IMPROVING EARLY DIAGNOSIS AND TREATMENT OF RHEUMATOID ARTHRITIS

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IMPROVING EARLY DIAGNOSIS AND TREATMENT OF
RHEUMATOID ARTHRITIS

• Michael Lockwood, MD, FACP, FACR
• Rheumatology
• Indiana University Health Arnett

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Presentation of Case

• March 1994 48 yo w F smoker, joint pain and
  swelling, RF 74
• June 1994 started hydroxychloroquin
• September 1994 feeling much better
• May 1998 started methotrexate
• April 2002 found benefit with COX 2 Selective
  NSAIDs
• August 2002 deformity and nodulosis
• 2005 methotrexate was increased
• May 2006 DAS 4.02, Hand films
• January 2007 Infliximab started
• Could a different outcome have been achieved?

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11/25/1996
8/19/2006
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Rheumatoid Arthritis CureWhy is it important?

• Severe disability after 20 year 19
• Lifetime Costs 225,000 - 370, 000
• Excess Deaths Mortality Ratio 2.26
• Excess Cardiovascular events 4x
• Increases risk of coronary artery disease Type
  2 diabetes

Wolfe, AR 37(4), p. 481
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Rheumatoid ArthritisApproach to Therapy
Timing

• Before 4 months
• Combination 42
• Single Drug 35
• After 4 months
• Combination 42
• Single Drug 11

Mottonen, AR, vol. 46, pp.894-98
Korpela, AR vol. 50, pp 2072-81
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Rheumatoid ArthritisAdvantage of Early Assessment
Timing
Van der Linden, AR Vol. 62 pp 3537-3547
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Rheumatoid Arthritis History

• Onset Weeks to Months
• Can be Palindromic onset
• Can have pauciarticular onset
• Constitutional features
• Morning stiffness lasting for hours
• Functional Questions

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Rheumatoid Arthritis Epidemiology

• WomenMen 31
• Peak onset age 30-55
• Incidence 30/100,000
• Prevalence
• 1 Caucasians
• 0.1 rural Africans

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Rheumatoid Arthritis Physical
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Rheumatoid Arthritis Physical
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Rheumatoid Arthritis Deformities
Ulnar Deviation
Swan neck deformities Boutenaire deformities
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Rheumatoid Arthritis Deformities
Bayonet Deformities
MTP Subluxation
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Rheumatoid Arthritis Deformities
Atlantoaxial Instability
MRI
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Rheumatoid Arthritis Extraarticular Involvement
Rheumatoid Nodules
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Rheumatoid Arthritis Extraarticular Involvement
Rheumatoid Vasculitis
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Rheumatoid Arthritis Extraarticular Involvement

• Pulmonary
• Pleurasy

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Rheumatoid Factor

• Antibodies to Fc portion of IgG
• 75-80 of Patients have during course of disease
• Useful for prognosis

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Cyclic Citrullinated PeptideAntibodies (anti
CCP)
Schellekens, AR, Vol 43, pp. 155-163
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Rheumatoid Arthritis X-Ray
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Rheumatoid Arthritis X-Ray
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Rheumatoid ArthritisClassification 1987 Criteria
Arnett, AR, Vol 31, pp. 315-324
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Rheumatoid ArthritisClassification 2010 Criteria
Aletaha, AR, Vol 62, pp. 2569-2581
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Rheumatoid ArthritisPathology
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Pathogenesis of Rheumatoid Arthritis
Choy, E. H.S. et al. N Engl J Med 2001344907-916
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Rheumatoid ArthritisPannus
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Rheumatoid ArthritisApproach to Therapy
Triple Drug Therapy

• Triple Drug 77 get 50 improvement
• Methotrexate 33
• Plaquenil/Sulfasalazine 40

ODell, NEJM vol. 334, pp 1287-1291
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Cytokine Signaling Pathways Involved in
Inflammatory Arthritis
Choy, E. H.S. et al. N Engl J Med 2001344907-916
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Rheumatoid Arthritis How do we proceed?

• Aggressive approach, lt5 yr disease, monthy
  followup
• DAS calculated monthly
• Aggressively escalating therapy
• Goal DAS remission or low disease activity
• Results ACR 50 84 vs 40 standard tx.
• Decrease erosions
• Total Costs less

Grigor, Lancet, Vol. 364, pp. 263-269
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Rheumatoid Arthritis Implementation DAS scoring
aggressive approach in a community rheumatology
practice
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Problem 1

• A 32 year old man presents with fatigue, low back
  pain and morning stiffness lasting 15 minutes. He
  notes that the back pain seems to get worse as he
  works through his day. He is a machinist at a
  local factory. What should you do next?
• Start a Medrol (methylprednisolone) dose pack
• Check a rheumatoid factor (RF), cyclic
  citrullinated peptide antibody (CCP), and an
  antinuclear antibody (ANA)
• Refer to physical therapy for back strengthening
  and instruction in back protection
• Get a lumbar sacral xray 3 views
• Get a MRI of the back.

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Problem 2

• A 26 year old women presents with a 4 week
  history of swelling and tenderness of all of the
  MCPs, PIPs and the MTPs of the feet. This is
  confirmed on physical examination. There are no
  other stigmata on examination. Her labs are
  remarkable for a sed rate of 35 but a negative
  rheumatoid factor (RF), CCP, and ANA. Her hand a
  feet xrays are normal. Her most likely diagnosis
  is
• Systemic lupus erythematosus
• Rheumatoid arthritis
• Psoriatic arthritis
• Fibromyalgia

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Problem 3

• What treatment would you initiate for the above
  patient?
• Monotherapy with methotrexate, hydroxychloroquin,
  or sulfasalazine but follow serial DAS (disease
  activity score) and treat to target.
• Combination therapy with methotrexate,
  hydroxychloroquin, and sulfasalazine but follow
  serial DAS (disease activity score) and treat to
  target.
• Combination therapy with methotrexate and a TNF
  blocker but follow serial DAS and treat to target.

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Problem 4

• A 45 year old women presents with swelling and
  pain in the joints of 8 months duration, morning
  stiffness lasting several hours, and she finds it
  difficult to do her work. She has swelling and
  tenderness in most of the MCPs, PIPs, and MTPs.
  There is also swelling of the wrist, ankles,
  elbows, and one knee. Her sed rate is 60, and she
  has a high titre positive rheumatoid factor and
  cyclic citrullinated peptic (CCP). The ANA is
  1160. Her hand films do show joint space
  narrowing in one of the MCP and there is an
  erosion of a couple of the PIP. What treatment
  would you initiate for the patient?
• Monotherapy with methotrexate, hydroxychloroquin,
  or sulfasalazine but follow serial DAS (disease
  activity score) and treat to target
• Combination therapy with methotrexate,
  hydroxychloroquin, and sulfasalazine but follow
  serial DAS (disease activity score) and treat to
  target.
• Combination therapy with methotrexate and a TNF
  blocker but follow serial DAS and treat to target