Rheumatology Rheumatology Update 2008Update 2008

R.W.Jackson,D.O.,F.A.C.O.I.R.W.Jackson,D.O.,F.A.C.O.I.

Kirksville, MO.Kirksville, MO.

rheumdr@hotmail.comrheumdr@hotmail.com

Rheumatology Three Major Rheumatology Three Major RisksRisks

>Heart<>Heart< >Head<>Head< >Bugs<>Bugs<

These represent the majorThese represent the major

Causes of death & lawsuits Causes of death & lawsuits

‘‘HEART’HEART’

Rheumatology patients have a major Rheumatology patients have a major increase risk in CAD due more to increase risk in CAD due more to ‘inflammation‘inflammation’ then atherosclerosis’ then atherosclerosis

Dr. Sherine Gabriel ACR Winter Conf.Dr. Sherine Gabriel ACR Winter Conf. Rheum pts. Have 2 X greater risk for CHFRheum pts. Have 2 X greater risk for CHF Anti-TNF therapy contra-indicated in Anti-TNF therapy contra-indicated in

patients who have advanced CHFpatients who have advanced CHF Rheum pts. Have 10yrs reduced life-spanRheum pts. Have 10yrs reduced life-span

‘‘HEART’HEART’

Aggressively evaluate patients with CP, Aggressively evaluate patients with CP, SOB, atypical CP & Pre-op. presentationsSOB, atypical CP & Pre-op. presentations

Stress to Cardiology consultants the Stress to Cardiology consultants the need for added attention to Rheum pts. need for added attention to Rheum pts.

Control the ‘inflammation’ with goals to Control the ‘inflammation’ with goals to normalize the ESR (sed rate) and CRP normalize the ESR (sed rate) and CRP

(C-reactive protein)(C-reactive protein)

‘‘HEAD’HEAD’

SLE, Temporary arteritis, Sjogrens, and SLE, Temporary arteritis, Sjogrens, and Vasculopathies all associated with CNS Vasculopathies all associated with CNS ds.ds.

CNS vasculopathies very difficult to dx.CNS vasculopathies very difficult to dx. Rheum diseases can result in CVA sx, MS, Rheum diseases can result in CVA sx, MS,

seizures, dementia and neuropathies.seizures, dementia and neuropathies. Rheum diseases are potentially Rheum diseases are potentially

preventable and quiet treatable causes of preventable and quiet treatable causes of these conditions.these conditions.

‘‘BUGS’BUGS’

Rheumatology patients are inherently Rheumatology patients are inherently prone to prone to ‘infections’‘infections’. (Pneumonia is . (Pneumonia is the number cause of death in RA the number cause of death in RA patients)patients)

Therapy with prednisone and Therapy with prednisone and immunosuppressive agents obviously immunosuppressive agents obviously increase this risk. By as much as 2X!increase this risk. By as much as 2X!

Treat all patients with autoimmune Treat all patients with autoimmune diseases as diseases as ‘high risk’‘high risk’

‘‘BUDS’BUDS’

Any fever in Rheum patients is significant Any fever in Rheum patients is significant and treat a temp of 100F = 104Fand treat a temp of 100F = 104F

Start antimicrobial therapy earlier and Start antimicrobial therapy earlier and more aggressivelymore aggressively

Withhold DMARDs (ie. MTX and Biologics) Withhold DMARDs (ie. MTX and Biologics) during the treatment if infectionsduring the treatment if infections

IMMUNIZE!!!! (avoid attenuated live virus IMMUNIZE!!!! (avoid attenuated live virus vaccinations in patients on Biologics!)vaccinations in patients on Biologics!)

Osteoarthritis UpdateOsteoarthritis Update

‘‘SINGLE” injection SINGLE” injection viscosupplementationviscosupplementation

Oral hyaluronates Oral hyaluronates (Membrell NEM)(Membrell NEM) Glucosamine/chondroitin sulfate Glucosamine/chondroitin sulfate

helpfulhelpful Traditional NSAIDs causing ‘havoc’ the Traditional NSAIDs causing ‘havoc’ the

only UGI protection is from PPIs & only UGI protection is from PPIs & misoprotolmisoprotol

Topical ketoprofen now available Topical ketoprofen now available

Rheumatoid Arthritis UpdateRheumatoid Arthritis Update

Anti-TNF + MTX ‘best hope’ of DMARDsAnti-TNF + MTX ‘best hope’ of DMARDs Certolizumab (Cimzia) fully human Certolizumab (Cimzia) fully human

monoclonal antibody; Golimumab (SQ monoclonal antibody; Golimumab (SQ monthly);Ocrelizumab & Atumumab deplete monthly);Ocrelizumab & Atumumab deplete B-cellsB-cells

