Rheumatoid Arthiritis Burhan - PowerPoint Presentation

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Rheumatoid Arthiritis

Burhan

Khan

Background

is a chronic autoimmune disease characterized by inflammation of the

synovium

polyarthritis affects particularly in the hands and feet, and is frequently symmetrical.

inflammation results in the release of cytokines (

ie

, interleukins [IL-1 and IL-6] and

tumor

necrosis factor [TNF])



activates macrophage-like

synoviocytes



further release of cytokines



chronic inflammatory state

IL-6 affects the neuroendocrine system and neuropsychological

behavior

.

Goal of targeted medications for the RA is to interfere with the inflammatory

signaling

by targeting the

Cytokine

its receptor

or the downstream

signaling

pathway (

eg

, Janus kinases [JAK])

Clinical Presentation

History

joint pain & swelling & morning stiffness lasts

>

30 minutes, stiffness after prolonged sitting

symptoms that have persisted for longer than 6 weeks

Physical examination

distribution of swollen or tender joints and limited joint motion

extra-articular disease manifestations (

ie

, rheumatoid nodules)

Symmetrical joint involvement

metacarpophalangeal

(MCP) & proximal

interphalangeal

(PIP) joints of the fingers, the

interphalangeal

joints of the thumbs, the wrists, the elbows, the shoulders, the ankles, the knees, and the metatarsophalangeal (MTP) joints of the toes.

Early signs of RA can often be found in the hands where joint tenderness and reduced grip strength are key indicators

Diagnosis

ESR; CRP; CBC with differential, liver and kidney function tests, serum uric acid

Urinalysis

rheumatoid factor (RF) & anti-cyclic

citrullinated

peptide antibody (ACPA); ANA; anti-double stranded DNA

Infectious disease screening

eg

tuberculosis, HBV, HCV

N.B.

both RF and ACPA may be negative in 20% to 50% of patients with RA OR

they may precede the clinical manifestation of RA by many years

Radiographic imaging

Imaging of hands, wrists, and feet is essential to establish a baseline for monitoring disease progression, exclude other diagnoses, and detect characteristic joint erosion.

MRI and ultrasound are not as commonly used to detect joint erosion in RA patients, but due to their increased sensitivity (compared to radiography); they may be useful in patients with negative radiographs or obesity.

ACR & EUALR

diagnostic criteria

European League Against Rheumatism (EULAR)

Nomenclature of RA Pharmacology

disease-modifying

antirheumatic

drugs (

DMARDs)

conventional

synthetic (

cDMARDs

or

csDMARDs

)

MTX,

Leflunomide

,

Hydroxychloroquine

,

sulfasalazine, azathioprine, cyclosporine, D-

penicillamine

,

minocycline

targeted

synthetic (

tDMARDs

or

tsDMARDs

),

biological

originator (

bDMARDs

or

boDMARDs

)

biosimilar

DMARDs (

bsDMARDs

)

Treat-to-target (T2T) approach

DMARD

monotherapy

(preferably MTX) regardless of disease activity

combination DMARDs

DMARDs + Biologics

:

DMARD +

tumor

necrosis factor

inhibitor (

TNFi

) or

non-TNF biologic or

tofacitinib

After

TNFi



another

TNFi

or a non-TNF biologic with or without MTX

Disease activity after

TNFi

therapy should be treated with a non-TNF biologic or

tofacitinib

with or without MTX

Disease activity on a non-TNF biologic should receive a second non-TNF biologic or

tofacitinib

with or without MTX

Escalating T2T

Pharmacological treatment options:

synthetic DMARDs (

hydroxychloroquine

,

leflunomide

, sulfasalazine, and methotrexate)

NSAIDS

Glucocorticoids

N

on-pharmacological measures

physical

occupational

psychological approaches

TNF1:

Adalimumab

,

Eternercept

,

Golimumab

, Infliximab,

Certolizumab

Anti-IL1:

Anakinra

Anti IL6:

Toclizumab

Co-stimulatory modulator:

Abatacept

Jak

inhibitor:

Tofacitinib

B-cell depletion: Rituximab,

Belimumab

Disease Assessment

patient-reported outcome measures (PROMs)

RAPID3

Pt-DAS28 (physician component removed from DAS28)

evaluation by a physician

CDAI (clinical disease activity index)

SDAI (simplified disease activity index)

DAS28 (disease activity score 28-joint count)

CDAI (clinical disease activity index)

outcome measure that is the arithmetic sum of 28 joints

the swollen joint count (SJC)

tender joint count (TJC)

patient's global assessment (PGA)

evaluator's global assessment (EGA)

Score: 0 to 76

No labs needed

SDAI

(simplified disease activity index)

the arithmetic sum of

SJC

TJC

PGA

EGA &

C-reactive protein (CRP)

Score: 0

to 100

DAS28 (disease activity score 28-joint count)

a weighed assessment that includes

SJC

TJC

PGA &

CRP or ESR