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Rheumatoid Arthritis :
Management (simplified)
Dr Pratap Sagar Tiwari
Note: This is just a lecture class slides to MBBS students
INTRODUCTION
• RA is characterized by acute and chronic inflammation in the
synovium, which is associated with a proliferative and destructive
process in joint tissues.
• The treatment of RA is directed toward the control of synovitis and
the prevention of joint injury.
• Achieving the benefits of early intervention with disease-modifying
antirheumatic drugs (DMARDs) depends upon making the diagnosis
of RA as early as possible.
• The recognition of RA early in the course of inflammatory arthritis,
before irreversible injury has occurred, is thus an important element
of effective management.
Principles of management
There are several general principles that are important in the
management of all patients with RA:
• Achievement and maintenance of tight control of disease activity,
defined as remission or a state of low disease activity.
• Treatment of all patients diagnosed with RA with DMARD therapy.
• Use of antiinflammatory therapies, including NSAIDs and
glucocorticoids, to help control symptoms until DMARDs take effect.
NONPHARMACOLOGIC THERAPIES
• A number of nonpharmacologic measures and other medical
interventions are important in the comprehensive management of RA
in all stages of disease, in addition to antiinflammatory and
antirheumatic drug therapies.
1. Patient education
2. Rest, exercise, and physical and occupational therapy
3. Nutritional and dietary counseling
4. Interventions to ↓ risks of CV disease, including smoking cessation.
5. Immunizations to ↓ risk of infectious complications of
immunosuppressive therapies
Pretreatment evaluation
Prior to starting, resuming, or significantly increasing therapy with
nonbiologic or biologic DMARDs, we do the following baseline studies :
• General testing for all patients —CBC, s. creatinine, AT, ESR, & CRP .
• Serologic testing for hepatitis prior to methotrexate , leflunomide , or
biologic DMARDs — (All patients at increased risk of hepatitis, such as those who have a
history of iv drug abuse, multiple sex partners in the previous 6 mnths, and those who are healthcare
workers, should be screened for hepatitis B and C before starting these medications )
• Ophthalmologic screening for hydroxychloroquine use .
• Testing for latent tuberculosis —skin testing or an interferon-gamma
release assay prior to all biologic DMARDs and prior to use of the
Janus kinase inhibitor, tofacitinib.
Choice of therapy
• Rapidly acting antiinflammatory medications, including nonsteroidal
antiinflammatory drugs (NSAIDs) and systemic and intraarticular
glucocorticoids.
• Nonbiologic DMARDs : hydroxychloroquine , sulfasalazine , methotrexate ,
and leflunomide .
• Biologic DMARDs: produced by recombinant DNA technology, generally
target cytokines or their receptors or are directed against other cell surface
molecules.
• Several kinase inhibitors : Tofacitinib . It is an orally administered small
molecule DMARD that inhibits cytokine and growth factor signalling
through interference with Janus kinases.
• Denosumab in Osteoporosis
Note: Ruxolitinib is used in Polycythemia Vera
NonBiologic DMARDs
Names Major Adverse effect
Hydroxychloroquine damage to the retina of the eye
Sulfasalazine nausea, vomiting, loss of appetite,
headache, dizziness, may cause skin and
urine to turn orange-yellow.
methotrexate Rash, liver/lung/ bone marrow toxicity
Leflunomide Diarrhea
Azathioprine nausea, vomiting, decreased appetite, liver
function abnormalities, low white blood cell
counts
Cyclosporine HTN, Renal dysfunction
Biologic DMARDs
Names Examples
TNF Inhibitor Etanercept, Golimumab, Adalimumab and
Certolizumab, Infliximab (E-GACI)
IL1 Antagonist Anakinra
IL-6 receptor antagonist Tocilizumab
T-cell costimulation blocker Abatacept
Anti-CD20 B-cell depleting
monoclonal antibody
Rituximab
Early use of DMARDs : stratification
mildly active RA
moderately to severely active RA,
resistant to initial DMARD therapy (eg,
MTX)
DEFINITION OF MILDLY ACTIVE RA
Patients with mildly active rheumatoid arthritis (RA) typically
meet ACR/EULAR criteria for RA and have all of the following
1. Fewer than five inflamed joints
2. Mildly elevated or normal ESR and C-rp levels
3. No extraarticular disease
4. No evidence of erosions/cartilage loss on radiographs of the hands,
wrists, and feet
5. Low levels of measures of disease activity such as the DAS28
DEFINITION OF MODERATELY TO SEVERELY
ACTIVE RA
• Patients with moderately to severely active RA are at greater risk of
developing joint damage and disability than patients with mildly active
disease . These patients typically meet the American College of
Rheumatology (ACR)/ European League Against Rheumatism (EULAR)
criteria for RA and exhibit a combination of the following:
1. At least 5 inflamed joints
2. Elevation in the ESR and/or serum CRP concentration
3. Positive RF and/or anticyclic citrullinated peptide (CCP) antibodies
4. Evidence of inflammation on plain radiography of the hands, wrists, or
feet, such as osteopenia and/or periarticular swelling. In addition,
minimal joint space narrowing and small peripheral erosions may be
observed.
