31316/
3 34/
3 1316/3 13
16/3 1316/3 13
16/3 1316/3 13
16/
332/
3 1116/
6 14/
34 18/
C L I N I C I A N E D U C A T O R V O L U M E 4
Rheumatoid Arthrit is: Primary care Initiative for improved D iagnosis and outcomes
Co-sponsored by
SIDE A is for clinicians FREE CME
See panel 2A
SIDE B is for patients
RHEUMATOID ARTHRITIS FACTSRA is a chronic, progressive, systemic inflammatory disease •Characterizedby: – Progressive destruction of synovial joints with bony erosions and
loss of cartilage – Symptoms usually begin in the small joints of the fingers, wrists, and
feet – Swollen, tender joints are painful and difficult to move – Loss of physical function and quality of life – Decreased work productivity and increased disability and job loss •1.3millionadultAmericanshavebeendiagnosedwithRA •Peakageofonset:30to60years •2to4timesmorecommoninwomenthanmen •RApatients7timesaslikelytohavegreater-than-moderatedisability
than age- or sex-matched individuals •Ifundertreated,lifeexpectancyisreducedby5to15years –RAaccountsfor22%ofalldeathsfromarthritisandother
rheumatic conditions
It is never too late to stop further damage.
HochbergMC,SilmanAJ,SmolenJS,etal.eds.Rheumatology.3rded.NewYork,NY:Mosby;2003.AmericanCollegeofRheumatology.Factsheet.Availableat:http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/ra.asp.AccessedOctober1,2010.MacLeanCH,LouieR,LeakeB,etal.Qualityofcareforpatientswithrheumatoidarthritis.JAMA.2000;284:984-992.
RA IS A DISEASE OF THE ENTIRE BODYHeart:Cardiovasculardisease(CVD)occursonaverage10yearsearlierinRA patients than in the general population •AcceleratedatherosclerosisLungs:Increasedriskofmultiplepulmonarycomorbidities •Pleuritismayoccur • InterstitiallungdiseasesGastrointestinal (GI):RApatientshaveahighincidenceofGIbleeding,which may be attributable to use of nonsteroidal anti-inflammatory drugs (NSAIDs)andsteroidsduringtherapyNervous system: The deformity and damage to joints in RA may lead to entrapment of nerves •PatientmaypresentwithcarpaltunnelsyndromeOsteoporosis: Generalizedbonelossmayresultfromimmobility,theinflammatoryprocess,and/ortreatmentssuchassteroids • PeriarticulardemineralizationmayresultfrommediatorsofinflammationInfections:RApatientshavea6-to9-foldincreaseintherateofseriousinfections, including tuberculosis (TB) Malignancy: RA doubles the risk of some malignancies, particularly lymphoma
DeaneK.ManagingcomorbiditiesinRA.J Musculoskel Med.2006;23(suppl):S24-S31.BöttcherJ,PfeilA.DiagnosisofperiarticularosteoporosisinrheumatoidarthritisusingdigitalX-rayradiogrammetry.Arthritis Res Ther.2008;10:103.
PRIMARY CARE: EARLY DETECTION IS CRITICALTo prevent the progressive destruction of synovial joints and improve long-termoutcomes,RAmustbedetectedandtreatedearly. •Jointdamagecanberapid;withouttreatment,bonyerosionsmaybe
detectablebymagneticresonanceimaging(MRI)within4monthsofdisease onset
•Rateofx-rayprogressionismorerapidinthefirstyearthaninthesecond and third
•Withoutoptimaltreatment,mostpatientsdevelopbonyerosionswithin2years,and~80%ofthesepatientsdeveloplong-termdisability
•Successfullong-termmanagementrequiresapartnershipbetweenthe PCP and the rheumatologist, the patient, and other health care team members
Benefits of early detection: •DecreasedRAseverity,disability,andmortalitywitheffectivetreat-
ments, such as disease-modifying antirheumatic drugs (DMARDs) •LowerratesofRAcomplications •Lowerratesoflower-extremityorthopedicsurgicalprocedures •Decreasedcardiacriskswithcontrolofinflammation
McQueenFM,StewartN,CrabbeJ,etal.Magneticresonanceimagingofthewristinearlyrheumatoidarthritisrevealsahighprevalenceoferosionsatfourmonthsaftersymptomonset.Ann Rheum Dis.1998;57:350-356.BykerkVP,KeystoneEC.RAinprimarycare:20clinicalpearls.J Musculoskelet Med.2004;21:133-146.
