Evidence-Informed Best PracticesRheumatoid Arthritis

Osteoarthritis

Dr. Diane Lacaille

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Describe the rationale for key recommendations for

best practice care for Rheumatoid Arthritis and

Osteoarthritis according to the BC Guidelines.

www.bcguidelines.ca

Objective

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Rationale for recommendations in guidelines Rheumatoid Arthritis

Early diagnosis and early treatment with DMARDs Prevention of joint damage Management of co-morbidities Monitoring of disease activity

Osteoarthritis Reduction of pain Improvement of function Optimization of conservative care Appropriate and timely referral for surgical

intervention

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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

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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

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Persistent Joint Swelling Leads to Joint Damage & Deformities

=>

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Early Diagnosis & Treatment of RAEarly 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 (viral) < 6 weeks Other inflammatory arthritis, also Rx with DMARDs

EARLY

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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

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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

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Role of steroids in RA Minimize steroids dose and duration, because

of long term risks, esp. cardiovascular diseases

Oral steroids do have a role: Small doses (< 10 mg daily), over short periods Bridging therapy, while waiting for DMARDs Early on at time of RA onset, but avoid prior to

rheumatologist referral for diagnosis bcse masks signs.

To control flare-ups Intramuscular (40 mg depomedrol) and intra-

articular are good alternatives to oral. If steroids are needed to control disease, then

DMARDs need to be adjusted11

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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

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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

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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

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Yes DMARDs are safe when monitored regularly

EARLY

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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

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NSAIDS

DMARDs

Treatment of RAthe standard of care has changed

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Management of Established RA

Objective: Suppress inflammation, prevent joint

damageTask Family Doctor RheumatologistMonitor Q 2-6 months Q 6-12 months

Assess disease activity

(Joint Count + Blood Work)

Review Meds, S/E Adherence/ Dosage

Refer to PT/OT

Review/adjust meds

Rating of Disease Activity for decision-making

Assess Joint Damage Pain Relief

Refer PT/OT, surgery

same

Review for Co-morbidities

Screen and Treat Screen and Treat

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Consider chronic disease implicationsComorbidities

Dealing with Chronic Pain Psychosocial Issues Increased infection risk Immunizations Osteoporosis Cardiovascular Disease Smoking Cessation Weight Management

Osteoarthritis

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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)

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Joint Distribution

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

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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

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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

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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

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Patient Education (OA and RA)

Guidelines Patient Support Family Support Community Support Patient Self Management (coping with pain

and other arthritis symptoms, stress, lifestyle changes e.g. exercise).

Arthritis Self Management Program (ASMP) and CDSMP.

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Patient education Self-management Weight management – support, dietician Exercise (ROM, strengthening, aerobic) Physiotherapy: prescribe specific therapeutic exercise

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

splints, ADL aids, ergonomic modifications at work

Management – Non pharmacological

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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

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Differentiating inflammatory from non-inflammatory arthritis Importance of early diagnosis and DMARD treatment in RA Monitoring of disease activity to achieve treatment target Goal of preventing joint damage, consequences of

inflammation Management of pain, improvement of function in OA Weight management, exercise and rehab in OA Multidisciplinary care of arthritis Appropriate and timely referral for surgery Management of co-morbidities, esp. cardiovascular diseases Need for shared approach to care Importance of patient education and self-management

Summary