurs EARLY –93% of patients with less than 2 years of disease have radiographic abnormalities –Rate of radiographic progression is higher in the first 2 years of disease Disability Occurs EARLY –50% out of work at 10 years Increased MORTALITY –With severe disease

56 Why is Early Treatment Important? EARLY Treatment has Long-Term Beneficial Effects –WINDOW OF OPPORTUNITY –Delay of 4 months can have long-term effects

57 Disability in Late RA (Too Late) Damage –Bones –Cartilage –Ligaments and other structures Fatigue Not Reversible

58 Induce Remission Maintain Remission

59 DMARDs Disease Modifying Anti-Rheumatic Drugs Reduce swelling & inflammation Improve pain Improve function Have been shown to reduce radiographic progression (erosions)

60 DMARDs Methotrexate Sulfasalazine Hydroxychloroquine (Plaquenil) Leflunomide (Arava) Gold Azathioprine (Imuran)

61 Combining DMARDs DMARDs all work slightly differently Never truly know how a patient will respond to an individual DMARD Most clinicians now agree that combinations of DMARDs are more effective than single agents This is now supported by some research

62 Combination therapy (using 2 to 3) DMARDs at a time works better than using a single DMARD

63 Common DMARD Combinations Triple Therapy –Methotrexate, Sulfasalazine, Hydroxychloroquine Double Therapy –Methotrexate & Leflunomide –Methotrexate & Sulfasalazine –Methotrexate & Hydroxychloroquine –Methotrexate & Gold –Sulfasalazine & Plaquenil

64 Case Study Began therapy with Methotrexate, Sulfasalazine, & Plaquenil Initially responded well and took them for 4 months On a friends “advice”, stopped all DMARDs in favour of “natural” therapy “Natural” therapy was a dismal failure Triple therapy re-instituted – difficulty obtaining adequate control

65 Case Study Change DMARDs – Add leflunomide Biologic Therapy

66 BIOLOGIC THERAPY

67 Tumour Necrosis Factor (TNF) TNF is a potent inflammatory cytokine TNF is produced mainly by macrophages and monocytes TNF is a major contributor to the inflammatory and destructive changes that occur in RA Blockade of TNF results in a reduction in a number of other pro-inflammatory cytokines (IL- 1, IL-6, & IL-8)

68 Macrophage Any Cell Trans-Membrane Bound TNF TNF Receptor Soluble TNF How Does TNF Exert Its Effect?

69

70 Any Cell Trans-Membrane Bound TNF TNF Receptor Soluble TNF How Are the Effects of TNF Naturally Balanced? Soluble Receptor Macrophage

71 Trans-Membrane Bound TNF Soluble TNF Strategies for Reducing Effects of TNF Macrophage Monoclonal Antibody (Infliximab & Adalimumab)

72 Infliximab (Remicade®) & Adalimumab (Humira®) Chimeric (murine & human) monoclonal antibody directed against TNF-α

73 Trans-Membrane Bound TNF Soluble TNF Strategies for Reducing Effects of TNF Macrophage Soluble Receptor Decoy (Etanercept)

74 Etanercept (Enbrel®) 2 soluble p75receptors attached to the Fc portion of the IgG molecule

75 Biologics Monoclonal Antibodies to TNF –Infliximab (Remicade®) –Adalimumab (Humira®) Soluble Receptor Decoy for TNF –Etanercept (Enbrel®) Receptor Antagonist to IL-1 –Anakinra (Kineret®) (rarely used) Monoclonal Antibody to prevent T-Cell Signaling –Abatacept (Orencia®) Monoclonal Antibody to CD-20 –Rituximab (Rituxan®)

76 Side Effects Infection –Common (Bacterial) –Opportunistic (Tb, Histo) Demyelinating Disorders Malignancy Worsening CHF Blood Counts

77 Do they work? Resounding YES! Outcome measured by ACR20 –20% reduction in swollen & tender joints –Plus 20% reduction in at least 3 of the following: Patient VAS pain Physician global VAS Patient global VAS HAQ ESR or CRP

78 SUMMARY Rheumatoid Arthritis is a chronic potentially debilitating illness Early treatment can have a PROFOUND effect on this disease Treatment is multidisciplinary


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