PROVISIONAL DIAGNOSIS OF RAPatientswhohaveatleast1jointwithdefinitiveclinicalsynovitis(swelling)and in whom the synovitis is not better explained by another disease shouldbeexaminedforRA.MAkE THE DIAGNOSIS Does your patient have: 3 Swollen or tender joints –Either>1largeor≥1smalljointofthehandsorfeet,or –Positivesqueezetest(painwhengentlysqueezingacrossthe
metacarpophalangeal/metatarsophalangealjoints) 3 Symptoms lasting ≥6weeks
If patient has swollen joints or a positive squeeze test as above for ≥6 weeks, refer to a rheumatologist for provisional RA.
If the patient does not meet these criteria but has at least 1 swollen or tender joint and a positive RF or anti-CCP test, he or she should be referred to a rheumatologist.
A rheumatologist will make a definitive diagnosis of RA based on the followingcriteria: 1.Clinicalsignsandsymptoms 2.Patternandnumbersofjointsinvolved 3.Laboratorymeasures(RFandanti-CCPantibody) 4.Radiographicfindings 5.Rulingoutothercausesofinflammatoryarthritis
AletahaD,NeogiT,SilmanAJ.2010rheumatoidarthritisclassificationcriteria:anAmericanCollegeofRheumatology/ EuropeanLeagueAgainstRheumatismcollaborativeinitiative.Arthritis Rheum.2010Sept;62:2569-2581.
COLLABORATION BETwEEN PRIMARY CARE AND RHEUMATOLOGY ENSURES OPTIMAL CARESuccessfulmanagementofRArequireslong-termteaminvolvement.Inthe first stages, the PCP is responsible for identifying possible cases of RA,providingearlyreferraltoarheumatologistandearlypaincontrol.TherheumatologistconfirmsthediagnosisandinitiatesDMARDtherapy. •EarlyreferraltoarheumatologistiscriticaltoearlyinitiationofDMARD
therapy and to stop joint damage •Tofacilitatetheevaluationofthepatientbytherheumatologist,itis
advisabletoobtain: –Rheumatoidfactor(RF) n30%–70%ofRApatientsarepositive,althoughpositiveRFcan
be caused by many conditions – Anti-CCP antibody n40%–60%ofRApatientsarepositive(maybeyearsbefore
clinical manifestation) nMaybedetectableearlierthanRF n Extremely high specificity for RA – C-reactive protein, erythrocyte sedimentation rate –Completebloodcount(CBC),liverfunctiontests(LFTs) –Optionalx-raysofthehands,wrists,andfeet •Monitorforalarmsigns(infection,dyspnea,neckpain,rheumatoideye
disease, painful red eye) •EarlytreatmentbythePCPisintendedtorelievepainandenhance
mobility –NSAIDs,shortcourseoflow-doseprednisone;rarely,opioidsfor
severe pain
A patient who is RF and anti-CCP negative may still have RA.
BridgesSL.SpottingaggressiveRAearly:thephysicalexamination,testing,andimaging.J Musculoskelet Med.2006;23(supplNov):S10-S14.
