1. going beyond STATE OF THE ARThritis
Gout, OA, RA, PsA, AS

2. Gout

3. 2015 ACR-EULAR Gout Classification Criteria

6. How I do it Hydrate aggressively: till urine is voluminous and clear
No medieval ages Colchicine regimens
High/full dose NSAIDs/coxibs
Steroids if swollen++
Intra-articular or tendon sheath; ultrasound-guided ideally; do NOT barbotage tophi
Oral mg/kg BW/day Prednisolone x5 days
RICE treatment
Do not stop ULT
OK to starting ULT
Refer/admit:
Comorbid: frail, elderly, dehydrated, renal-impaired/oliguric, congestive heart failure
Complicated: febrile, septic arthritis/tenosynovitis suspected, tophaceous, neurological deficit

8. How I do it
Educate: Fear Factor (joint damage & disability, kidney failure, heart attack & stroke)
Hydrate: till urine is clear
Diet & Beverages: Karma Balancing; avoid fructose
Metabolic screening: smoking, DM, hypertension, dyslipidaemia, obesity, psoriasis, OSA
Uricosuric (Probenecid, Benzbromarone, Lesinurad, …Losartan, Atorvastatin, Gliflozins) as firstline:
>80% under-excretors
Contraindications: renal impairment, nephrolithiasis, fluid restriction, [hepatic dysfunction], [tophaceous]
XOI (Allopurinol, Febuxostat) if uricosuric contraindicated or failed to achieve target:
Warn about Allopurinol hypersensitivity reactions; HLA-B5801 assay
start low, go slow, especially in renal impairment; go up to 800mg if necessary
Combination Uricosuric + XOI to achieve target: <6 mg%, or <5 mg% if still flare
Colchicine prophylaxis (with education) till 6 months flare-free and on-target
Monitor LFT, UFEME, FBC, Cr, SUA

9. Going beyond Consider atypical presentations:
Subacute Gout without visible tophi
Chronic mechanical pain of tendons and entheses
Advanced imaging evaluation:
Ultrasound
Double contour sign
Juxta-articular erosion
Hyperaemic rim around tophus
Echogenic specks in effusion
Dual-energy CT (DECT)

10. osteoarthritis

13. OA Management Guidelines
American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee
OARSI guidelines for the non-surgical management of knee osteoarthritis (2014)
2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: Terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures
2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions)
Osteoarthritis Treatment & Management (Medscape 2016)

14. How I do it Identify source(s) of pain: history, examination, imaging
Identify precipitating/aggravating factor(s)
Refer for biomechanical assessment and therapy
SYSADOA/DMOAD 3-months’ trial:
Glucosamine/Chondroitin Sulphate
Avocado Soybean Unsaponifiables
Strontium Ranelate
Viscosupplementation
Recurrent effusions:
Exclude chronic infection (TB), tumour (PVNS), crystal deposition (MSU, CPPD)
Consider colchicine, spironolactone, Methotrexate, IA steroid, lavage, synovectomy
Going beyond the standard mile for the younger, active set

15. Going beyond: T2T for OA
Imaging to confirm diagnosis and quantify cartilage damage
Imaging to pinpoint pain generator:
MSUS for soft tissue pathologies (bursitis, tendinosis, enthesopathy, synovitis, crystal deposition)
MRI for bone marrow oedema (BME)
DECT for subclinical gouty deposits
Targeted treatment of pathologies:
BME: anti-resorptives
Synovitis: IA steroid, viscosupplement, PRP/ACP
Biomechanic assessment: strength training, taping, podiatry
Full-thickness chondral defect: ACI/MSC repair/regeneration

16. Rheumatoid arthritis

17. 2010 ACR/EULAR “Diagnostic Criteria” for RA

18. 2010 EULAR Recommendations for the Targeted Treatment of RA: A 3-Phase Approach

19. 2014 EULAR Recommendations for Treating RA to Target
Algorithm of treating rheumatoid arthritis (RA) to target based on the updated recommendations provided in the table 1 and discussed in detail in the 'Results' section. Indicated as separate threads are the main target (remission and sustained remission) and the alternative target (low-disease activity in patients with long-term disease and sustained low-disease activity), but the approaches to attain the targets and sustain them are essentially identical. Adaptation of therapy should be usually done by performing control examinations with appropriate frequency and using composite disease activity measures that comprise joint counts, but should take comorbidities and other patient factors into account. Setting the target as well start and adaptation of therapy should be done as a shared decision with the patient.

