Management of Rheumatoid Arthritis · 2019-02-28 · 2/28/2019 1 64C-1873093 1 Management of Rheumatoid Arthritis Early detection to ensure appropriate care 64C-1873093 2 Learning

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Management ofRheumatoid ArthritisEarly detection to ensure appropriate care

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Learning objectives

• Recognize the signs and symptoms of Rheumatoid Arthritis (RA)

• Assess the patient in order to provide a provisional diagnosis

• Understand the importance of an early and accurate diagnosis

• Recognize the importance of referring patients to a rheumatologist for co-management care

• Understanding the morbidity and risks associated with the disease

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Rheumatoid Arthritis (RA)

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What is RA and who does it affect?1

• A chronic, systemic, inflammatory autoimmune disease

• Most common form of inflammatory disease that affects diarthrodial joints

• As disease progresses, it can lead to irreversible joint damage and disability

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1. Tehlirian CV, Bathon JM. In: Kippel JH, et al., eds. Primer on the Rheumatic Diseases; 2008:114-121.

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How does RA present?• Polyarticular (>4 joints), often

symmetric1

– Swelling and tenderness of small peripheral joints [metacarpophalangeal (MCP) joints, proximal interphalangeal (PIP) joints of the fingers, interphalangeal joints of the thumbs, metatarsophalangeal (MTP) joints, and wrists]2

– As disease progresses, larger peripheral joints may become affected (ankles, knees, elbows, and shoulders)

• Systemic1

– Fever, weight loss, or fatigue

– Morning stiffness ≥1 hour

– Limited range of motion

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1. Berman JR, Paget SA. Polyarticular pain.The Merck Manuals. Available at: http://www.merckmanuals.com/professional/sec04/ch033/ch033b.html. Accessed Jan. 4th, 2011.


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Radiographic damage can occur early in RA

• Researchers studying RA now believe that joint damage can begin in the first year or 2 of the disease1,2

– Structural damage continues to progress throughout the course of the disease

• A key reason RA patients are seen late by rheumatologists is that patients delay talking about symptoms with their PCP1

1. Bernatsky S, et al. Clin Rheumatol. 2010;29(6):645-657.2. NIH. Handout on health: rheumatoid arthritis. http://www.niams.nih.gov/Health_Info/Rheumatic_Disease/default.asp. Accessed August 31, 2016.3. Kumar K, et al. Rheumatology (Oxford). 2007;46(9):1438-1440.4. ACR. RA: radiographic progression, hand and wrist. [Rheumatology image library]. http://images.rheumatology.org/bp/#/folder/75692#3011199.

Accessed August 23, 2016.

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Did you know?3

In a survey of 168 RA patients, there was a median delay of 12 weeks before a patient was assessed in primary care.

• May be driven by a lack of awareness

of RA

Serial radiographs taken at 4-year intervals show progressive joint damage as evidenced by worsening carpal bone ankylosis, joint space loss, and metacarpophalangeal (MCP) erosions.4

© 2011 ACR; used with permission.

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The case for early identification and referral to a rheumatologist

1. Emery P, et al. Ann Rheum Dis. 2002;61(4):290-297.2. ACR Subcommittee on RA Guidelines. Arthritis Rheum. 2002;46(2):328-346.

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• Early identification of RA and referral to a rheumatologist can improve the long-term outcome of the disease

Did you know?In a recent survey of 138 PCPs, 96% made a correct provisional RA diagnosis. Many RA cases were targeted for rheumatology referral, but 22% of cases were not.

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Primary Caregivers and RA

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Primary caregivers and RA: Recognize, Assess, and Advocate1-3

1. ACR Subcommittee on RA Guidelines. Arthritis Rheum. 2002;46(2):328-346.2. Kountz DS, Von Feldt JM. J Fam Pract. 2007;56(10)(suppl A):59A-73A.3. Thompson AE. Rheumatol Natl Grand Rounds. 2010;1(3):1-6.

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• Identify the signs and symptomsof RA

• Order baseline and diagnostic lab/imaging tests

• Perform a clinical examination

• Provide a provisional diagnosis

• Direct the patient to the appropriate specialist

• Relay important patient assessment information

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Joints of the hands and feet commonly affected by RA

• The physical examination is a critical component in making a diagnosis1

• The condition of the hands and wrists often indicates the patient’s overall disease status2

– Symmetric swelling and tenderness upon palpation are usually first noted at wrist, MCP joints, PIP joints of the fingers, and MTP joints3

– Rheumatoid joints are normally boggy and warm, but they typically are not erythematous


2. Weinblatt ME, Kuritzky L. J Fam Pract. 2007;56(4 suppl):S1-8.3. Rindfleisch JA, Muller D. Am Fam Physician. 2005;72(6):1037-1047.4. ACR. RA: fusiform swelling, hand. [Rheumatology image library]. http://images.rheumatology.org/bp/#/folder/75692#2862485. Accessed August 23, 2016.5. ACR. RA: foot. [Rheumatology image library]. http://images.rheumatology.org/bp/#/folder/75692#2862535. Accessed August 23, 2016.