LONG-TERM MANAGEMENT OF RA PATIENTSCVD: Patients with RA and persistent inflammation may have additional risk for CVD and require more aggressive cholesterol lowering •MinimizeCVDriskfactors(eg,smoking,lipids,bloodpressure) •MaintainhighindexofsuspicionforCVDFever and infections:RApatientsonsteroids,methotrexate(MTX),leflunomide,orbiologic agents are at increased risk of serious infection •AssessRApatientswithfever,suspectedinfection – Prompt and thorough evaluation of symptoms, antibiotics if warranted – Biologics may need to be held until infection is resolved – Prompt initiation of antibiotics (especially for patients on biologics) nAvoiduseoftrimethoprim/sulfamethoxazoleinpatientsonMTX •Ifpatientsonimmunosuppressiveagentsandbiologicsdonotrespondrapidlytoinitial
treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc) •Considersepticarthritiswhenthereis –Isolatedmonoarthritiswhenallotherjointsstable – Swelling and tenderness in a patient with total joint replacement n RA patients may not mount a febrile response and the white blood cell count
may not be elevated in this setting •AcutedyspneaandcoughinapatientonMTXmayrepresentpneumonitis
VACCINATIONS AND DMARD THERAPY •Recommendedbeforetherapybegins –Influenzaandpneumococcalvaccinations –HepatitisBimmunizationifappropriate •Safe –Influenza(injection),tetanus,pneumococcus,meningococcus,hepatitisA,
hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV) •Avoid – Live virus vaccines such as intranasalinfluenza,mumps/measles/rubella(MMR),
yellow fever, and typhoid should be avoided in patients on immunomodulators –Waitatleast2weeksaftergivingthesevaccinesbeforeinitiatingimmunomodulators – Zoster vaccine, should be avoided in patients on biologic agents, but can be
giventopatientstakingMTXandprednisone<20mg/day
DeaneK.J Musculoskel Med.2006;23(supplNov):S24-S31.RavikumarR,etal.Curr Rheumatol Rep.2007;9:407-415;CDC.MMWR.2004;53:Q1-Q4;AveryRK.Rheum Dis Clin North Am.1999;25:567-584;ChalmersA,etal.J Rheumatol.1994;21:1203-1206;HarpazR,etal.MMWR Recomm Rep.2008;57 (RR-5):1-30;ACR.Herpeszoster(shingles)vaccineguidelinesforimmunocompromisedpatients.Availableat:http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp.AccessedOctober1,2010.
Issue date: February 2011 • Expiration date: February 29, 2012
OVERVIEwThispocketeducatorisdesignedtoaidprimarycareproviders(PCPs)inrecognizingtheearly signs of rheumatoid arthritis (RA) and determining when to refer a patient to a rheumatologist.SideAdiscussestheroleofthePCPintheearlydiagnosisofRAanddescribes how the PCP can work in tandem with the patient’s rheumatologist to effectively managethisdisease.SideBisdesignedtohelppatientsunderstandRA.LEARNING OBjECTIVES•IdentifypatientswhohaveprobableearlyRAandshouldbereferredtoarheumatologist•EmploythesqueezetesttoassistwithdiagnosisofRA•OrderappropriatelaboratorytestswhenRAissuspectedINTENDED AUDIENCEThistoolisintendedforPCPs.FACULTYClifton O. Bingham III, MD Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, Johns Hopkins University, Baltimore, MarylandJoyce P. Carlone, MN, RN, FNP-BC, CCRC NursePractitioner,DivisionofRheumatology,EmoryUniversity,Atlanta,GeorgiaMary Suzanne Cleveland, JD (Patient/Patient Educator) SeniorAnalyst,KansasHealthInstitute,Topeka,KansasLauren G. Collins, MD AssistantProfessorofFamilyandCommunityMedicine,JeffersonMedicalCollegeofThomas Jefferson University, Philadelphia, PennsylvaniaSTEERING COMMITTEE Michael E. Weinblatt, MD–Co-Chair JohnR.andEileenK.RiedmanProfessorofMedicine,HarvardMedicalSchool,Co-Director,ClinicalRheumatology,DivisionofRheumatology,Immunology,andAllergy,BrighamandWomen’sHospital,Boston,MassachusettsLauren G. Collins, MD–Co-ChairClifton O. Bingham III, MDJoyce P. Carlone, MN, RN, FNP-BC, CCRC Mary Suzanne Cleveland, JD (Patient/Patient Educator)Jeanne G. Cole, MS Director,OfficeofCME,JeffersonMedicalCollegeofThomasJeffersonUniversity,Philadelphia, PennsylvaniaKaren H. Costenbader, MD, MPH AssociatePhysician,DivisionofRheumatology,ImmunologyandAllergy,BrighamandWomen’sHospital, Assistant Professor of Medicine, Harvard Medical School, Boston, MassachusettsPaul P. Doghramji, MD, FAAFP MedicalDirectorforHealthServicesatUrsinusCollege,FamilyPhysician,CollegevilleFamilyPractice,Collegeville,PennsylvaniaDaniel Duch, PhD MedicalDirector,CuratioCMEInstitute,Exton,PennsylvaniaDavid S. Kountz, MD, MBA, FACP Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical Center,AssociateProfessorofMedicine,RobertWoodJohnsonMedicalSchool,NewBrunswick,NewJersey
