hot topics in rheumatology prof. mg molloy. overview rheumatoid arthritis psoriatic arthritis...
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Hot Topics in Hot Topics in RheumatologyRheumatology
Prof. MG Molloy
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OverviewOverview
• Rheumatoid Arthritis
• Psoriatic Arthritis• Vasculitides: SLE• Osteoarthritis• Osteoporosis
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Rheumatoid arthritisRheumatoid arthritis
– RA is a condition involving inflammation of the joints• It has the potential to result in serious joint
damage• It may come on suddenly or appear slowly
over time• Its symptoms may include pain, swelling,
stiffness in the joints, and general tiredness
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Rheumatoid ArthritisRheumatoid Arthritis• Damage occurs early in most patients
• 50% show joint space narrowing or erosions in the first 2 years
• By 10 years, 50% of young working patients are disabled
• Death comes early• Multiple causes• Compared to general population
• Women lose 10 years, men lose 4 years
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Who is affected by RA?Who is affected by RA?
– RA is one of the most common forms of inflammatory arthritis
• Affects about 1% of the world’s population
• Occurs 2 to 3 times more often in women than in men
• In most cases it develops between the ages of 25 and 50
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RA: Multisystem diseaseRA: Multisystem disease
• Extra-articular:– Cardiac
• coronary heart disease
– Pulmonary• fibrosis
– Haematological• Anaemia
– Ophthalmology– Dermatology– Renal
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Cardiac disease in RACardiac disease in RA
• Mortality in RA is unchanged in 40yrs despite DMARDS
• Patients unlikely to report symptoms of angina
• Not all IHD risk is due to traditional risk factors nor drugs such as Pred use, HRT DM etc
• Control BP, cholesterol etc
• High index of suspicion: cardiology referral
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Management RAManagement RA
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Medications for RAMedications for RA
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Corticosteroids
• Disease-modifying antirheumatic drugs (DMARDs)
• Biologics
• Combination
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DMARD options DMARD options
• Hydroxychloroquine
• Sulphasalazine
• Methotrexate
• Azathioprine • Slow onset, reasonably effective
• Leflunomide• Pyrimidine inhibitor• Effect and side effects similar to those of MTX
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DMARDsDMARDs Combination or monotherapy Combination or monotherapy
• No superiority of traditional combination DMARD therapy over monotherapy
• Some trials did not control for glucocorticoid use
• Review of studies since 2000 have shown that step-up therapy of Leflunomide +MTX is superior but, with significant toxicity
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MethotrexateMethotrexate
• Commonest DMARD• 30 year experience• Monitoring: monthly FBC, ESR, CRP,
Bioprofile, LFTs• Complications:
– Haem:Neutropenia, thrombocytopenia, ? Leukemia
– Liver dysfunction
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New BiologicsNew Biologics
• Infliximab ( chimeric monoclonal antibody to TNF)
• Etanercept (soluble TNF receptor)
• Adalimumab (humanised monoclonal antibody to TNF)
• Rituximab (anti-CD 20 )
• Anti-Interleukin 6 (in clinical trials for JRA)
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Biologic agents in RABiologic agents in RA
• Indication: Refractory RA
• Prior to commencing: CXR, Mantoux
• Contraindications/Precautions:– Previous TB, COPD, Chronic infections, HIV
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Biologic agents in RABiologic agents in RA• Monitoring:
– Monthly bloods: FBC, ESR, CRP, Bioprofile
– Regular physical examination
– Beware infection
• NB: Normal WCC, ESR, CRP does not exclude infection
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New drugs New drugs
• Rituximab (anti- CD 20)- in use• Epratuzumab anti-CD22 – better risk profile than ritux• Anti-CD4 – was good but CD4 counts dropped so low trials
stopped• Efalizumab – anti-CD11a –used in psoriasis, no good in PSA• CTLA4-Ig (in trials)- binds CD80/86 and blocks cell activation• Alefacept- binds LFA-3• Anti-RANKL• SOCS• IL1-trap• Anti-IL6 receptor antibody• Soluble IL-15 receptor antagonist – 62% ACR 20 scores in high
dose group• Other targets – IL-12, IL-17, IL-18, IL-23, IL-27,IFN alpha and
gamma
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Summary RA Summary RA RA – early treatment = better outcome MTX good monotherapy in many patients Combo therapy of traditional DMARDs is possibly
superior but conflicting studies
Biologics =higher expectations Currently combo biologics +MTX better than biologic
monotherapy Are biologics capable of inducing remission in early
disease – then do we switch to mainteance therapy with MTX – unknown yet
Anti – CCP antibody - predictor of erosive disease course
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SpondyloarthropathiesSpondyloarthropathies
Ankylosing SpondylitisPsoriatic arthropathy
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Ank SpondAnk Spond
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Ank SpondAnk Spond
• Diagnosis:– Clinical: Backpain and stiffness: EMS– Age 20-40yrs male– Xray: late changes
• Treatment:– Exercises, NSAIDS– Biologics
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Gout & PseudogoutGout & PseudogoutCrystal arthropathiesCrystal arthropathies
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Gout Gout uric acid depositionuric acid deposition
• Clinical– Monoarticular– The most painful
arthropathy
• Treatment– NSAIDS– Allopurinol:
prophylaxis– Colchicine:
• Nausea, vomting, diarrhoea
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Pseudo-goutPseudo-gout
• 2nd, 3rd MCPs, wrists, shoulders, knees, feet
• Associations:– Haemochromatosis– Age
• Treatment– Underlying disease– NSAIDS
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VasculitidesVasculitides
SLE
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SLESLE
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Management of SLEManagement of SLE
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OsteoarthritisOsteoarthritis
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OsteoarthritisOsteoarthritis
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OsteoporosisOsteoporosis
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Osteoporosis Osteoporosis
• Diagnosis
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Osteoporosis Osteoporosis
• Management
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ThankyouThankyou