20. 2015 ACR Guideline for the Treatment of Early RA
2015 American College of Rheumatology recommendations for the treatment of Early rheumatoid arthritis (RA), defined as disease duration <6 months. ∗ = consider adding low‐dose glucocorticoids (≤10 mg/day of prednisone or equivalent) in patients with moderate or high RA disease activity when starting disease‐modifying antirheumatic drugs (DMARDs) and in patients with DMARD failure or biologic failure. † = also consider using short‐term glucocorticoids (defined as <3 months treatment) for RA disease flares. Glucocorticoids should be used at the lowest possible dose and for the shortest possible duration to provide the best benefit‐risk ratio for the patient. # = treatment target should ideally be low disease activity or remission. For the level of evidence supporting each recommendation, see the related section in the Results. This figure is derived from recommendations based on PICO (population, intervention, comparator, and outcomes) questions A.1 to A.12. For definitions of disease activity (categorized as low, moderate, or high) and descriptions, see Tables and . MTX = methotrexate.
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21. 2015 ACR Guideline for the Treatment of Established RA
2015 American College of Rheumatology (ACR) recommendations for the treatment of Established rheumatoid arthritis (RA), defined as disease duration ≥6 months, or meeting the 1987 ACR classification criteria . Due to complexity of management of established RA, not all clinical situations and choices could be depicted in this flow chart, and therefore we show the key recommendations. For a complete list of recommendations, please refer to the Results. ∗ = consider adding low‐dose glucocorticoids (≤10 mg/day of prednisone or equivalent) in patients with moderate or high RA disease activity when starting traditional disease‐modifying antirheumatic drugs (DMARDs) and in patients with DMARD failure or biologic failure. † = also consider using short‐term glucocorticoids (defined as <3 months treatment) for RA disease flares. Glucocorticoids should be used at the lowest possible dose and for the shortest possible duration to provide the best benefit‐risk ratio for the patient. # = treatment target should ideally be low disease activity or remission. ∗∗ = tapering denotes scaling back therapy (reducing dose or dosing frequency), not discontinuing it and if done, must be conducted slowly and carefully. For the level of evidence supporting each recommendation, see the related section in the Results. This figure is derived from recommendations based on PICO (population, intervention, comparator, and outcomes) questions B.1 to B.38. For definitions of disease activity (categorized as low, moderate, or high) and descriptions, see Tables and . MTX = methotrexate; TNFi = tumor‐necrosis factor inhibitor.
IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER.

22. ACR-EULAR 2011 Definition of Remission
For clinical practice
Boolean – SJC, TJC, PtGA all ≤1
Index-based – CDAI ≤2.8
CDAI=SJC+TJC+PhGA+PtGA
For clinical trials
Boolean – SJC, TJC, PtGA, CRP all ≤1
Index-based – SDAI ≤3.3
SDAI=SJC+TJC+PhGA+PtGA+ CRP (mg/dl)

23. Going beyond… that’s how I’ve been doing it
Predicting who will develop RA:
Ultrasound for early diagnosis of synovitis and tenosynovitis
Trial of steroid
Predicting who will do badly:
Combine
Fast-acting DMARD (steroid, targeted agents) for 3-6 months to induce remission
Slow-acting DMARD (MTX, Leflunomide, Rituximab) for at least 1 year to maintain remission
Intra-articular steroid
Subcutaneous MTX 25-30mg/wk before combination csDMARDs
Predicting who will respond to which targeted therapy:
First Biologic: anti-TNF
Anti-TNF failure:
Switch class especially in primary failure
Pan-JAK inhibitor as first choice
Tapering: biologic-free before drug-free
Flares:
Search for triggers (eg infections, dysbiosis)
Abridged re-induction
Protracted maintenance for longer sustained remission

24. Psoriatic arthritis

25. 2015 EULAR Recommendations for the Treatment of Psoriatic Arthritis*
anti-TNF
or anti-IL12/23
or anti-IL17
or tsDMARD
(+/- csDMARD) * *

26. How I do it: going beyond a la RA
Screen for concomitant Gout/hyperuricaemia
Screen for Metabolic Syndrome
csDMARD (MTX, Leflunomide, Cyclosporin) as monotherapy or in combination with targeted therapy
Steroids, if needed, preferably intra-articular
Biologics: anti-TNF for joint-predominant, anti-IL17 or anti-12/23 for skin-predominant
Severe disease:
s/c MTX
Loading dose monoclonal anti-TNF
Refractory disease:
Combination anti-TNF with anti-IL17
Evaluate for dysbiosis, weight gain, DM, HIV, malignancy
New agents: Tofacitinib, Guselkumab
Tapering and spontaneous remission

27. Ankylosing spondylitis

28. 2012 ASAS Classification Criteria for Axial & Peripheral Spondyloarthritis (SpA)

29. 2010 ASAS/EULAR Recommendations for the Management of Spondyloarthritis
*anti-IL17A

30. How I do it: going beyond a la PsA
Non-radiographic SpA treated like established AS, perhaps more urgently and aggressively
Full dose NSAID/coxib is first-line for pure axial disease
Sulfasalazine is preferred csDMARD in peripheral and extra-articular involvement
Steroids, if needed, preferably intra-articular
Biologics: monoclonal anti-TNF as first-line, anti-IL17 upon anti-TNF inadequate response
Debatable whether continuing NSAID upon starting biologic confers benefit against ankylosis
Secondary anti-TNF failure:
Anti-biologic antibodies
Dysbiosis: silent ileitis in 50%; check stool calprotectin, ASCA, KIV scopes
Tapering to longterm maintenance vs on-demand treatment
70% flare within 6 months off biologic
Flare triggers: infection, trauma, entheseal strain

31. Fast & Furious Treat To Target Whatever It Takes

32. The Rheuma Muse