2A 3A 4A 5A 6A 7A 8A 9A
�Osteoporosis 6–9��Seriousinfection rate
CVD10 years earlier
2��Rate ofmalignancy
�Pulmonarydisease
�GI bleeding
Jo
int destruction
Pain
D
is
abilit
y
RA symptom onset
Bony erosions70%–80%
Long-term disability80%
Rheumatologists:• Await early referral• Confirm diagnosis• Initiate DMARD/ biologics treatment
Rheumatologists:Long-termmanagementof RA
PCP:• Suspect diagnosis• “Immediate” referral• Baseline labs
PCP:• Surveillance• Comorbidity management• CVD risk reduction
4 Months
2 Years
10–20 Years
Immune responsedevelops
Joint destruction
Lymphomas
ComplicationsComorbidities
RAClinicalonset
EnvironmentGenes
Time
Pathologic inflammatoryresponse
CVD
Primary Care• Provisional diagnosis• Immediate referral to rheumatologist• Monitor for toxicities and disease progression• Address CVD risk and extra- articular issues
Rheumatologist• Confirm diagnosis• Initiate early, aggressive DMARD therapy• Monitor for toxicities and disease progression
Collaboration
Swelling on the proximal interphalangeal (PIP) joints
ReprintedfromTheLancet373,KlareskogLetal.Rheumatoidarthritis,659-672.Copyright2009,withpermissionfromElsevier.
Squeeze test
Participation in this activity includes reviewing the clinician educator and completing a posttest and evaluation. For additional information,
and to obtain 0.5 CME credits for participating in this activity, please visit http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
ACCREDITATION AND DESIGNATIONThis activity has been planned and implemented in accordance with the Essential Areas andPoliciesoftheAccreditationCouncilforContinuingMedicalEducation(ACCME).Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to providecontinuingmedicaleducationforphysicians.JeffersonMedicalCollegeofThomasJeffersonUniversitydesignatesthisenduringmaterialforamaximumof0.5AMA PRA Category 1 Credit™.Physiciansshouldclaimonlythecreditcommensuratewiththeextentoftheirparticipationintheactivity.DISCLOSUREJefferson Medical College of Thomas Jefferson University endorses the Standards of the ACCMEandtheGuidelinesforCommercialSupport.Thefollowingindividualshavedeclarednofinancialinterestsand/oraffiliations:Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; Jonathan S. Simmons, ELSThefollowingindividualshavedeclaredfinancialinterestsand/oraffiliations:Clifton O. Bingham III, MD Grant/Research Support: BMS, Genentech, UCB, Roche Consultant: Genentech,Roche,CentocorOrthoBiotech,Merck,UCB,Flexion,CelgeneJoyce P. Carlone, MN, RN, FNP-BC, CCRC Consultant, Product/Speakers Bureau, Other: UCBDavid S. Kountz, MD, MBA, FACPConsultant:NiCox,NovartisMichael E. Weinblatt, MDGrant/Research Support: AbbottConsultant:Abbott,CentocorOrthoBiotech,Pfizer/WyethCONTENT DISCLAIMER The information presented in this enduring material is for continuing medical education purposes only and is not meant to substitute for the independent medical judgment of a physicianregardingdiagnosisandtreatmentofaspecificpatient’smedicalcondition.The views or opinions expressed in the resources provided do not necessarily reflect those of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson HealthSystemorstaff.
ThisprogramissupportedbyeducationalgrantsfromAbbott,CentocorOrthoBiotechInc.,andPfizer.
Youcandownloadafree barcode reader app for your smartphone by searchingforQRCODESCANNERin the iPhone App Store, Android Market,orBlackberryAppWorld.
©2
010
Amer
ican
Col
lege
ofR
heum
atol
ogy.
Used
with
per
mis
sion
.
