1. Hatem H Eleishi, MD Professor of Rheumatology, Cairo University Consultant Rheumatologist, Dr. Soliman Fakeeh Hospital Rheumatoid Arthritis Wednesday, April 29 th, 2009 Lecture 3 Diagnosis of Rheumatoid Arthritis Assessment of Rheumatoid Arthritis Guidelines for the Management of Rheumatoid Arthritis (June, 2008)

2. Diagnosis of Rheumatoid Arthritis Cardinal features: Objective evidence of inflammatory synovitis (i.e. with MS) for at least 6 weeks Affecting at least 3 joint areas on condition that they include at least one of the following (MCP, PIP, wrist) In a symmetric pattern (unless in PIP, MCP, MTP) Additional features: Rheumatoid nodules Positive RF Radiographic changes Consideration and exclusion of other cause of polyarthritis is to be considered

3. Assessment of Activity of Rheumatoid Arthritis Symptoms Signs Laboratory parameters Pain (VAS), Duration of morning stiffness Joint tenderness (TJC), Joint swelling (SJC) ESR, CRP Functional assessments Health assessment questionnaire (HAQ) Composite measures DAS, DAS28

4. Remission, low, moderate and high disease activity DAS28: DAS28 values range from 2 to 10 where 10 represents maximum disease activity: Using the DAS28 score, the cut off values of 2.4 3.6 5.5 low disease activity remission moderate disease activity high disease activity In accordance with the new criteria of remission and active disease defined by Daniel et al., in 2005.

5. Published in the June issue of the journal Arthritis Care & Research The recommendations on the use of non-biologic and biologic DMARDs in RA The recommendations developed are not intended to be used in a 'cookbook' or prescriptive manner or to limit a physician's clinical judgment, but rather to provide guidance based on clinical evidence and expert panel input

6. The recommendations on the use of non-biologic and biologic DMARDs in RA address five key areas: indications for use; monitoring for side effects; assessing clinical response; screening for tuberculosis (a risk factor associated with biologic DMARDs); and under certain circumstances (i.e. high disease activity) the roles of cost and patient preference in choosing biologic agents.tuberculosis

7. The recommendations developed are not intended to be used in a 'cookbook' or prescriptive manner or to limit a physician's clinical judgment, but rather to provide guidance based on clinical evidence and expert panel input

8. MethotrexateMethotrexate or leflunomide therapy is recommended for most RA patients.leflunomide Methotrexate plus hydroxychloroquine is endorsed for patients with moderate to high disease activity.hydroxychloroquine The triple DMARD combination of methotrexate plus hydroxychloroquine plus sulfasalazine for patients with poor prognostic features and moderate to high levels of disease activity. sulfasalazine

9. Prescribing anti-TNF agents — etanercept, infliximab, or adalimumab — along with methotrexate in early RA (less than 3 months) only for patients with high disease activity who had never received DMARDs. In intermediate- and longer- duration RA, anti-TNF agents are recommended for patients who had failed to respond adequately to methotrexate therapy.etanerceptinfliximabadalimumab

10. Reserving the fusion protein abatacept and the B-cell antibody rituximab for patients with at least moderate disease activity and poor disease prognosis for whom methotrexate in combination with or sequential administration of other nonbiologic DMARDs led to an inadequate response.abataceptrituximab

11. Avoiding the initiation or resumption of treatment with methotrexate, leflunomide, or biologic agents for patients with active bacterial infection, active herpes-zoster viral infection, active or latent tuberculosis, or acute or chronic hepatitis B or C. hepatitis B Not prescribing anti-TNF agents to patients with a history of heart failure, with a history of lymphoma, or with multiple sclerosis or demyelinating disorders.heart failuremultiple sclerosis Avoiding the initiation or resumption of methotrexate, leflunomide, or minocycline for RA patients planning for pregnancy and throughout the duration of pregnancy and breastfeeding.pregnancybreastfeeding

12. Thank you