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Treatment of Rheumatoid Arthritis Then and Now

Treatment of Rheumatoid Arthritis Then and Now. Objectives:. Outline the diagnostic criteria for Rheumatoid Arthritis, its systemic manifestation, and the complication of untreated RA. Identify and discuss laboratory tests that aid in the diagnosis of RA.

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Treatment of Rheumatoid Arthritis Then and Now

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  1. Treatment of Rheumatoid ArthritisThen and Now

  2. Objectives: • Outline the diagnostic criteria for Rheumatoid Arthritis, its systemic manifestation, and the complication of untreated RA. • Identify and discuss laboratory tests that aid in the diagnosis of RA. • Explain the differences between oral disease modifying anti-rheumatic medications and biologic medications, including medication risks and safety profiles.

  3. Pathophysiology Rheumatology Nurse Newsletter Volume2:2

  4. Cytokines

  5. Rheumatology Nurse Newsletter Volume 2:2 Summer 2009

  6. Paradigm shift in the treatment of rheumatoid and inflammatory Arthritis

  7. THEN…

  8. Mary’s Story 31 year old female who presents to the Beals Institute in 1982 with five year history of RA Disability at age 27 First joint replacement surgery at age 29

  9. Mary’s treatments: Tried and Failed • 24 aspirin daily • Cyclosporin (Neoral) • Plaquenil (Hydroxychloroquine) • Injectable Gold • Methotrexate • Azulfidine • Enbrel (Etanercept) • D-penicillamine • Prednisone • NSAIDs • Plasmaphoresis • Arava (Leflunomide)

  10. Mary’s Numbers 3 reconstructive hand surgeries last one 2007 1 wrist fusion 2 hip replacements 2 total knee replacements 1 elbow replacement 1 ulnar fracture repair and prosthetic repair > 10 hospitalizations for flares of uncontrolled disease process

  11. AND NOW…

  12. …Now

  13. Abigail’s Story • 34 year old presents in 2005 with shoulder, wrist and hand pain for 2 months • Started on combination therapy using Arava and Enbrel • Due to diarrhea and weight loss, changed to Methotrexate and Enbrel

  14. Abigail’s Numbers 0 days missed work due to disability 0 hospitalizations, surgeries and joint replacements due to RA 5K - the length of the races she runs regularly

  15. Why Is Early Diagnosis and Treatment Imperative? Rheumatoid arthritis progression is the most rapid in the first two years of disease onset 75% of joint damage will occur within the first five years of disease onset. Rheumatoid Arthritis is as lethal as lymphoma if left untreated!

  16. Diagnostic Criteria for RA >4 of the following must be present • Morning stiffness > 1 hour • > 3 joints involved • Symmetrical swelling; usually in hands, wrists and MTP joints in feet • Rotating joint pain • Positive Rheumatoid Factor (Note: 20% of patients with RA will not test positive) • Positive CCP • Erosive joint changes on x-ray • RA nodules

  17. Complications of Untreated RA • Pulmonary fibrosis • Disability • Deformity • ↓ QOL • ↑ morbidity and mortality All Slides (c) Current Medicine

  18. Clinical Pearl Hepatitis C presents with identical symptomatology and will cause the Rheumatoid Factor to be positive..

  19. Labs Eval: Arthritis • SPEP • Sed rate • CBC • CCP • RF • HLA-B27 • CRP • Hepatic panel • ANA, ENA, DNA • Hepatitis panel • Vitamin D

  20. Celebrex Relafen Lodine Arthrotec Feldene Voltaren Mobic Indocin Daypro Colchicine Treatment: NSAIDs

  21. Methotrexate Arava (Leflunomide) Plaquenil (hydroxychloroquine) Azulfidine (sulfasalazine) Imuran (azathioprine) Minocin (minocycline) Gold (myochrysine) Neoral (cyclosporine) Treatment: DMARDs

  22. Treatment: Biologic Agents IL-1 antagonist • Kineret: sc daily TNF inhibitor • Enbrel: sc 1-2 times/week • Humira: sc 2 times a month • Remicade: IV q 6 to 8 weeks • Simponi: sc q month • Cimzia: sc q month T-cell inhibitor • Orencia: IV q month B-cell inhibitor • Rituximab: IV load, 2 weeks then PRN

  23. Contraindications of Biologic Agents • Active Lupus • Tuberculosis • Active infection • Hypogammaglobulinemia • Hepatitis B / C • CHF III & IV • Demyelinating Disorder

  24. A Happy Ending? In January 2004 Mary started Humira Continued Methotrexate, Gold, and episodic prednisone for flares Since that time, she has avoided hospitalization and disease has been more consistently in remission.

  25. Summary Refer to rheumatology early and treat aggressively Rheumatoid arthritis and inflammatory arthritis shorten the patient’s life expectancy if left untreated Many treatment options exist and treatment can be tailored to the patient’s needs.

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