QR Code
31316/
3 34/
3 1316/3 13
16/3 1316/3 13
16/3 1316/3 13
16/
332/
3 1116/
6 14/
34 18/
C L I N I C I A N E D U C A T O R V O L U M E 4
Rheumatoid Arthrit is: Primary care Initiative for improved D iagnosis and outcomes
Co-sponsored by
SIDE A is for clinicians FREE CME
See panel 2A
SIDE B is for patients
RHEUMATOID ARTHRITIS FACTSRA is a chronic, progressive, systemic inflammatory disease •Characterizedby: – Progressive destruction of synovial joints with bony erosions and
loss of cartilage – Symptoms usually begin in the small joints of the fingers, wrists, and
feet – Swollen, tender joints are painful and difficult to move – Loss of physical function and quality of life – Decreased work productivity and increased disability and job loss •1.3millionadultAmericanshavebeendiagnosedwithRA •Peakageofonset:30to60years •2to4timesmorecommoninwomenthanmen •RApatients7timesaslikelytohavegreater-than-moderatedisability
than age- or sex-matched individuals •Ifundertreated,lifeexpectancyisreducedby5to15years –RAaccountsfor22%ofalldeathsfromarthritisandother
rheumatic conditions
It is never too late to stop further damage.
HochbergMC,SilmanAJ,SmolenJS,etal.eds.Rheumatology.3rded.NewYork,NY:Mosby;2003.AmericanCollegeofRheumatology.Factsheet.Availableat:http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/ra.asp.AccessedOctober1,2010.MacLeanCH,LouieR,LeakeB,etal.Qualityofcareforpatientswithrheumatoidarthritis.JAMA.2000;284:984-992.
RA IS A DISEASE OF THE ENTIRE BODYHeart:Cardiovasculardisease(CVD)occursonaverage10yearsearlierinRA patients than in the general population •AcceleratedatherosclerosisLungs:Increasedriskofmultiplepulmonarycomorbidities •Pleuritismayoccur • InterstitiallungdiseasesGastrointestinal (GI):RApatientshaveahighincidenceofGIbleeding,which may be attributable to use of nonsteroidal anti-inflammatory drugs (NSAIDs)andsteroidsduringtherapyNervous system: The deformity and damage to joints in RA may lead to entrapment of nerves •PatientmaypresentwithcarpaltunnelsyndromeOsteoporosis: Generalizedbonelossmayresultfromimmobility,theinflammatoryprocess,and/ortreatmentssuchassteroids • PeriarticulardemineralizationmayresultfrommediatorsofinflammationInfections:RApatientshavea6-to9-foldincreaseintherateofseriousinfections, including tuberculosis (TB) Malignancy: RA doubles the risk of some malignancies, particularly lymphoma
DeaneK.ManagingcomorbiditiesinRA.J Musculoskel Med.2006;23(suppl):S24-S31.BöttcherJ,PfeilA.DiagnosisofperiarticularosteoporosisinrheumatoidarthritisusingdigitalX-rayradiogrammetry.Arthritis Res Ther.2008;10:103.
PRIMARY CARE: EARLY DETECTION IS CRITICALTo prevent the progressive destruction of synovial joints and improve long-termoutcomes,RAmustbedetectedandtreatedearly. •Jointdamagecanberapid;withouttreatment,bonyerosionsmaybe
detectablebymagneticresonanceimaging(MRI)within4monthsofdisease onset
•Rateofx-rayprogressionismorerapidinthefirstyearthaninthesecond and third
•Withoutoptimaltreatment,mostpatientsdevelopbonyerosionswithin2years,and~80%ofthesepatientsdeveloplong-termdisability
•Successfullong-termmanagementrequiresapartnershipbetweenthe PCP and the rheumatologist, the patient, and other health care team members
Benefits of early detection: •DecreasedRAseverity,disability,andmortalitywitheffectivetreat-
ments, such as disease-modifying antirheumatic drugs (DMARDs) •LowerratesofRAcomplications •Lowerratesoflower-extremityorthopedicsurgicalprocedures •Decreasedcardiacriskswithcontrolofinflammation
McQueenFM,StewartN,CrabbeJ,etal.Magneticresonanceimagingofthewristinearlyrheumatoidarthritisrevealsahighprevalenceoferosionsatfourmonthsaftersymptomonset.Ann Rheum Dis.1998;57:350-356.BykerkVP,KeystoneEC.RAinprimarycare:20clinicalpearls.J Musculoskelet Med.2004;21:133-146.
