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Rheumatoid Arthritis 8 th September 2005 South Worcestershire VTS Dr A Walder.

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Presentation on theme: "Rheumatoid Arthritis 8 th September 2005 South Worcestershire VTS Dr A Walder."— Presentation transcript:

1 Rheumatoid Arthritis 8 th September 2005 South Worcestershire VTS Dr A Walder

2 Is a lifelong progressive disease that produces significant morbidity, and premature mortality in some 50% have to stop work after 10y

3 Epidemiology May present at any age Commonly, late child bearing age in females, and 6 th -8 th decade in males Affects 1% of population

4 Pathology Symmetrical deforming polyarthropathy, affecting the synovial membrane of peripheral joints Has a genetic component, but many do not have a FHx

5 Presentation May have a fulminant onset, but commonly insidious over weeks to months Classically small joints initially – PIPs, MCPs, MTPs Pain, swelling, stiffness – esp early morning Can affect any synovial joint - may involve TMJ, cricoarytenoids, or SCJs Spares DIPs (cf OA & psoriatic arthritis) May involve C1-2 articulation – rarely affects the rest of the spine

6 O/E Early -> boggy warm joints in typical distribution Hands – ulnar devation, swan neck & boutonieres deformity, tendon rupture Wrists – radial devation, volar subluxation, synovial proliferation may compress median nerve Feet – sublux at MTPs, skin ulceration, painful ambulation Large joints – affects whole joint surface in symmetrical fashion eg med & lat compartment of knees Synovial cysts eg Bakers cyst of the knee, ganglions

7 Extra –articular manifestations Common: Fatigue, wt loss, low grade fever Subcutaneous nodules; –almost exclusively sero-positive pts –thought to be triggered by small vessel vasculitis Carpel & tarsal tunnel syndromes Capsulitis eg shoulder Increased mortality & morbidity from CVS dx if have RhA Uncommon: Polyartritis nodosa-like vasculitis Pyoderma gangrenosum Pericardial effusions Pulmonary effusions Diffuse interstitial fibrosis Scleritis Mononeuritis multiplex C1-2 -> myelopathy

8 Bloods Anaemia of chronic disease ESR^ + CRP ^ - acute phase reactants –CRP is more specific than ESR –Not always ^ in small joint dx RhF - +ve in 50% Include U+Es, LFTs pre-DMARD use

9 Radiology Xray hands (include wrists) and feet Loss of joint space Soft tissue swelling Erosions – partic look 5 th MC & MT & ulnar styloid, & scaphoid/trapezium Peri-articular osteoporosis Joint destruction

10 Differential Diagnosis Viral syndromes – hep B or C, EBV, parvovirus, rubella Psoriatic arthritis Reactive arthritis Enteropathic arthritis Tophaceous gout Ca pyrophoshate disease (pseudogout) PMR OA SLE Hypothroid association Sarcoidosis Lyme disease Rheumatic fever

11 Diagnosis Distribution of joint involvement Morning stiffness Active synovitis. Inflammation (swelling, warmth, or both) on examination Symptoms for > 6 weeks RhF, ESR, CRP

12 Diagnosis ( American College of Rheumatology) Morning stiffness* Arthritis of 3 joint areas* Arthritis of hands* Symmetric arthritis* Sero +ve Radiological changes * for greater than 6 weeks

13 Who to refer >12w 3 or more joints Skin rash - ? vascultis

14 Treatment To relieve pain & inflammation Prevent joint destruction Preserve / improve function

15 Treatment Early diagnosis is essential Aim to treat with DMARDs at 3 months Once RA damage is done radiologically, it is largely irreversible. This usually occurs within first 2 years of the disease The goal is to put the disease into remission

16 MDT GP Rheumatologist Specialist rheumatology nurses + help line Physio + hydrotherapy OT Pharmacist Phlebotomist

17 NSAIDs Symptom relief Minimal role in altering disease process

18 Gluccocorticoids Symptom relief Some slowing of radiological progression Prednisolone > 10mg/d is rarely indicated Avoid using without a DMARD Use to bridge effective DMARD therapy Minimise duration and dose Always consider osteoporosis prophylaxis

19 Methotrexate Oral 7.5mg - ^ by 2.5mg every 6w to max 25mg. ONCE WEEKLY (allows liver to recover) Is an anti-metabolite, cytotoxic drug, which inhibs DNA synthesis & cellular replication Lower dose in elderly & renal impairment as its renally excreted Folic acid (3d after methotrexate) thought to decrease toxicity Avoid cotrimoxazole, trimethoprim, XS ETOH, live vaccines Give annual flu jab Can be given subcut if oral absorption poor

