Rheumatoid Arthritis Ajay Bhatia Rheumatology Consultant Hillingdon Hospital ajay.bhatia@thh.nhs.uk
Rheumatoid Arthritis When to refer to secondary care? Why early referral is beneficial for the patient? How to establish a diagnosis? How do you treat RA Treat to Target? What other conditions need be considered?
When to refer to secondary care? 30 mins of Stiffness Swelling of one or more joints Squeezing causes tenderness
Why early referral is beneficial for the patient?
Why early referral is beneficial for the patient? Pierre-Auguste Renoir 1841 to 1919 Developed RA 1892 Luncheon of the Boating Party 1880-81 Women Bathers 1916
Why early referral is beneficial for the patient?
Why early referral is beneficial for the patient? ERAS (Early Rheumatoid Arthritis Study) (James D et al 2004, 43,369-376 Rheumatology) n=1064 prospective study 7% underwent replacement of major joints within 5 years 4% underwent hand or foot surgery 48% are in paid employment at presentation, 60% of these remain working at 5 years (loss of work more common in those with a manual component their work) THEREFORE: Early recognition, referral and treatment of new patients to prevent joint damage and improve outcomes is recommended
Why early referral is beneficial for the patient? Fries JF et al. Arthritis Rheum 1996,39,616-22 Prospective cohort of 2888 over 20 years f/u Increased DMARD was associated with a reduction in disability of 30% over the duration of RA
How to establish a diagnosis? What are the problems? CRP and ESR are normal in 40% of patients with RA at the time of diagnosis Rheumatoid factor is neither specific nor completely sensitive for the diagnosis of rheumatoid Infections, Post immunisations, Cancers, 25% of those with a family member with RA, 14.1 % of Elderly (Manoussakis MN et al. High prevalence of anticardiolipin and other autoantibodies in a healthy elderly population. Clin & Experiment Immunol. 69:557-65 Only 20-30% of RA patients will have erosions at the time of diagnosis
How to establish a diagnosis? Straightforward History of symmetrical pain, stiffness and swelling in wrists, small joints of hands/feet with clinical evidence of synovial swelling Raised ESR/CRP and Positive RF
How to establish a diagnosis? Difficult Symmetrical arthralgia in wrists, small joints of hands/feet with no synovial swelling evident on examination Negative RF, normal CRP/ESR, normal x rays
Improvements in the Early Diagnosis of Rheumatoid Arthritis What Has Changed? MRI and High Resolution Ultrasound can detect synovitis and erosions in seven times more patients compared to plain radiographs (Wakefield RJ et al, The value of sonography in the detection of bone erosions in patients with RA. 2000, Arth Rheum, 43, 2762-70)
A. Ultrasound longitudinal on a tender joint in a patient with RA but clinically not swollen B. Axial section MRI of same patient with iv gadolinium Richard Wakefield Dept of Rheumatology Leeds
The effect of joint position on Doppler flow in finger synovitis R J Wakefield University of Leeds, UK Dr Richard J Wakefield, Senior Lecturer and Honorary Consultant in Rheumatology, Academic Department of Musculoskeletal Disease, Chapel Allerton Hospital, Leeds
How to establish a diagnosis? Serological aids to diagnosis Anti cyclic citrulinated peptide (anti-ccp) Citruline is the product of post-translational modification of protein-bound arginine Anti-CCP produced locally in joints Sensitivity Specificity Established RA 70-80% 95-98% Vosse naar ER et al 2004, Arth Rheum 50,3485-94
How do you treat RA Treat to Target? Treating rheumatoid arthritis to target: 10 recommendations of an international task force Josef S Smolen et al 2010;69:631-637 doi:10.1136/ard.2009.123919 Regular follow up 1-3 months in patients Therapeutic adaptation (escalation of DMARD therapy) Aim to achieve remission or low disease activity within 3-6 months Analagous to targets in DM, HT and dyslipidaemia
How do you treat RA? ESR OR CRP VAS Pain last week DAS SCORE > 5.1 High disease activity DAS SCORE< 2.6 Remission
How do you treat RA? Ticora study Grigor C et al Lancet 2004,364,263-9 (Glasgow) FIN-RACo trial Markku Korpela et al Arthritis Rheum 2004; 50:2072-2081 (Finland) BeSt (Behandel Strategieen) Goekoop-Ruiterman YPM et al EULAR 2005 (Dutch Study) Cobra study Boers M et al Lancet 1997;350:309-18. (Amsterdam The Netherlands) Early Diagnosis Early treatment with combination of DMARDs to achieve tight control
How do you treat RA? Methotrexate Hydroxychloroquine Sulfasalazine Gold IM Leflunamide Prednisolone Certolizumab pegol Entanercept Adalimumab Infliximab Rituximab Tocilizumab Abatacept +/- Joint injection New awaiting licensing and NICE Guidance Fostamatinib Golimumab
What other conditions need be considered? TRACE RA Trial (TRial of Atorvastatin fo the Primary Prevention of Cardiovasscular Events in RA) Recruiting patients 4000 5 year prospective study 40 mg atorvastatin vs placebo 100 UK Hospitals Funded by Arthritis Research UK and British Heart Foundation www.dgoh.nhs.uk/tracera
What other conditions need be considered?
What other conditions need be considered?