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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 -
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