Treatment of Rheumatoid Arthritis Then and Now

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Treatment of Rheumatoid ArthritisThen and Now
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Objectives

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

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Pathophysiology
Rheumatology Nurse Newsletter Volume22
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Cytokines
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Rheumatology Nurse Newsletter Volume 22 Summer
2009
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Paradigm shift in the treatment of rheumatoid and
inflammatory Arthritis
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THEN
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Marys 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

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Marys treatments Tried and Failed

• 24 aspirin daily
• Cyclosporin (Neoral)
• Plaquenil (Hydroxychloroquine)
• Injectable Gold
• Methotrexate
• Azulfidine

• Enbrel (Etanercept)
• D-penicillamine
• Prednisone
• NSAIDs
• Plasmaphoresis
• Arava (Leflunomide)

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Marys 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
• gt 10 hospitalizations for flares of uncontrolled
  disease process

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AND NOW
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Now
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Abigails 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

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Abigails 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

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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!

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Diagnostic Criteria for RA

• gt4 of the following must be present
• Morning stiffness gt 1 hour
• gt 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

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Complications of Untreated RA

• Pulmonary fibrosis
• Disability
• Deformity
• ? QOL
• ? morbidity and mortality

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Clinical Pearl

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

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Labs Eval Arthritis

• SPEP
• Sed rate
• CBC
• CCP
• RF
• HLA-B27

• CRP
• Hepatic panel
• ANA, ENA, DNA
• Hepatitis panel
• Vitamin D

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Treatment NSAIDs

• Voltaren
• Mobic
• Indocin
• Daypro
• Colchicine

• Celebrex
• Relafen
• Lodine
• Arthrotec
• Feldene

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Treatment DMARDs

• Methotrexate
• Arava (Leflunomide)
• Plaquenil (hydroxychloroquine)
• Azulfidine (sulfasalazine)

• Imuran (azathioprine)
• Minocin (minocycline)
• Gold (myochrysine)
• Neoral (cyclosporine)

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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

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Contraindications of Biologic Agents

• Active Lupus
• Tuberculosis
• Active infection
• Hypogammaglobulinemia
• Hepatitis B / C
• CHF III IV
• Demyelinating Disorder

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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.

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Summary

• Refer to rheumatology early and treat
  aggressively
• Rheumatoid arthritis and inflammatory arthritis
  shorten the patients life expectancy if left
  untreated
• Many treatment options exist and treatment can be
  tailored to the patients needs.