Understanding Rheumatoid Arthritis Randall J Reed MD Friday

Understanding Rheumatoid Arthritis Randall J. Reed, MD Friday, November 13, 2015 11: 00 a. m. EST

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Understanding Rheumatoid Arthritis Randall J. Reed, MD Rheumatology Associates, PC Indianapolis, Indiana

Arthritis l 66 million people with arthritis in America l 2 nd only to heart disease in disability l Costs US $86. 2 billion l More common in women than men l Limits everyday activities for 7 million Americans

Types of Arthritis l Over l l l l l 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) l Around 2 million people in the US l More common in women than men l Can occur at any age, onset usually in 3 rd to 5 th decades of life l Chronic, inflammatory disease that primarily involves joints l Rheumatoid arthritis can also affect the skin, saliva glands, eyes, lungs, and heart

Inflammatory versus degenerative arthritis www. vics. com

What’s happening in RA? l Immune system attacks proteins in joints l Thickening of synovium l Influx of immune cells into joint

Why do people get RA? l Genetic predisposition – Family History – Certain Ethnic populations – Genetic marker HLA-DR 4 l Environmental exposures? – Viruses – Bacteria – Food allergies? Role of Hormones l Immune System l

Symptoms of RA l l l 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 Swelling

Joint Deformity

Nodules of RA

How is RA diagnosed? l Clinical History and Exam l Blood tests – Rheumatoid Factor – Anti-CCP antibody l X-rays l MRI

X-ray image

MRI Image of RA From Bocaradiology. com

What should I expect with RA? l. A chronic illness, only 5 -10% remission rate l Untreated, 90 -95% of patients will have bone damage, usually within first 2 years l 5 -10% of RA patients become disabled every year (old data) l Associated with increased risk of infections, heart disease, and lymphoma

What’s the good news? ! l Advancements in diagnosis – CCP antibody – MRI and Ultrasound l Better treatments! l Advancing Research – Stem cell – Genetic based therapies – Individualized therapies

Goals of therapy for RA Reduce joint pain and swelling l Improve Function l Prevent erosions and joint deformity l Minimize risk of adverse events from medications l

How is RA treated l Most patients will require a “disease modifying anti-rheumatic drug”, or DMARD l Corticosteroids, i. e. prednisone l Non-steroidal anti-inflammatory drugs (NSAIDS) / COX-2 inhibitors l Joint injections l Biological Response Modifiers

Disease Modifying Anti. Rheumatic Drugs (DMARDS) Methotrexate (Trexall) l Sulfasalazine (Azulfidine) l Hydroxychloroquine (Plaquenil) l Leuflonomide (Arava) l Azathioprine (Imuran) l Cyclosporine (Neoral) l Minocycline (Minocin) l Gold (Auranofin) First Line Therapy l Second Line Therapy

Biological therapy l Biologics - drugs derived from living organisms that are designed to either inhibit or supplement a specific component of the immune system

Biologic Response Modifiers l l l 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 Study l. Figure 1: ACR 20 Responses over 52 Weeks

Anti-TNF medicines have revolutionized 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, Netherlands –from Arthritis News June 9 th 2005.

Risks of therapy l All treatments will carry some risk! l Not treating RA also carries a risk l Ask doctor about increased risk of infection, potential liver toxicity, stomach upset, interactions with other medicines; recent press about increased cancer risk l Many of the medications require chronic laboratory monitoring

Diet and Arthritis l Weight loss l Anti-oxidants? l Vitamin C l Supplements

Exercise and arthritis l Water Aerobics l Walking l Physical Therapy l Yoga

Surgery for RA

Summary 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 •