Understanding Understanding Rheumatoid ArthritisRheumatoid Arthritis

Randall J. Reed, MD

Friday, November 13, 201511:00 a.m. EST

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Understanding Rheumatoid Understanding Rheumatoid ArthritisArthritis

Randall J. Reed, MD

Rheumatology Associates, PC

Indianapolis, Indiana

ArthritisArthritis

66 million people with arthritis in America2nd only to heart disease in disabilityCosts US $86.2 billionMore common in women than menLimits everyday activities for 7 million

Americans

Types of ArthritisTypes of Arthritis

Over 100 different types of arthritis Osteoarthritis Rheumatoid Arthritis Gout Psoriatic Arthritis Systemic Lupus Erythematosus Septic Arthritis Lyme Disease Ankylosing Spondylitis CPPD Deposition Disease Temporal Arteritis/Polymyalgia Rheumatica

Rheumatoid Arthritis (RA)Rheumatoid Arthritis (RA)

Around 2 million people in the USMore common in women than menCan occur at any age, onset usually in 3rd to

5th decades of lifeChronic, inflammatory disease that

primarily involves jointsRheumatoid arthritis can also affect the

skin, saliva glands, eyes, lungs, and heart

Inflammatory versus Inflammatory versus degenerative arthritisdegenerative arthritis

www.vics.com

What’s happening in RA?What’s happening in RA?

Immune system attacks proteins in joints

Thickening of synovium

Influx of immune cells into joint

Why do people get RA?Why do people get RA?

Genetic predisposition– Family History – Certain Ethnic populations– Genetic marker HLA-DR4

Environmental exposures?– Viruses– Bacteria– Food allergies?

Role of Hormones Immune System

Symptoms of RASymptoms of RA Pain and swelling of joints,

usually symmetrical pattern Morning stiffness lasting

longer than 1 hour Nodules underneath the skin Joint deformity Non-joint symptoms

Joint SwellingJoint Swelling

Joint DeformityJoint Deformity

Nodules of RANodules of RA

How is RA diagnosed?How is RA diagnosed?

Clinical History and ExamBlood tests

– Rheumatoid Factor– Anti-CCP antibody

X-raysMRI

X-ray imageX-ray image

MRI Image of RAMRI Image of RA

From Bocaradiology.com

What should I expect with RA?What should I expect with RA?

A chronic illness, only 5-10% remission rate

Untreated, 90-95% of patients will have bone damage, usually within first 2 years

5-10% of RA patients become disabled every year (old data)

Associated with increased risk of infections, heart disease, and lymphoma

What’s the good news?!What’s the good news?!

Advancements in diagnosis– CCP antibody– MRI and Ultrasound

Better treatments!Advancing Research

– Stem cell– Genetic based therapies– Individualized therapies

Goals of therapy for RAGoals of therapy for RA

Reduce joint pain and swelling Improve Function Prevent erosions and joint deformity Minimize risk of adverse events from medications

How is RA treatedHow is RA treated

Most patients will require a “disease modifying anti-rheumatic drug”, or DMARD

Corticosteroids, i.e. prednisoneNon-steroidal anti-inflammatory drugs

(NSAIDS) / COX-2 inhibitorsJoint injectionsBiological Response Modifiers

DDisease isease MModifying odifying AAnti-nti-RRheumatic heumatic DDrugs (DMARDS)rugs (DMARDS)

Methotrexate (Trexall) Sulfasalazine (Azulfidine) Hydroxychloroquine (Plaquenil) Leuflonomide (Arava)

Azathioprine (Imuran) Cyclosporine (Neoral) Minocycline (Minocin) Gold (Auranofin)

First Line Therapy

Second Line Therapy

Biological therapyBiological therapy Biologics - drugs derived from living

organisms that are designed to either inhibit or supplement a specific component of the immune system

Biologic Response ModifiersBiologic Response Modifiers

Tumor necrosis factor Inhibitors- “Anti-TNF therapy”– Humira (Adalimumab)– Enbrel (Etanercept)– Remicade (Infliximab)– Cimzia (certolizumab pegol)– Simponi (golimumab)

Kineret (Anikinra) Orencia (Abatacept) Rituxan (Rituximab) Actemra (tocilizumab)

Abbvie StudyAbbvie StudyFigure 1: ACR 20 Responses over 52 Weeks

Anti-TNF medicines have Anti-TNF medicines have revolutionized treatment for RArevolutionized treatment for RA

"The PREMIER data are encouraging because they suggest that early and aggressive treatment may slow or inhibit patients' joint damage," said Ferdinand Breedveld, M.D., professor, Department of Rheumatology, University of Leiden, Leiden, Netherlands –from Arthritis News June 9th 2005.

Risks of therapyRisks of therapy

All treatments will carry some risk!Not treating RA also carries a riskAsk doctor about increased risk of

infection, potential liver toxicity, stomach upset, interactions with other medicines; recent press about increased cancer risk

Many of the medications require chronic laboratory monitoring

Diet and ArthritisDiet and Arthritis

Weight lossAnti-oxidants?Vitamin CSupplements

Exercise and arthritisExercise and arthritis

Water AerobicsWalkingPhysical TherapyYoga

Surgery for Surgery for RARA

SummarySummary

• Rheumatoid arthritis is a chronic inflammatory disease that affects joints in a symmetrical pattern; usually hands, wrists and feet become involved

• Left untreated, RA typically leads to joint damage and disability

• Medical treatment for RA can halt disease progression and has improved quality of life for patients