1. DMARDs in RASIDNEY ERWIN T. MANAHAN, MDInternal Medicine - Rheumatology2012 ACR Update

2. Disclosures Training sponsorship from Pfizer Speakers Bureau for Celebrex and Lyrica, Pfizer Honoraria from Ajanta Phils (Atenurix) Participated in clinical drug trials for Roche, Wyeth,Novartis, and Parexel

3. 1996 Goals oftreatment Evaluationtools in RA Management2002 New drugs Benefit ofearlytreatment2008 Definedscenarios Indicationsfor initiatingor resumingDMARDS

4. 2012 Defines Treat to Target Progressing DMARDtreatment Vaccination Schedule Updates on TB Screening

5. Defining ScenariosDURATION EARLY - 6months OR satisfies 1987ACR Criteria for RADISEASE ACTIVITY LOW MODERATE HIGH

6. FEEARunctional Disabilityxtra-articular DiseaserosionsCPA PositivityF PositivityPoor Prognostic Factors

7. Treat-to-TargetTools Remission Low Moderate HighPATIENT-DRIVEN COMPOSITE TOOLSPAS 8.00RAPID-3 1.0-2.0 >2.0-4.0 >4.0PATIENT-PROVIDER COMPOSITE TOOLSCDAI 2.8-10.0 >10.0-22.0 >22.0PATIENT, PROVIDER, LABORATORY COMPOSITE TOOLSDAS28 2.6-3.2-5.1SDAI 3.3-11.0-26.0

8. Medication List Methotrexate (MTX) Leflunomide (LEF) Sulfasalazine (SSZ) Hydroxychloroquine(HCQ) Minocycline MTX + HCQ MTX + LEF MTX + SSZ SSZ + HCQ MTX + SSZ + HCQ Infliximab (INF) Etanercept (ETN) Adalimumab (ADA) Golimumab (GOL) Certolizumab Pegol Abatacept (ABA) Rituximab (RTX) Tocilizumab (TCZ)Items in bold readily available locally

9. EarlyDiseaseDMARD Monotherapy Low Disease Activity Moderate Disease Activitywithout Poor PrognosticFeaturesMTX + HCQ High Disease Activitywithout Poor PrognosticFeaturesDMARD Combination Moderate-High DiseaseActivity with PoorPrognostic FeaturesAnti-TNF + MTX High Disease Activity withPoor Prognostic Features *

10. EarlyDiseasePH StyleDisease ActivityPoor Prognostic FactorsAbsent PresentLow MTX or HCQ MTX or HCQModerate MTX or HCQ MTX + HCQHigh MTX + HCQMTX + HCQAnti-TNF + MTX

11. EstablishedDiseaseDMARD Monotherapy Low Disease Activity withoutPoor Prognostic FeaturesMTX Monotherapy ORDMARD Combination Low Disease Activity withPoor Prognostic Features Moderate-High DiseaseActivity regardless of PoorPrognositc Features**

12. EstablishedDiseasePH StyleDisease ActivityPoor Prognostic FactorsAbsent PresentLow MTX or HCQMTXMTX + HCQModerateMTXMTX + HCQMTXMTX + HCQHighMTXMTX + HCQMTXMTX + HCQ

13. ShiftingTreatmentDMARD Monotherapy Add MTX, LEF or HCQMTX MonotherapyOR MTX Combination Add LEF, HCQ, SSZ Shift to a non-MTX DMARDMTX Monotherapy ORDMARD Combination Add Anti-TNF, Abatacept orRituximabIntensified DMARDCombination ORfollowing 2nd DMARD Add Anti-TNF(3 months)

14. ShiftingTreatmentAnti-TNF Shift to another Anti-TNF Shift to Abatacept,Rituximab or TocilizumabNon-TNF Biologic Shift to other Non-TNFBiologic Shift to Anti-TNF AgentNon-Serious AE whileon Anti-TNF Shift to Another Anti-TNFSerious AE while onAnti-TNF Shift to Non-TNFBiologic(3-6 months)

15. ShiftingTreatmentPH StyleAt 3-6 months AND stillwith moderate-highdisease activityMethotrexate HCQMethotrexate + HCQAdd Anti-TNF or RTXShift to another Anti-TNF or TCZ or RTX*similar recommendationsif patient develops AEswhile on biologic agents

16. High Risk PopulationsNo Biologics Untreated Hep B or Chronic Hep B Child PughClass B or CEtanercept Hepatitis CRituximab Treated solid organ tumors or non-melanomaskin CA 5 yearsNo Anti-TNFs CHF FC III or IV or EF