Evidence-Informed Best PracticeRA and OA

Dr. Diane Lacaille

2

Describe the rationale for key recommendations for

best practice care for Rheumatoid Arthritis and

Osteoarthritis according to the BC Guidelines.

www.bcguidelines.ca

Objectives

NECESSARY

SAFE

EFFECTIVE

Early Treatment of RA with DMARDs

4

EARLY Treatment of RA with DMARDs

EARLY DIAGNOSIS AND TREATMENT OF RA

AGGRESSIVE USE OF DMARDS ALTERS THE COURSE OF RA

REMISSION IS THE NEW TARGET OF RA TREATMENT

LONG TERM USE OF DMARDS

YES, DMARDS ARE SAFE WHEN MONITORED REGULARLY

This is the new standard of care.

EARLY

5

If not controlled, RA inflammation leads to:

joint damage and joint deformitiesprogressive loss of physical functionwork disability (32-50% after 10 years of RA)premature mortality, mainly from cardiovascular disease (50% increase in risk of death from CVD)

All these outcomes are preventable.

RA is Not a Benign Disease

6

Persistent Joint Swelling Leads to Joint Damage & Deformities

=>

7

Early Diagnosis & Treatment of RA

Early diagnosis

Recognizing signs of inflammation – clues pointing to RAEarly morning stiffness > 30 minutesWorse pain in the morning and post immobilitySwelling of small jointsPain or tenderness on squeezing the MTPs, MCPs or wristsSymmetrical involvementSystemic symptoms, such as fatigue

Ruling out other diagnosis Septic arthritis, especially if monoarthritisCrystal arthritis, such as gout or pseudogout Joint aspiration for acute monoarthritis to R/O infection

or when crystal arthritis is suspectedTransient inflammatory arthritis, i.e. viral

lasts 6 weeks or less

EARLY

8

Early treatment of RA

Capture the window of opportunityEarly treatment with DMARDs alters the disease course.Joint damage occurs early (within months) and is

irreversible.RA is more responsive to treatment early on.Early treatment increases the chances of remission.

New onset RA requires urgent careDMARDs should be started within 2 months of symptoms.Referral to a rheumatologist for new onset RA should be

seen within 4 weeks. State ‘new onset of RA’ on referral.Rheumatologists prefer early referrals.

EARLY

Early Diagnosis & Treatment of RA

9

Aggressive use of DMARDs Alters the course of RA

What are DMARDs?

Disease Modifying Anti-Rheumatic Drugs

They improve symptoms and prevent joint damage.

Methotrexate, Sulfasalazine, Hydroxychloroquine, Gold, Cyclosporine, Leflunomide and biologic agents.

Think RA, think DMARDs

All RA patients with active inflammation should be on a DMARD.

NSAIDs and prednisone are not enough NSAIDs improve symptoms but fail to prevent joint damage. Prednisone should not be used alone because

of long term toxicities

EARLY

10

DMARDs alter the course of RA by:

• Preventing joint damage and deformities

• Reducing physical and work disability

• Preventing premature mortality

Aggressive use of DMARDs means:

• Starting DMARDs early

• Using DMARDs continuously, often in combination

• Evaluating response every 1 to 3 months

• Modifying DMARD therapy until the target is reached

• Aiming to eradicate inflammation

Aggressive Use of DMARDs Alters the Course of RA

EARLY

11

The goal of RA treatment is no longer to simply control symptoms, but to eradicate inflammation.

The target of DMARD therapy is no signs of active

inflammation i.e.,

• No swollen joints

• Normal ESR or CRP

• Little to no radiographic progression

Although remission is the target, minimal disease activity may be an acceptable alternative, when remission is not possible, especially in established long-standing disease, or when co-morbidities or other patient factors limit DMARD options.

EARLY

Remission is the new target of RA treatment

12

DMARDs should be used continuously, throughout the disease.

When sustained remission is achieved, DMARDs may be slowly decreased to find a lower dose that maintains remission.

DMARD discontinuation is not recommended because of high risk of flare off DMARDs.

All RA requires DMARD, the earlier the better, but even late RA requires DMARDs to reduce further damage.

Long-term use of DMARDs

EARLY

13Benefits of early DMARDs outweigh their risks

Yes DMARDs are safe when monitored regularly

EARLY

14

Family physicians play a critical role in early diagnosis and treatment of RA.

