Consultant Rheumatologist Rheumatoid arthritis: the importance of early diagnosis and treatment November 2011 Helen Linklater Consultant Rheumatologist Epsom and St Helier

The race to diagnosis... £1.8 billion a year! Common: 1% of adults worldwide Progressive: joint pain joint damage increased mortality Estimated cost of sick leave/work-related disability for people with RA: £1.8 billion a year! DISABILITY

A new approach...

What is early RA? “Very early” = three months after disease onset (Hyrich, 2008) This may be a window of opportunity “Early” =  12 months into disease (Hyrich, 2008) Prompt introduction of DMARDs can lead to benefits up to 5 years after the drugs are introduced when compared with a delayed start (Raza, 2010)

Spotting a winner... Undifferentiated inflammatory arthritis (anti-CCP positive) treated with 12/12 methotrexate - outcome at 18 months Early therapeutic intervention improves clinical outcomes (van Dongen, 2007)

Diagnosing early RA - before damage occurs Anti-CCP Ultrasound MRI imaging +/- gadolinium

Anti-CCP - anti-cyclic citrullinated peptide (CCP) Diagnosis ACPA Anti-citrullinated peptide antibody (ACPA) - anti-cyclic citrullinated peptide (CCP) Diagnosis  50% patients with RA have anti-CCP or IgM-RF several years before symptom onset (Nielen, 2004) Strongly associated with genetic phenotypes associated with RA, and with smoking ACPA Prognosis Poorer response to therapy Predicts erosions (Aggarwal, 2009) > 95% positive predictive value in early inflammatory arthritis

Ultrasound assessment MCP joint Synovial hypertrophy Synovial fluid Synovial thickening Effusion PP head MC head MCP joint Erosion Power Doppler Doppler signal Erosion But operator dependent, non-standardised, variability...

ACR/EULAR criteria 2010

Obstacles to treating early RA... Services for people with rheumatoid arthritis 15 July 2009 - 50-75% people with RA delay seeking medical help from GP for  3 months following symptom onset - 20% delay for  1 year - Average length of time (symptom onset - Rx) 9 months Subject of much research!

Combination therapy in early RA  2 DMARDs + steroid DMARD + Infliximab Difficult to have complex treatment discussion at diagnosis Time limitations Lack of CNS support % without radiological progression “Despite …evidence in favour of intensive treatment strategies based on combinations of DMARDs with glucocorticoids... they are not often used in daily practice” BeSt Study (2005) (Verschueren, 2011)

Summary New criteria explicitly designed to find early disease ACPA very specific USS/MRI imaging aids diagnosis Facilitates disease stratification and early treatment

Does this alter your practice? Persistent joint swelling in  1 joint, or involvement of MCP or MTP joints = consider urgent referral (ideally within 6 wks of symptom onset) RhF and radiographs will probably be normal (NICE, 2009)

References 1. Hyrich, K Patients with suspected rheumatoid arthritis should be referred early to rheumatology BMJ 2008 336 : 215 2. Raza, K The Michael Mason prize: early rheumatoid arthritis—the window narrows Rheumatology 2010;49:406–410 3. Van Dongen H et al. Efficacy of Methotrexate Treatment in Patients With Probable Rheumatoid Arthritis Arthritis and Rheumatism 56, No. 5, May 2007, pp 1424–1432 4. Nielen M et al (2004) Specific Autoantibodies Precede the Symptoms of Rheumatoid Arthritis Arthritis and Rheumatism 50, (2) pp 380–386 5. Aggarwal, R et al (2009) Anti–Citrullinated Peptide Antibody Assays and Their Role in the Diagnosis of Rheumatoid Arthritis Arthritis & Rheumatism (Arthritis Care & Research) 61 (11) pp 1472–1483 5. ACR/EULAR Classification criteria for RA 2010 6. Verschueren P, Westhovens R Optimal care for early RA patients: the challenge of translating scientific data into clinical practice Rheumatology 2011;50:11941200 7. NICE guidance CG79 (Feb 2009) Rheumatoid arthritis: the management of rheumatoid arthritis in adults

Any Questions?