Orencia (abataxcept) – AG presenting processOrencia (abataxcept) – AG presenting process Rituxan (rituximab: anti CD-20 B-cells)Rituxan (rituximab: anti CD-20 B-cells) IL-6 inhibitor tocilizumab (Actemra)IL-6 inhibitor tocilizumab (Actemra) Kenerit (IL-1 ihibitor) remains disappointingKenerit (IL-1 ihibitor) remains disappointing

Fibromyalgia UpdateFibromyalgia Update

Lyrica (pregabalin) first FDA Lyrica (pregabalin) first FDA approved medication for fibromyalgia approved medication for fibromyalgia (FM)(FM)

Cymbalta (duloxetine) soon to be Cymbalta (duloxetine) soon to be approved for FMapproved for FM

Mirapex (pramipexole) has showen Mirapex (pramipexole) has showen new promise in the treatment of FMnew promise in the treatment of FM

Systemic Lupus Erythematosus Systemic Lupus Erythematosus UpdateUpdate

Biologics now show promise in the treatment Biologics now show promise in the treatment of Lupus nephritis with both rituxan and of Lupus nephritis with both rituxan and ataciceptatacicept

Lower dose cyclosporine (European minipulse) Lower dose cyclosporine (European minipulse) 500mg/2 weeks x 12weeks; instead of USA 500mg/2 weeks x 12weeks; instead of USA 1g/m2 per month for 6 to 12 months.(*)1g/m2 per month for 6 to 12 months.(*)

CellCept (mycophenolate) now less exciting for CellCept (mycophenolate) now less exciting for SLE nephritis in Caucasians (*) SLE nephritis in Caucasians (*)

Dr. David Wofsy reports at ACR Winter Conf.Dr. David Wofsy reports at ACR Winter Conf.

GOUT UpdateGOUT Update

Febuxostat (Adenuric/Puricase) first new Febuxostat (Adenuric/Puricase) first new medication in 40 years (1964) for gout!medication in 40 years (1964) for gout!

-more twice as effective than allopurinol-more twice as effective than allopurinol

-less adverse side-effects than allopurinol-less adverse side-effects than allopurinol

-useful in patients with advance renal ds.-useful in patients with advance renal ds. New goal : reduce the uric acid New goal : reduce the uric acid <4.5mg%<4.5mg%

Scleroderma with Pulmonary Scleroderma with Pulmonary Artery Hypertension (PAH) Artery Hypertension (PAH)

UpdateUpdate PAH now treatable! (Past Mortalities PAH now treatable! (Past Mortalities

<2yr)<2yr)

-epoprostenol-epoprostenol

-bosentan-bosentan

-inhaled treprostinil-inhaled treprostinil

-tadafil-tadafil

Very expensive & requires Sub-Very expensive & requires Sub-specialists specialists

Juvenile Ideopathic Arthritis Juvenile Ideopathic Arthritis UpdateUpdate

JIR ‘New title’ for Juvenile JIR ‘New title’ for Juvenile Rheumatoid ArthritisRheumatoid Arthritis

JIR probably represents 5 different JIR probably represents 5 different conditionsconditions

More common overlap of More common overlap of RA/SLE/Spondylitis featuresRA/SLE/Spondylitis features

Arthralgias during the daytime Arthralgias during the daytime notnot “growing pains”“growing pains”

Don’t forget about Don’t forget about Rheumatic FeverRheumatic Fever

Osteoporosis UpdateOsteoporosis Update

““Best Calcium” > Best Calcium” > Membrell EggshellMembrell Eggshell CalciumCalcium for Bone Health – 3 caps/day for Bone Health – 3 caps/day

““Best Vitamin D” 25-hydroxyvitamin Best Vitamin D” 25-hydroxyvitamin (D3) Maxium D3 10000 iu / week (D3) Maxium D3 10000 iu / week

Vit D3 treatment goal Vit D3 treatment goal >40ng/ml>40ng/ml New FDA guidelines will increase Vit D New FDA guidelines will increase Vit D

suggested supplementation to suggested supplementation to 1000iu/d1000iu/d

Questions? Questions? Comments.Comments.

Thank you!Thank you!R.W.Jackson,D.O.,F.A.C.O.I.R.W.Jackson,D.O.,F.A.C.O.I.

Kirksville, MOKirksville, MOrheumdr@hotmail.comrheumdr@hotmail.com