DMARDs should be prescribed in all RA patients and should be started early.

EARLY is the new standard of care

15

NSAIDS

DMARDs

Treatment of RAthe standard of care has changed

16

Guidelines and Protocols Advisory Committee. Rheumatoid Arthritis: Diagnosis and Management. British Columbia Medical Association. 2006. www.bcguidelines.ca

American College of Rheumatology Ad Hoc Committees on Clinical Guidelines. Guidelines for the management of rheumatoid arthritis. Arthritis Rheum.1996,39:713-22.

American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 Update. Arthritis Rheum 2002;46:328-346.

Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifyingantirheumatic drugs in rheumatoid arthritis. Arthritis Rheum 2008;59:762-84.

Bykerk V, replace with 2010 CRA RA guidelines

Smolen JS, Aletaha D, Bijlsma JW, et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis 2010;69:631–637

Recommendations are based on the following references:

Osteoarthritis

18

Features suggestive of OA:Absence of inflammatory features: morning stiffness < 30 min; gelling < 5 min; minimal swelling & heat; no redness.Pain worse with activity, better with restAdvanced OA => constant pain including at restAbsence of systemic symptomsGradual onsetHistory of prior injury (e.g. knee), prior deformity / malalignement Joint distribution: hips, knees, C & L spine, hands: DIP, PIP, 1st CMC, 1st MTP. Bony enlargement, crepitus, malalignementIf joint swelling, synovial fluid non-inflammatory, no crystals.

Osteoarthritis (OA)

19

Joint Distribution

Black= joints most commonly affectedGrey= joints often affectedWhite= joints usually not affected

20

Septic arthritis (acute monoarthritis requires joint aspiration)

Crystal arthritis: gout, pseudogout (CPPD) (joint aspiration)

Inflammatory arthritis: esp. psoriatic arthritis Non-articular : e.g. bursitis (trochanteric, pes anserine),

tendonitis (shoulder, elbow) Bone pain (multiple myeloma, metastasis) Soft tissue pain syndromes Referred pain

Other Diagnoses to Exclude

21

X Rays

› Provide clinical information

› Can be normal in early OA

› Often don’t correlate with degree of pain

› Knee Xrays must be ordered weight bearing (PA, lat, skyline)

› Hip (OA hip series: incl. lateral view and upper 1/3 femur)

Absence of inflammatory markers (CBC, CRP normal)

Labs can be useful to rule out other conditions (e.g. thyroid disease) or to assess for comorbidities prior to Rx (e.g. Cr, LFT)

Investigations

22

Severity of pain (with activity, at rest, interferes with sleep)

Impact on function (ADLs, IADLs) Impact on participation (work, family obligations, social

activities, leisure) Impact on independence Psychosocial issues (pain amplification, coping

strategies, depression, adherence to treatment, social support)

Management - Considerations

23

Patient education Self-management (pain, limited physical function, stress,

exercise, coping, pacing) Weight management – support, dietician Exercise Physiotherapy: prescribe specific therapeutic exercise

program Walking aids Occupational therapy: Orthotics, footwear, braces, ADL

aids, ergonomic modifications at work

Management – Non pharmacological

24

Acetaminophen:

› regular schedule vs. prn

› up to 4 gm/day, less if liver disease NSAIDs:

› Gastroprotection if high GI risk

› Consider cardiovascular risk factors

› Topical NSAIDs Glucosamine and chondroitin sulfate:

› Not recommended, insufficient evidence of efficacy Intra-articular steroids Hyaluronic acid – limited benefit, can cause inflammatory

reaction

Management - Pharmacological

25

Failure of conservative management (trial acetaminophen, NSAIDs, intraarticular injection steroids, physiotherapy, regular exercise program)

Inadequate pain control (pain at rest, significant pain with walking, pain interfering with sleep, incr. need for narcotics)

Impact on function (limited ADLs, limitations in meaningful activities – work, family, leisure)

Threat to independence Significant deformities (e.g. FD, valgus knees, loss IR hip,

LLD) Xray flags: acetabular protrusion, femoral head collapse,

progressive bone loss,

Management – Indications for Surgery

26

Summary