Definition of resistance to initial DMARDs
Resistance to initial DMARD therapy is defined as one of the following:
• Failure to achieve remission or low disease activity within 3-6 mnths
of initiating (MTX) or other DMARD therapy in maximally tolerated
doses.
• A requirement, in addition to DMARDs, for chronic glucocorticoid
therapy in a dose of greater than about 5-
7.5 mg/day of prednisone or equivalent to achieve or maintain
remission or low disease activity after 3-6 mnths of Rx with DMARDs.
• A requirement for multiple courses with glucocorticoids, in excess of
doses used for chronic therapy, for the treatment of recurrent disease
flares.
Early use of DMARDs
mildly active RA Initiate antiinflammatory therapy with a NSAID for rapid
symptomatic relief and begin DMARD treatment with either
hydroxychloroquine (HCQ) or sulfasalazine (SSZ).
moderately to severely active RA, Initiate antiinflammatory therapy with either a NSAID or
glucocorticoid, and generally start DMARD therapy with
methotrexate (MTX).
resistant to initial DMARD therapy (eg, MTX) treat with a combination of DMARDs (eg, MTX plus either a
TNF inhibitor or SSZ and HCQ) or, alternatively, we switch the
patient to a different DMARD of potentially comparable
efficacy (eg, leflunomide or a TNF inhibitor), while also treating
the active inflammation with antiinflammatory drug therapy.
Prognosis
• Outcome in RA is compromised when diagnosis and treatment are delayed.
• Approximately 40% of patients with this disease become disabled after 10 years, but outcomes
are highly variable. Some patients experience a relatively self-limited disease, whereas others
have a chronic progressive illness.
• It has been shown that intervention with DMARDs in very early RA (symptom duration < 12 weeks
at the time of first treatment) gives the best opportunity for attempting to achieve disease
remission.
Unfavorable prognostic factors:
• HLA-DR4 genotype
• High serum titer of autoantibodies (eg, RF and ACPA)
• Extra-articular manifestations
• Large number of involved joints
• Age younger than 30 years
• Female sex
• Systemic symptoms
End of slides
• Davidson’s
• Uptodate 21.0
• Medscape
• ARA/EULAR guidelines

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Rheumatoid arthritis treatment

  • 1. Rheumatoid Arthritis : Management (simplified) Dr Pratap Sagar Tiwari Note: This is just a lecture class slides to MBBS students
  • 2. INTRODUCTION • RA is characterized by acute and chronic inflammation in the synovium, which is associated with a proliferative and destructive process in joint tissues. • The treatment of RA is directed toward the control of synovitis and the prevention of joint injury. • Achieving the benefits of early intervention with disease-modifying antirheumatic drugs (DMARDs) depends upon making the diagnosis of RA as early as possible. • The recognition of RA early in the course of inflammatory arthritis, before irreversible injury has occurred, is thus an important element of effective management.
  • 3. Principles of management There are several general principles that are important in the management of all patients with RA: • Achievement and maintenance of tight control of disease activity, defined as remission or a state of low disease activity. • Treatment of all patients diagnosed with RA with DMARD therapy. • Use of antiinflammatory therapies, including NSAIDs and glucocorticoids, to help control symptoms until DMARDs take effect.
  • 4. NONPHARMACOLOGIC THERAPIES • A number of nonpharmacologic measures and other medical interventions are important in the comprehensive management of RA in all stages of disease, in addition to antiinflammatory and antirheumatic drug therapies. 1. Patient education 2. Rest, exercise, and physical and occupational therapy 3. Nutritional and dietary counseling 4. Interventions to ↓ risks of CV disease, including smoking cessation. 5. Immunizations to ↓ risk of infectious complications of immunosuppressive therapies
  • 5. Pretreatment evaluation Prior to starting, resuming, or significantly increasing therapy with nonbiologic or biologic DMARDs, we do the following baseline studies : • General testing for all patients —CBC, s. creatinine, AT, ESR, & CRP . • Serologic testing for hepatitis prior to methotrexate , leflunomide , or biologic DMARDs — (All patients at increased risk of hepatitis, such as those who have a history of iv drug abuse, multiple sex partners in the previous 6 mnths, and those who are healthcare workers, should be screened for hepatitis B and C before starting these medications ) • Ophthalmologic screening for hydroxychloroquine use . • Testing for latent tuberculosis —skin testing or an interferon-gamma release assay prior to all biologic DMARDs and prior to use of the Janus kinase inhibitor, tofacitinib.