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Swelling and tenderness of the PIP is a common early finding in RA.4

Soft-tissue swelling, osteopenia, and narrowing of the MTP joints.5

© 2011 ACR; used with permission


PIP

MTP

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Extra-articular manifestations of RA

• Clinical evaluations should be done periodically as a response to new symptoms

• It is important to monitor patients for the conditions in the table below

• A referral to a specialist should be made if any co-morbidities arise that would require a specialist’s attention

• Prevalence: 40% at any time during course of disease

Mielants H et al. Clin Exp Rheumatol. 2009;27(suppl 55):S56-S61.

Rheumatoidnodules

Episcleritis

Pulmonary nodules

© 2011 ACR

© 2011 ACR

Vasculitis of the fingers

© 2011 ACR


Extra-articular manifestations of RA1

1. Mielants H, Van den Bosch F. Clin Exp Rheumatol. 2009;27(4)(suppl 55):S56-61.

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PsA, RA, OA, and AS: differential diagnoses1

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1. Gottlieb A, et al. J Am Acad Dermatol. 2008;58(5):851-864.

PsA=Psoriatic Arthritis; OA=Osteoarthritis; AS=Ankylosing Spondylitis.

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Differential diagnosis (continued)1,2

• Systemic connective tissue disorders– Systemic lupus erythematosus (SLE)– Mixed connective tissue disease (MCTD)– Sjögren’s syndrome

• Seronegative spondyloarthropathies– Psoriatic arthritis (PsA)– Ankylosing spondylitis (AS)– Reactive arthritis– Arthritis associated with inflammatory bowel

disease (IBD)• Infectious arthritis

– Lyme-associated arthritis– Hepatitis C-associated arthritis– Parvovirus B19-associated arthritis

1. Rindfleisch JA, Muller D. Am Fam Physician. 2005;72(6):1037-1047.2. Tehlirian CV, Bathon JM. In: Kippel JH, et al., eds. Primer on the Rheumatic Diseases; 2008:114-121.

Swelling of the DIP joints, skin, and nail changes are common in PsA.

Malar or “butterfly” rash is often seen in SLE.

Lyme-associated arthritis can occur weeks after the acute infection, which is characterized by a bullseye rash.

Raynaud’s disease is common in MCTD.

© 2011 ACR© 2011 ACR© 2011 ACR


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• Prompt referral is advised when RA is suspected based on supportive clinical criteria:

1. ≥3 swollen joints

2. MCP/MTP involvement: positive “squeeze test,” pain following hand or foot compression

3. Morning stiffness ≥30 min

Criteria for early referral1

1. Emery P, et al. Ann Rheum Dis. 2002;61(4):290-297.

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2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR)Classification Criteria for Rheumatoid Arthritis1

“Definite” RA is defined as:

Patients who:

• Have at least 1 joint with definite clinical synovitis (swelling)

• With the synovitis not better explained by another disease

Achievement of a total score of 6 or greater (of a possible 10) fromthe individual scores in 4 domains:

• Number and site of involved joints

• Serologic abnormality

• Elevated acute-phase response

• Symptom duration

1. Aletaha D, et al. Arthritis Rheum. 2010;62(9):2569-2581.

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The new 2010 classification system, a score-based algorithm of 4 domains, redefines the current RA paradigm by focusing on the features at earlier disease stages that are associated with persistent and/or erosive disease, rather than defining the disease by its late-stage features.

ACR/EULAR 2010 classification criteria for RA (continued)

Aletaha D, et al. Arthritis Rheum. 2010;62(9):2569-2581.

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RF=rheumatoid factor; ACPA=anti-citrullinated protein antibody; ESR=erythrocyte sedimentation rate; CRP=C-reactive protein.

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Laboratory markers

• Based on the ACR/EULAR 2010 RA classification criteria, in orderto classify a patient with definite RA, physicians must obtain:

– A history of symptom duration

– A thorough joint evaluation

– At least 1 serologic test (RF or Anti-CCP [ACPA])

– At least 1 acute-phase response measure (ESR or CRP)

• Baseline complete blood count, urinalysis, and liver function tests are recommended and help to guide medication choices

ACR Subcommittee on RA Guidelines. Arthritis Rheum. 2002;46(2):328-346.Aletaha D et al. Arthritis Rheum. 2010;62(9):2569-2581.Rindfleisch JA et al. Am Fam Physician. 2005;72(6):1037-1047.

