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Human Rheumatoid Arthritis PowerPoint Presentation

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  • Slide 1 - Rheumatoid Arthritis Presented by: Praharsha R. Menon PGY 2 03/18/2010
  • Slide 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
  • Slide 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
  • Slide 4 - www.cks.nhs.uk/.../rheumatoid_arthritis_arc
  • Slide 5 - ppt slide no 5 content not found
  • Slide 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
  • Slide 7 - Rheumatoid Nodule
  • Slide 8 - Stage I:Acute: synovial thickening; confined to joint capsule
  • Slide 9 - Stage II:Persistent inflammation  c/c pain, joint damage
  • Slide 10 - Stage III:Inflammation and damage limiting joint function
  • Slide 11 - Stage IV:Permanent joint damage and deformity  disability
  • Slide 12 - Extra-articular features General fever, lymphadenopathy, weight loss, fatigue Dermatologic palmar erythema, nodules, vasculitis Ocular episcleritis/scleritis, scleromalacia perforans, choroid and retinal nodules Cardiac pericarditis, myocarditis, coronary vasculitis, nodules on valves
  • Slide 13 - Neuromuscular entrapment neuropathy, peripheral neuropathy, mononeuritis multiplex Hematologic Felty’s syndrome, large granular lymphocyte syndrome, lymphomas Pulmonary pleuritis, nodules, interstitial lung disease, bronchiolitis obliterans, arteritis, effusions Others Sjogren’s syndrome, amyloidosis
  • Slide 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
  • Slide 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)
  • Slide 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
  • Slide 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
  • Slide 18 - Clinical course Type 1 = Self-limited: 5% to 20% Type 2 = Minimally progressive:5% to 20% Type 3 = Progressive: 60% to 90%
  • Slide 19 - Bloodwork CBC: AOCD Thrombocytosis Leukopenia in Felty’s syndrome ESR CRP RF Other: based on Differential diagnosis
  • Slide 20 - Radiologic progression
  • Slide 21 - Differential Diagnosis Spondyloarthropathies CTD’s Gout CPPD Viral infections Fibromyalgia Lyme disease Rheumatic fever
  • Slide 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
  • Slide 23 - Medications: NSAID’s Steroids DMARD’s: Biologic: anti- TNF, Abatacept, Etanercept, Rituximab, Infliximab, Adalimumab Non- biologic: Methotrexate, Leflunamide, Sulfasalazine, Hydroxychloroquine, Minocycline, Gold
  • Slide 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)
  • Slide 25 - Adverse Effects of DMARDs Drug Hem Liver Lung Renal Infect Ca 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.
  • Slide 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
  • Slide 27 - Baseline evaluation MTX, Lef, Min, SSZ, HCQ, all biologic agents: CBC, Liver transaminases, Crn In addition: Ophthal. Exam for HCQ; Hep B and C testing for Lef, MTX Monitoring:
  • Slide 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
  • Slide 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
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