Rheumatoid arthritis and Psoriatic arthritis: a guide for Primary Care. Nina Flavin, MD Rheumatology Confluence Health April 13 th, 2018

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1 Rheumatoid arthritis and Psoriatic arthritis: a guide for Primary Care Nina Flavin, MD Rheumatology Confluence Health April 13 th, 2018

2 No Disclosures

3 Objectives Recognize early signs of RA/PsA what to ask, what to look for, what to order, when to refer Review treatment for RA/PsA and how it impacts the patient s general health Review importance of managing co morbidities in patients with RA/PsA

4 Rheumatoid arthritis Most common chronic inflammatory arthritis Primary site of pathology is joint synovium pannus Etiology unknown Genetics Environmental factors (smoking, silica) 1% adults in USA Age All races (Native American have higher prevalence) Female > males 2-3:1

5 Psoriatic arthritis Inflammatory arthritis affecting 7-42% patients with psoriasis Psoriasis prevalence 2-3% population White 2x > other races No relation between extent of psoriasis and severity of arthritis In most patients, psoriasis precedes arthritis 6-10 years (can be vice versa in 1/3 of patients)

6 Recognize early signs of RA/PsA what to ask, what to look for RA Synovitis (swelling, effusion, warmth, pain) Symmetric joint involvement (small joints MCPs, PIPs, wrists, elbows, ankles, MTPs) > 6 weeks duration Morning stiffness > 1 hour Subcutaneous nodules PsA More commonly asymmetric Oligoarticular Small and large joints Axial involvement (spine, SI joints) Skin and nail exam findings Tendonitis, enthesitis Dactylitis

7 Recognize early signs of RA/PsA what to ask, what to look for RA Synovitis (swelling, effusion, warmth, pain) Symmetric joint involvement (small joints MCPs, PIPs, wrists, elbows, ankles, MTPs) > 6 weeks duration Morning stiffness > 1 hour Subcutaneous nodules

involvement (small joints MCPs, PIPs, wrists, elbows, ankles,

8 Recognize early signs of RA/PsA what to ask, what to look for RA Synovitis (swelling, effusion, warmth, pain) Symmetric joint involvement (small joints MCPs, PIPs, wrists, elbows, ankles, MTPs) > 6 weeks duration Morning stiffness > 1 hour Subcutaneous nodules

9 Recognize early signs of RA/PsA what to ask, what to look for RA Synovitis (swelling, effusion, warmth, pain) Symmetric joint involvement (small joints MCPs, PIPs, wrists, elbows, ankles, MTPs) > 6 weeks duration Morning stiffness > 1 hour Subcutaneous nodules

Recognize early signs of RA/PsA what to ask, what to look for PsA Synovitis (swelling, effusion, warmth, pain) Symmetric joint involvement (small joints MCPs, PIPs, wrists, elbows, ankles, MTPs) > 6

11 Recognize early signs of RA/PsA what to ask, what to look for PsA Synovitis (swelling, effusion, warmth, pain) Symmetric joint involvement (small joints MCPs, PIPs, wrists, elbows, ankles, MTPs) > 6 weeks duration Morning stiffness > 1 hour Subcutaneous nodules More commonly asymmetric Oligoarticular Small and large joints Axial involvement (spine, SI joints) inflammatory back pain Skin and nail exam findings Tendonitis, enthesitis Dactylitis

Morning stiffness > 1 hour Subcutaneous nodules More commonly asymmetric Oligoarticular Small and large

12 Recognize early signs of RA/PsA what to ask, what to look for PsA Synovitis (swelling, effusion, warmth, pain) Symmetric joint involvement (small joints MCPs, PIPs, wrists, elbows, ankles, MTPs) > 6 weeks duration Morning stiffness > 1 hour Subcutaneous nodules More commonly asymmetric Oligoarticular Small and large joints Axial involvement (spine, SI joints) Skin and nail exam findings Tendonitis, enthesitis Dactylitis = sausage digits