Laboratory markers

1. Aletaha D, et al. Arthritis Rheum. 2010;62(9):2569-2581.2. ACR Subcommittee on RA Guidelines. Arthritis Rheum. 2002;46(2):328-346.3. Rindfleisch JA, Muller D. Am Fam Physician. 2005;72(6):1037-1047.

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Laboratory markers (cont’d)

Bizarro N et al. Clin Chem. 2001;47(6):1089-1093.Rindfleisch JA et al. Am Fam Physician. 2005;72(6):1037-1047.Tehlirian CV et al. In: Klippel JH et al, eds. Primer on the Rheumatic Diseases. 13th ed. 2008:114-121.

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RF=rheumatoid factor; anti-CCP=anticyclic citrullinated peptide; ESR=erythrocyte sedimentation rate; CRP=C-reactive protein.

Laboratory markers cont'dLaboratory markers cont’d

1. Bizzaro N, et al. Clin Chem. 2001;47(6):1089-1093.2. Rindfleisch JA, Muller D. Am Fam Physician. 2005;72(6):1037-1047.3. Tehlirian CV, Bathon JM. In: Kippel JH, et al., eds. Primer on the Rheumatic Diseases; 2008:114-121.

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Serologic factors in RA: anti-CCP and RF

• RF and anti-CCP are serum parameters strongly associated with an aggressive disease course

– High levels of both correlate with erosive joint disease, functional disability, and extra-articular disease

• Diagnostic yield is enhanced by measuring both RF and anti-CCP in a patient suspected of having RA

Tehlirian CV et al. In: Klippel JH et al, eds. Primer on the Rheumatic Diseases. 13th ed. 2008:114-121.

Serological factors in RA: anti-CCP and RF1


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Radiographic imaging in RA

• In early stages, radiographs of the small joints of the hands and feet will show periarticular osteopenia. This is variable and nondiagnostic

• With disease progression, loss of cartilage causes symmetric joint space narrowing

• Bony erosions generally appear on the margin of joints, both medially and laterally, and on both opposing bones

Kountz DS et al. J Fam Pract. 2007;56(suppl 10A):59a-74a.

Tehlirian CV et al. In: Klippel JH et al, eds. Primer on the Rheumatic Diseases. 13th ed. 2008:114-121.

Progressive changes seen on an MCP joint with (A) soft-tissue swelling, but no erosions, (B) thinning of the cortex on the radial side and minimal joint space narrowing, and (C) marginal erosion at the radial side with joint space narrowing


Radiographic imaging in RA

1. Kountz DS, Von Feldt JM. J Fam Pract. 2007;56(10)(suppl A):59A-73A.2. Tehlirian CV, Bathon JM. In: Kippel JH, et al., eds. Primer on the Rheumatic Diseases; 2008:114-121.3. ACR. RA: hand, progressive metacarpophalangeal erosion. [Rheumatology image library].

http://images.rheumatology.org/bp/#/folder/75692#2862526. Accessed August 23, 2016.

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The value of triage information in the referral process1-3

• Priority-setting tools can help improve the referral process

1. Thompson AE. Rheumatol Natl Grand Rounds. 2010;1(3):1-6.2. Graydon SL, Thompson AE. J Rheumatol. 2008;35(7):1378-1383.3. Kountz DS, Von Feldt JM. J Fam Pract. 2007;56(10)(suppl A):59A-73A.4. ACR Subcommittee on RA Guidelines. Arthritis Rheum. 2002;46(2):328-346.5. Weinblatt ME, Kuritzky L. J Fam Pract. 2007;56(4 suppl):S1-8.

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Primary caregivers1,4,5

• Recognize RA and provide aprovisional diagnosis based onthe criteria for early referral

• Referral to specialist to ensure early intervention

• Optional: order baseline testing/imaging

Rheumatologist4

• Confirm diagnosis and prescribeappropriate therapy

• Jointly monitor patient progress,RA complications, and/or possible drug AEs with primary caregiver

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Patient assessment andreferral form1

• Important information includes:

– Basic details of patient’s history, including symptom duration

– Physical examination results

– Documentation of swollen joints

– Inflammatory and serologic lab data

1. Thompson AE. Rheumatol Natl Grand Rounds. 2010;1(3):1-6.

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Referral form provided by Dr. Robin Dore.