20 Methotrexate cont….. SEs: oral ulcers, nausea, hepatotoxicity, bone marrow suppression, pneumonitis All respond to dose reduction except pneumonitis Stop 3/12 before pregnancy – remember males Pre-Rx: FBC, U+E, LFT, CXR, Pt education Monitoring: –every 2/52 for 1 st 2/12. –then every 1/12

21 Methotrexate Withhold and d/w rheumatologist if; –WBC < 4 –Neuts <2 –Plts< 150 –> x2 ^ AST, ALT –Unexplained low albumin –Rash or oral ulcers –New or ^ing dyspnoea Ix if MCV > 105 (B12/ Folate) Deterioration in renal func – decease dose Abnormal bruising or sore throat – stop and check FBC

22 Sulfasalazine / Salazopyrine 500mg/day - ^ by 500mg weekly to 2-3g/d Pre-Rx: FBC, LFT, U+E Monitor: –FBC, LFT every 2/52 for 8/52 –then 1/12 for 10/12 –Then every 3/12 after 1ys treatment Stop and d/w rheumatologist as indicated before Headaches, dizziness, nausea – decrease dose

23 Hydroxychloroquine Least toxic Is an anti-malarial Yearly optician review – retinal toxicity mg/d Often used in combo with other DMARDs Check U+E prior to starting Avoid in eye related maculopathy, diabetes or other significant eye disease Consider stopping after 5 years Yearly bloods

24 Leflunomide (Arava) 100mg for 3 days, then 20mg/d, can decrease to 10mg/d 2 nd line treatment. Is a new drug. Should not be used with other DMARDs May inhibit metab of warfarin, phenytoin, tolbutamide Long elimination half life – so may react with other DMARDs even after stopping it Must not procreate within 2y of stopping. Do serum levels.

25 Leflunomide cont….. SEs: blood dyscrasias, hepatotoxicity, mouth ulcers, skin rash (inc stevens-johnson & toxic epidermal necrolysis), mild ^BP, GI upset, wt loss, headaches, dizziness, tenosynovitis, hair loss. If severe SEs – elim with cholestyramine 8g or activated charcoal Pre-Rx: FBC, U+E, LFT, BP Monitor: FBC, LFT, U+E, BP –Every 2/52 for 6/12 –Then every 8/52 Withhold as above

26 Azathioprine 1mg/kg/d - ^ after 4-6/52 to 2-3mg/kg/d Immunosuppressant, antiproliferative, inhibits DNA synthesis Lower dose in hepatic or renal impairment If on allopurinol cut dose by 25% Avoid live vaccines Give pneumovax and flu jab Passive immunisation for varicella zoster in non-immune pts if exposed to chicken pox or shingles Pre-Rx: FBC, U+E, LFT Monitor: –Every 2/52 for 2/12 & after every dose change –Then every 1/12

27 Gold / Sodium Aurothiomalate (Myocrisin) 10mg im test dose (done in clinic) then 20mg, then weekly 50mg to dose of 1g – then reassess Pre-Rx: FBC, U+E, LFT, urinalysis Monitor: –FBC and urinalysis at each injection –Results to be available at next dose –Each time ask about oral ulcers & rashes Withhold as above

28 Penicillamine Rarely used!

29 Cyclosporin Is an immunosuppressant 2.5mg/kg/d in 2 divided doses. ^ after 4/52 by 25mg to max 4mg/kg/d Avoid in renal impairment or uncontrolled BP Numerous drug interactions -> BNF Need to ½ dose of diclofenac Avoid colchine & nifedipine Use k-sparing diuretics with care Avoid grapefruit juice & live vaccines

30 Pre-Rx: FBC, U+E X2, LFT, lipids, BP X2, 24 hour creatinine clearance Monitor: FBC, LFT, ESR, BP –2/52 till on stable dose for 3/12 –Then 1/12 –LFTs every 1/12 until on stable dose for 3/12 then every 3/12 –Serum lipids every 6/12 – 1 year Withhold and d/w rheumatologist; ^ by 30% of baseline creat Anormal bruising ^K ^BP ^lipids Plts < 150 >X2 ^ of AST, ALT, ALP

31 Anti-TNF alpha Use for highly active RhA in adults who have failed at least 2 DMARDs, including methotrexate Etanercept 25mg subcut twice a week Infliximab 3-10mg/kg iv every 4-8 weeks Adalimumab 40mg subcut alternate weeks Rapid onset (days to weeks) Disadvantages: cost & unknown long term effects, infections, demyelinating syndromes Should be given with methotrexate High risk atypical infections – low threshold for abx prophylaxis

32 IL-1 receptor antagonist Not commonly used yet! Anakinra 100mg/d subcut In combo with methotrexate Slower onset than anti-TNF SE; injection site reactions, pneumonia (esp in elderly with asthma)

33 Conclusion RhA is a lifelong dx Ideally want an early diagnosis MDT + pt education Effective new drugs Safe monitoring (pt + MDT responsibility)

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