  • 6. Choice of therapy • Rapidly acting antiinflammatory medications, including nonsteroidal antiinflammatory drugs (NSAIDs) and systemic and intraarticular glucocorticoids. • Nonbiologic DMARDs : hydroxychloroquine , sulfasalazine , methotrexate , and leflunomide . • Biologic DMARDs: produced by recombinant DNA technology, generally target cytokines or their receptors or are directed against other cell surface molecules. • Several kinase inhibitors : Tofacitinib . It is an orally administered small molecule DMARD that inhibits cytokine and growth factor signalling through interference with Janus kinases. • Denosumab in Osteoporosis Note: Ruxolitinib is used in Polycythemia Vera
  • 7. NonBiologic DMARDs Names Major Adverse effect Hydroxychloroquine damage to the retina of the eye Sulfasalazine nausea, vomiting, loss of appetite, headache, dizziness, may cause skin and urine to turn orange-yellow. methotrexate Rash, liver/lung/ bone marrow toxicity Leflunomide Diarrhea Azathioprine nausea, vomiting, decreased appetite, liver function abnormalities, low white blood cell counts Cyclosporine HTN, Renal dysfunction
  • 8. Biologic DMARDs Names Examples TNF Inhibitor Etanercept, Golimumab, Adalimumab and Certolizumab, Infliximab (E-GACI) IL1 Antagonist Anakinra IL-6 receptor antagonist Tocilizumab T-cell costimulation blocker Abatacept Anti-CD20 B-cell depleting monoclonal antibody Rituximab
  • 9. Early use of DMARDs : stratification mildly active RA moderately to severely active RA, resistant to initial DMARD therapy (eg, MTX)
  • 10. DEFINITION OF MILDLY ACTIVE RA Patients with mildly active rheumatoid arthritis (RA) typically meet ACR/EULAR criteria for RA and have all of the following 1. Fewer than five inflamed joints 2. Mildly elevated or normal ESR and C-rp levels 3. No extraarticular disease 4. No evidence of erosions/cartilage loss on radiographs of the hands, wrists, and feet 5. Low levels of measures of disease activity such as the DAS28
  • 11. DEFINITION OF MODERATELY TO SEVERELY ACTIVE RA • Patients with moderately to severely active RA are at greater risk of developing joint damage and disability than patients with mildly active disease . These patients typically meet the American College of Rheumatology (ACR)/ European League Against Rheumatism (EULAR) criteria for RA and exhibit a combination of the following: 1. At least 5 inflamed joints 2. Elevation in the ESR and/or serum CRP concentration 3. Positive RF and/or anticyclic citrullinated peptide (CCP) antibodies 4. Evidence of inflammation on plain radiography of the hands, wrists, or feet, such as osteopenia and/or periarticular swelling. In addition, minimal joint space narrowing and small peripheral erosions may be observed.
  • 12. Definition of resistance to initial DMARDs Resistance to initial DMARD therapy is defined as one of the following: • Failure to achieve remission or low disease activity within 3-6 mnths of initiating (MTX) or other DMARD therapy in maximally tolerated doses. • A requirement, in addition to DMARDs, for chronic glucocorticoid therapy in a dose of greater than about 5- 7.5 mg/day of prednisone or equivalent to achieve or maintain remission or low disease activity after 3-6 mnths of Rx with DMARDs. • A requirement for multiple courses with glucocorticoids, in excess of doses used for chronic therapy, for the treatment of recurrent disease flares.
  • 13. Early use of DMARDs mildly active RA Initiate antiinflammatory therapy with a NSAID for rapid symptomatic relief and begin DMARD treatment with either hydroxychloroquine (HCQ) or sulfasalazine (SSZ). moderately to severely active RA, Initiate antiinflammatory therapy with either a NSAID or glucocorticoid, and generally start DMARD therapy with methotrexate (MTX). resistant to initial DMARD therapy (eg, MTX) treat with a combination of DMARDs (eg, MTX plus either a TNF inhibitor or SSZ and HCQ) or, alternatively, we switch the patient to a different DMARD of potentially comparable efficacy (eg, leflunomide or a TNF inhibitor), while also treating the active inflammation with antiinflammatory drug therapy.
  • 14. Prognosis • Outcome in RA is compromised when diagnosis and treatment are delayed. • Approximately 40% of patients with this disease become disabled after 10 years, but outcomes are highly variable. Some patients experience a relatively self-limited disease, whereas others have a chronic progressive illness. • It has been shown that intervention with DMARDs in very early RA (symptom duration < 12 weeks at the time of first treatment) gives the best opportunity for attempting to achieve disease remission. Unfavorable prognostic factors: • HLA-DR4 genotype • High serum titer of autoantibodies (eg, RF and ACPA) • Extra-articular manifestations • Large number of involved joints • Age younger than 30 years • Female sex • Systemic symptoms
  • 15. End of slides • Davidson’s • Uptodate 21.0 • Medscape • ARA/EULAR guidelines

Hinweis der Redaktion

  1. DMARDs can be further subdivided into traditional small molecular mass drugs synthesised chemically and newer 'biological' agents produced through genetic engineering.
  2. We recommend that all patients diagnosed with RA be started on disease-modifying antirheumatic drug (DMARD) therapy as soon as possible. The choice of initial drug therapy depends in large part upon the degree of disease activity. We distinguish between those patients with mildly active disease and the majority of patients with more active disease.
  3. We recommend that all patients diagnosed with RA be started on disease-modifying antirheumatic drug (DMARD) therapy as soon as possible. The choice of initial drug therapy depends in large part upon the degree of disease activity. We distinguish between those patients with mildly active disease and the majority of patients with more active disease.