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RA Case Study

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Case study1

• MP, a 50-year-old woman noted bilateral hand discomfort for 3 months, followed 1 month later by bilateral foot pain when walking

• Self-medicated with OTC ibuprofen, 400 mg tid with minimal benefit; visits her family physician

– Complains of stiffness after awakening (1 or 2 hours), which improves gradually in the course of the day

– Remarks that she sometimes has difficulty turning faucets and firmly holding a toothbrush

– Sleep is sometimes disturbed by pain; feels tired throughout the day

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1. Weinblatt ME, Kuritzky L. J Fam Pract. 2007;56(4 suppl):S1-8.

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Case study1-3

• Physical examination normal, except for:

– 4 swollen proximal interphalangeal (PIP) joints on the right hand and 4 on the left

– Compression of metacarpophalangeal (MCP) joints indicate symmetric tenderness and pain (positive squeeze test)

– Feet tender to palpation without obvious synovitis

– Compression of metatarsophalangeal (MTP) joints causes pain (positive squeeze test)

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1. Rindfleisch JA, Muller D. Am Fam Physician. 2005;72(6):1037-1047.2. Weinblatt ME, Kuritzky L. J Fam Pract. 2007;56(4 suppl):S1-8.3. Emery P, et al. Ann Rheum Dis. 2002;61(4):290-297.


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• Lab values1

• X-ray of hands, feet, and wrists

– Soft tissue swelling most apparentaround PIP and MCP joints in theindex and middle fingers

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Case study conclusion

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Provisional diagnosis: rheumatoid arthritis– Prescribe naproxen 500 mg bid and prednisone 7.5 mg qd– Refer to rheumatologist for an early appointment


ALT/AST=aspartate aminotransferase/alanine aminotransferase. 1. Kountz DS, Von Feldt JM. J Fam Pract. 2007;56(10)(suppl A):59A-73A.2. ACR. Rheumatoid arthritis: hand, soft-tissue swelling. [Rheumatology image library].

http://images.rheumatology.org/bp/#/folder/75692#2862524. Accessed August 23, 2016.

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Co-morbidities in RA

• Clinical evaluations should be done periodically as a response to new symptoms1-3

• It is important to monitor patients for any potential co-morbidities

• A referral to a specialist should be made if any co-morbidities arise that would require a specialist’s attention

Cardiovascular disease3,4

• Patients with RA have a higher incidence of fatal and nonfatal cardiovascular events (MI and stroke) than the general population

Infectious diseases3

• RA patients are at an increased risk for infections

Malignancies

• There is an increased risk of certain types of cancer in RA patients: The link between RA and cancer is unclear.

1. Bruce TO. Curr Psychiatry Rep. 2008;10(3):258-264.2. Mines D, et al. Presented at: EULAR 2008; Paris, France.

http://www.abstracts2view.com/eular/view.php?nu=EULAR08L_OP-0138&terms=. Accessed Sept 1, 2016.

3. Bingham CO, 3rd, Miner MM. J Fam Pract. 2007;56(10 suppl):S1-7.4. Semb AG, et al. Ann Rheum Dis. 2010;69(11):1996-2001.

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Therapeutic management of RA1,2

Goals of treatment

• Decrease pain

• Prevent or control joint damage

• Prevent loss of function

1. Singh JA, et al. Arthritis Care Res (Hoboken). 2016;68(1):1-25.2. Rindfleisch JA, Muller D. Am Fam Physician. 2005;72(6):1037-1047.

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NSAIDs=nonsteroidal anti-inflammatory drugs; DMARDs=disease-modifying antirheumatic drugs.

Pharmacologic treatments

To help relieve joint pain and swelling To help reduce joint pain, swelling and may slow progression of joint damage

NSAIDs• Naproxen• Ibuprofen

Glucocorticoids • Prednisone• Prednisolone

Nonbiologic DMARDs• Methotrexate (MTX)• Hydroxychloroquine• Sulfasalazine• Leflunomide

Biologic DMARDs• TNF-α antagonists• IL-1 and IL-6 antagonists• Selective T-cell costimulation modulator• B-cell targeting

JAK Inhibitors

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Conclusion1-3

• Joint damage occurs early in most RA patients

• Early diagnosis and referral to a rheumatologist can make a difference in outcomes and patient benefit

• The quality of communication between providers can help to improve the efficiency of the referral process

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1. Aletaha D, et al. Arthritis Rheum. 2010;62(9):2569-2581.2. Emery P, et al. Ann Rheum Dis. 2002;61(4):290-297.3. van der Heijde DM. Br J Rheumatol. 1995;34(suppl 2):74-78.

Documents

Management of Rheumatoid Arthritis · 2019-02-28 · 2/28/2019 1 64C-1873093 1 Management of Rheumatoid Arthritis Early detection to ensure appropriate care 64C-1873093 2 Learning