13 Recognize early signs of RA/PsA what to ask, what to look for PsA Synovitis (swelling, effusion, warmth, pain) Symmetric joint involvement (small joints MCPs, PIPs, wrists, elbows, ankles, MTPs) > 6 weeks duration Morning stiffness > 1 hour Subcutaneous nodules More commonly asymmetric Oligoarticular Small and large joints Axial involvement (spine, SI joints) Skin and nail exam findings Tendonitis, enthesitis Dactylitis

14 Recognize early signs of RA/PsA what to ask, what to look for PsA Synovitis (swelling, effusion, warmth, pain) Symmetric joint involvement (small joints MCPs, PIPs, wrists, elbows, ankles, MTPs) > 6 weeks duration Morning stiffness > 1 hour Subcutaneous nodules More commonly asymmetric Oligoarticular Small and large joints Axial involvement (spine, SI joints) Skin and nail exam findings Tendonitis, enthesitis Dactylitis

15 Recognize early signs of RA/PsA what to ask, what to look for PsA Synovitis (swelling, effusion, warmth, pain) Symmetric joint involvement (small joints MCPs, PIPs, wrists, elbows, ankles, MTPs) > 6 weeks duration Morning stiffness > 1 hour Subcutaneous nodules More commonly asymmetric Oligoarticular Small and large joints Axial involvement (spine, SI joints) Skin and nail exam findings Tendonitis, enthesitis Dactylitis

16 Osteoarthritis, not RA

17 Recognize early signs of RA/PsA what to ask, what to look for extraarticular manifestations RA Constitutional symptoms Episcleritis, scleritis Pericarditis, pleuritis Interstitial lung disease Osteoporosis Atheroslerosis Vasculitis Felty s syndrome Sjogren s Amyloidosis PsA Iritis/Uveitis conjunctivitis Nonspecific colitis Nails Pitts, transverse ridges, onycholysis, hyperkeratosis Urethritis Oral ulcers Aortic insufficiency (rare)

18 6 or more points = RA Ann Rheum Dis 69:

19 Recognize early signs of RA/PsA what to order, clues to diagnosis RA/PsA CBC, CMP ESR and CRP RF and CCP antibody (RA only). ANA panel positive in 30% patients Hepatitis panel Quantiferon TB gold Inflammatory fluid (WBC > 5k 50k) Xrays (look for periarticular osteopenia, erosions, pencil-in-cup deformity ) HIV for severe psoriasis CXR, especially in smokers (higher incidence of ILD in RA patients)

20 RA PsA

21 Just because RF is +, doesn t mean it s RA Differential: HEPATITIS B and C (HCV can mimic RA symptoms) Cryoglobulins Sjogren s Syndrome (with or without SSA and SSB, + sicca symptoms) SLE Sarcoidosis Subacute bacterial endocarditis

22 Just because RF is (-) doesn t mean it s NOT RA 10% are seronegative CCP + in 10-15% of RF negative RA patients

23 Recognize early signs of RA/PsA when to refer Suspicion high Positive serologies Erosions on xrays Targeted treatment within first 3-6 mo of symptom onset associated with better outcomes

24 Review treatment for RA/PsA and how it impacts the patient s general health Synthetic DMARDS Anti-TNF Anti-IL-6 Anti CD 80/86 Jak kinase inhibitor Anti- CD20 Il-17 PDE inhibitor Anti IL-12/IL-23 Methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, cyclosporine Enbrel, Humira, Simponi, Remicade, Inflectra, Cimzia Actemra, Kevzara Orencia Xeljanz (oral) Rituximab Cosentyx, Taltz Otezla Stelara

25 Which one do we use or start with? Depends on severity of disease and comorbidities? Infection risk? Liver disease? Pregnancy? Hx of TB exposure? CHF Initially start conventional synthetic DMARD (mono therapy or in combination) Biologic if DMARDs ineffective or intolerance Insurance coverage may impact decision on which specific one

