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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 pseudogout crystal arthropathies
Gout & PseudogoutCrystal arthropathies


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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