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Hot Topics in Rheumatology. Prof. MG Molloy. Overview. Rheumatoid Arthritis Psoriatic Arthritis Vasculitides: SLE Osteoarthritis Osteoporosis. Rheumatoid arthritis. RA is a condition involving inflammation of the joints It has the potential to result in serious joint damage

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overview
Overview
  • Rheumatoid Arthritis
  • Psoriatic Arthritis
  • Vasculitides: SLE
  • Osteoarthritis
  • Osteoporosis
rheumatoid arthritis
Rheumatoid arthritis
  • RA is a condition involving inflammation of the joints
    • It has the potential to result in serious joint damage
    • It may come on suddenly or appear slowly over time
    • Its symptoms may include pain, swelling, stiffness in the joints, and general tiredness
rheumatoid arthritis1
Rheumatoid Arthritis
  • Damage occurs early in most patients
    • 50% show joint space narrowing or erosions in the first 2 years
    • By 10 years, 50% of young working patients are disabled
  • Death comes early
    • Multiple causes
    • Compared to general population
      • Women lose 10 years, men lose 4 years
who is affected by ra
Who is affected by RA?
  • RA is one of the most common forms of inflammatory arthritis
    • Affects about 1% of the world’s population
    • Occurs 2 to 3 times more often in women than in men
    • In most cases it develops between the ages of 25 and 50
ra multisystem disease
RA: Multisystem disease
  • Extra-articular:
    • Cardiac
      • coronary heart disease
    • Pulmonary
      • fibrosis
    • Haematological
      • Anaemia
    • Ophthalmology
    • Dermatology
    • Renal
cardiac disease in ra
Cardiac disease in RA
  • Mortality in RA is unchanged in 40yrs despite DMARDS
  • Patients unlikely to report symptoms of angina
  • Not all IHD risk is due to traditional risk factors nor drugs such as Pred use, HRT DM etc
  • Control BP, cholesterol etc
  • High index of suspicion: cardiology referral
medications for ra
Medications for RA
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Corticosteroids
  • Disease-modifying antirheumatic drugs (DMARDs)
  • Biologics
  • Combination
dmard options
DMARD options
  • Hydroxychloroquine
  • Sulphasalazine
  • Methotrexate
  • Azathioprine
    • Slow onset, reasonably effective
  • Leflunomide
    • Pyrimidine inhibitor
    • Effect and side effects similar to those of MTX
dmards combination or monotherapy
DMARDs Combination or monotherapy
  • No superiority of traditional combination DMARD therapy over monotherapy
  • Some trials did not control for glucocorticoid use
  • Review of studies since 2000 have shown that step-up therapy of Leflunomide +MTX is superior but, with significant toxicity
methotrexate
Methotrexate
  • Commonest DMARD
  • 30 year experience
  • Monitoring: monthly FBC, ESR, CRP, Bioprofile, LFTs
  • Complications:
    • Haem:Neutropenia, thrombocytopenia, ? Leukemia
    • Liver dysfunction
new biologics
New Biologics
  • Infliximab ( chimeric monoclonal antibody to TNF)
  • Etanercept (soluble TNF receptor)
  • Adalimumab (humanised monoclonal antibody to TNF)
  • Rituximab (anti-CD 20 )
  • Anti-Interleukin 6 (in clinical trials for JRA)
biologic agents in ra
Biologic agents in RA
  • Indication: Refractory RA
  • Prior to commencing: CXR, Mantoux
  • Contraindications/Precautions:
    • Previous TB, COPD, Chronic infections, HIV
biologic agents in ra1
Biologic agents in RA
  • Monitoring:
    • Monthly bloods: FBC, ESR, CRP, Bioprofile
    • Regular physical examination
    • Beware infection
  • NB: Normal WCC, ESR, CRP does not exclude infection
new drugs
New drugs
  • Rituximab (anti- CD 20)- in use
  • Epratuzumab anti-CD22 – better risk profile than ritux
  • Anti-CD4 – was good but CD4 counts dropped so low trials stopped
  • Efalizumab – anti-CD11a –used in psoriasis, no good in PSA
  • CTLA4-Ig (in trials)- binds CD80/86 and blocks cell activation
  • Alefacept- binds LFA-3
  • Anti-RANKL
  • SOCS
  • IL1-trap
  • Anti-IL6 receptor antibody
  • Soluble IL-15 receptor antagonist – 62% ACR 20 scores in high dose group
  • Other targets – IL-12, IL-17, IL-18, IL-23, IL-27,IFN alpha and gamma
summary ra
Summary RA
  • RA – early treatment = better outcome
  • MTX good monotherapy in many patients
  • Combo therapy of traditional DMARDs is possibly superior but conflicting studies
  • Biologics =higher expectations
  • Currently combo biologics +MTX better than biologic monotherapy
  • Are biologics capable of inducing remission in early disease – then do we switch to mainteance therapy with MTX – unknown yet
  • Anti – CCP antibody - predictor of erosive disease course
spondyloarthropathies

Spondyloarthropathies

Ankylosing Spondylitis

Psoriatic arthropathy

ank spond1
Ank Spond
  • Diagnosis:
    • Clinical: Backpain and stiffness: EMS
    • Age 20-40yrs male
    • Xray: late changes
  • Treatment:
    • Exercises, NSAIDS
    • Biologics
gout uric acid deposition
Gout uric acid deposition
  • Clinical
    • Monoarticular
    • The most painful arthropathy
  • Treatment
    • NSAIDS
    • Allopurinol: prophylaxis
    • Colchicine:
      • Nausea, vomting, diarrhoea
pseudo gout
Pseudo-gout
  • 2nd, 3rd MCPs, wrists, shoulders, knees, feet
  • Associations:
    • Haemochromatosis
    • Age
  • Treatment
    • Underlying disease
    • NSAIDS
osteoporosis1
Osteoporosis
  • Diagnosis
osteoporosis2
Osteoporosis
  • Management
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