26 General facts and FAQs Main risk for most DMARDs and for ALL biologics are INFECTIONs This includes steroids! Consider them immunosuppressed/immunocompromised Strict Lab monitoring every 1-3 mo: Methotrexate, leflunomide, xeljanz, sulfasalazine, Actemra, Kevzara CBC and CMP Lipid panel for xeljanz, Actemra No live vaccine (ie shingles) while on biologic Give live vaccine 4 weeks before starting biologic Wait 3 mo after stopping to give it if already on biologic (ok to give if prednisone dose < 20 mg a day, MTX < 0.4 mg/kg/week) Before treatment: screen for hepatitis B and C and TB TB screen once yearly for biologic

27 General facts and FAQs Special consideration: Glucocorticoids Start lowest dose possible, d/c as soon as disease activity permits Implement fall prevention program Avoid immobilization, encourage weight bearing exercises Calcium and vit D Bisphosphonates, esp for high risk patients Think AVN for acute and severe hip or knee pain Glucose intolerance Osteonecrosis Cataracts Skin changes Delayed wound repair Peptic ulcer (w/nsaids) Weight gain Infection HTN Abnormal menstruation Mental disturbance Weakness Osteoporosis

28 General facts and FAQs Special consideration: MTX and leflunomide watch closely for liver disease, minimize etoh use (best to avoid), needs close lab monitoring CBC/CMP (monthly at start, then q 3 mo maintenance) MTX rare reaction causing pneumonitis Anti-TNF therapy drug induced lupus, demyelinating disease, CHF exacerbation NSAIDs Not disease modifying Cautious use in elderly Cardio, nephro and GI toxicities

29 General facts and FAQs Preoperative management: No need to stop plaquenil, sulfasalazine MTX or arava (can hold the week of surgery) Biologic hold 1 dose of the biologic prior, can resume 2-4 weeks after RA patients xray C spine (dynamic view flex/ext to assess for C1-C2 subluxation)

30 Review importance of managing co morbidities in patients with RA/PsA Increased mortality in RA patients: Cardiovascular frequency increased 2x over general population Infection (esp pneumonias) 5x over general population Cancer Leukemia and lymphoma 2-3x over general population Lung cancer x over general population Increased mortality in Psoriatic patients Metabolic syndrome Hyperuricemia Obesity Premature atherosclerosis

31 Review importance of managing co morbidities in patients with RA/PsA Increased morbidity: GI hemorrhage (NSAIDs) Fractures from osteoporosis (RA and steroids) Lung disease ILD, BOOP Medication toxicity Sjogren s Obesity Depression Fatigue Chronic pain

32 Preventative therapy Immunizations Flu, pneumovax NO live vaccines for patients on biologics Cardiovascular risk factor modification Smoking BP monitoring Lipids Screen for depression Situational Medication related (ie-steroids) Fatigue very common Osteoporosis Calcium and Vit D Anti-resorptive therapy

33 Pregnancy and lactation 50-75% of patients with RA improve during pregnancy Always discuss birth control and pregnancy planning at every visit for patients of child bearing age Safe meds: Sulafasalazine Hydroxychloroquine Low dose prednisone (5-10 mg/day) Anti-TNF therapy (Cimzia the safest) Stelara Contraindicated meds: Methotrexate Leflunomide Limited data in other biologics Stop meds 3 months before conception

34 References and patient resources Sterling West. Rheumatology Secrets. Third edition

Patient #1. Rheumatoid Arthritis. Rheumatoid Arthritis. 45 y/o female Morning stiffness in her joints >1 hour

Patient #1. Rheumatoid Arthritis. Rheumatoid Arthritis. 45 y/o female Morning stiffness in her joints >1 hour Patient #1 Rheumatoid Arthritis Essentials For The Family Medicine Physician 45 y/o female Morning stiffness in her joints >1 hour Hands, Wrists, Knees, Ankles, Feet Polyarticular, symmetrical swelling