Rheumatoid Arthritis

1. Rheumatoid Arthritis Presented by: Praharsha R. Menon PGY 2 03/18/2010

2. Q: What do comedienne Lucille Ball, French painter Pierre-Auguste Renoir, Hollywood actress Kathleen Turner and heart transplant surgeon Dr. Christiaan Barnard have in common? A: Rheumatoid Arthritis

3. Key Features • Symmetric, inflammatory polyarthritis • Autoimmune • Females > Males • Symptoms > 6 wks • Morning stiffness > 1 hr • > 3 joints involved • Spares: • Thoracolumbar spine • DIP of fingers

4. www.cks.nhs.uk/.../rheumatoid_arthritis_arc

6. Nodules: S/C or periosteal, at pressure points • Rheumatoid factor : • Ab : recognizes Fc portion of IgG • +: implies c/c inflammation • 70 % + at onset, 85% + in first 2 yrs • Associated with more severe disease, extra-articular manifestations, mortality

7. Rheumatoid Nodule

8. Stage I:Acute: synovial thickening; confined to joint capsule

9. Stage II:Persistent inflammation  c/c pain, joint damage

10. Stage III:Inflammation and damage limiting joint function

11. Stage IV:Permanent joint damage and deformity  disability

12. Extra-articular features • General • fever, lymphadenopathy, weight loss, fatigue • Dermatologic • palmarerythema, nodules, vasculitis • Ocular • episcleritis/scleritis, scleromalaciaperforans, choroid and retinal nodules • Cardiac • pericarditis, myocarditis, coronary vasculitis, nodules on valves

13. Neuromuscular • entrapment neuropathy, peripheral neuropathy, mononeuritis multiplex • Hematologic • Felty’s syndrome, large granular lymphocyte syndrome, lymphomas • Pulmonary • pleuritis, nodules, interstitial lung disease, bronchiolitisobliterans, arteritis, effusions • Others • Sjogren’s syndrome, amyloidosis

14. Diagnosis • Score >/= 6 : diagnosis • Joint Involvement • Serology • Duration of synovitis • Acute phase reactants MITCHEL L. ZOLER; FEBRUARY 1 5 , 2 0 1 0 • FAMILY PRACTICE NEWS

15. Joint Involvement • 1 medium-large joint (0 points) • 2-10 medium-large joints (1 point) • 1-3 small joints (2 points) • 4-10 small joints (3 points) • More than 10 small joints (5 points)

16. Serology • RF neg, Anti CCP neg (0 points) • RF +/ Anti CCP + at low titer (2 points) • RF +/ Anti CCP + at high titer (3 points) • Low titer: > upper lmt. of normal, upto 3x upper lmt of normal • High titer: > 3 x upper lmt. of normal

17. Duration of synovitis • < 6 weeks: 0 points • >/= 6 weeks: 1 point Acute phase reactants: • CRP and ESR normal : 0 points • Abnormal CRP or abnormal ESR : 1 point

18. Type 1 = Self-limited: 5% to 20% Type 2 = Minimally progressive:5% to 20% Type 3 = Progressive: 60% to 90% Clinical course

19. Bloodwork • CBC: AOCD Thrombocytosis Leukopenia in Felty’s syndrome • ESR • CRP • RF • Other: based on Differential diagnosis

20. Radiologic progression

21. Differential Diagnosis • Spondyloarthropathies • CTD’s • Gout • CPPD • Viral infections • Fibromyalgia • Lyme disease • Rheumatic fever

22. Treatment guidelines • Confirm the diagnosis • Determine where the patient stands in the spectrum of disease • When damage begins early, start aggressive treatment early • Use the safest treatment plan that matches the aggressiveness of the disease • Monitor treatment for adverse effects • Monitor disease activity, revise Rx as needed

23. Medications: • NSAID’s • Steroids • DMARD’s: • Biologic: anti- TNF, Abatacept, Etanercept, Rituximab, Infliximab, Adalimumab • Non- biologic: Methotrexate, Leflunamide, Sulfasalazine, Hydroxychloroquine, Minocycline, Gold

24. The 2008 ACR Recommendations for Rheumatoid Arthritis Treatment • Initiate: MTX/ Lef. in most patients • Mod. to high D/S activity: MTX +HCQ • Mod. to high D/S activity + poor prognosis: MTX+HCQ+SSZ (if inadequate response  consider Rituximab and Abatacept) • High D/S activity + sx < 3 mo.s: anti- TNF +MTX (pt. w/o prior DMARD treatment)

25. Adverse Effects of DMARDs Drug Hem Liver Lung Renal InfectCa Other HCQ + -- - - - Eye SSZ + + + - - - GI Sx Gold ++ - + ++ - - Rash MTX + + ++ - ++ ? Mucositis AZA ++ + -- ++ + Pancreas PcN ++ + + ++ - - SLE, MG Cy +++ - - - +++ +++ Cystitis CSA + ++ - +++ ++ + HTN ¶TNF* - - - - ? ? Local Lef* ++ ++ - - ? ? *Long-term data not available. Adapted from Paget. Primer on Rheum Dis. 11th edition. 1997:168.

26. Contraindications • MTX, Lef., or biologic DMARDs (Enbrel, Remicade, Humira, Orencia, or Rituxan): active bacterial infection, active VZV infection, active or latent TB, or acute or chronic Hep B or Hep C • TNF blockers: heart failure, lymphoma, multiple sclerosis or other demyelinating disorders • Pregnancy and lactation: MTX, Lef., Minocycline

27. Baseline evaluation • MTX, Lef, Min, SSZ, HCQ, all biologic agents: CBC, Liver transaminases, Crn In addition: Ophthal. Exam for HCQ; HepB and C testing for Lef, MTX Monitoring:

28. Summary: Evidence- based rating of recommendations • Patients with rheumatoid arthritis should be treated ASAP with DMARDs to control symptoms and delay disease progression. A • Patients with persistent inflammatory joint disease (> 6-8 weeks) already receiving analgesics or NSAIDs should be considered for rheumatology referral, preferably within 12 weeks. C • Combination therapy may be more effective than treatment with one drug alone. A • Exercise is beneficial for aerobic capacity and muscle strength with no detrimental effects on disease activity or pain levels. C Rindfleisch J.A.: American Family Physician; Sep 15, 2005

29. References • Saag K.G., Teng G.G. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis . Arthritis &Rheumatism2008; Vol. 59, No. 6 : p 762-784) • Rindfleisch J.A. Diagnosis and Management of Rheumatoid Arthritis. the American Family Physician; September 15, 2005 ; Volume 72, Number 6 • Family Practice News Feb 15, 2010 • www.medscape.com