PROVISIONAL DIAGNOSIS OF RAPatientswhohaveatleast1jointwithdefinitiveclinicalsynovitis(swelling)and in whom the synovitis is not better explained by another disease shouldbeexaminedforRA.MAkE THE DIAGNOSIS Does your patient have: 3 Swollen or tender joints –Either>1largeor≥1smalljointofthehandsorfeet,or –Positivesqueezetest(painwhengentlysqueezingacrossthe
metacarpophalangeal/metatarsophalangealjoints) 3 Symptoms lasting ≥6weeks
If patient has swollen joints or a positive squeeze test as above for ≥6 weeks, refer to a rheumatologist for provisional RA.
If the patient does not meet these criteria but has at least 1 swollen or tender joint and a positive RF or anti-CCP test, he or she should be referred to a rheumatologist.
A rheumatologist will make a definitive diagnosis of RA based on the followingcriteria: 1.Clinicalsignsandsymptoms 2.Patternandnumbersofjointsinvolved 3.Laboratorymeasures(RFandanti-CCPantibody) 4.Radiographicfindings 5.Rulingoutothercausesofinflammatoryarthritis
AletahaD,NeogiT,SilmanAJ.2010rheumatoidarthritisclassificationcriteria:anAmericanCollegeofRheumatology/ EuropeanLeagueAgainstRheumatismcollaborativeinitiative.Arthritis Rheum.2010Sept;62:2569-2581.
COLLABORATION BETwEEN PRIMARY CARE AND RHEUMATOLOGY ENSURES OPTIMAL CARESuccessfulmanagementofRArequireslong-termteaminvolvement.Inthe first stages, the PCP is responsible for identifying possible cases of RA,providingearlyreferraltoarheumatologistandearlypaincontrol.TherheumatologistconfirmsthediagnosisandinitiatesDMARDtherapy. •EarlyreferraltoarheumatologistiscriticaltoearlyinitiationofDMARD
therapy and to stop joint damage •Tofacilitatetheevaluationofthepatientbytherheumatologist,itis
advisabletoobtain: –Rheumatoidfactor(RF) n30%–70%ofRApatientsarepositive,althoughpositiveRFcan
be caused by many conditions – Anti-CCP antibody n40%–60%ofRApatientsarepositive(maybeyearsbefore
clinical manifestation) nMaybedetectableearlierthanRF n Extremely high specificity for RA – C-reactive protein, erythrocyte sedimentation rate –Completebloodcount(CBC),liverfunctiontests(LFTs) –Optionalx-raysofthehands,wrists,andfeet •Monitorforalarmsigns(infection,dyspnea,neckpain,rheumatoideye
disease, painful red eye) •EarlytreatmentbythePCPisintendedtorelievepainandenhance
mobility –NSAIDs,shortcourseoflow-doseprednisone;rarely,opioidsfor
severe pain
A patient who is RF and anti-CCP negative may still have RA.
BridgesSL.SpottingaggressiveRAearly:thephysicalexamination,testing,andimaging.J Musculoskelet Med.2006;23(supplNov):S10-S14.
LONG-TERM MANAGEMENT OF RA PATIENTSCVD: Patients with RA and persistent inflammation may have additional risk for CVD and require more aggressive cholesterol lowering •MinimizeCVDriskfactors(eg,smoking,lipids,bloodpressure) •MaintainhighindexofsuspicionforCVDFever and infections:RApatientsonsteroids,methotrexate(MTX),leflunomide,orbiologic agents are at increased risk of serious infection •AssessRApatientswithfever,suspectedinfection – Prompt and thorough evaluation of symptoms, antibiotics if warranted – Biologics may need to be held until infection is resolved – Prompt initiation of antibiotics (especially for patients on biologics) nAvoiduseoftrimethoprim/sulfamethoxazoleinpatientsonMTX •Ifpatientsonimmunosuppressiveagentsandbiologicsdonotrespondrapidlytoinitial
treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc) •Considersepticarthritiswhenthereis –Isolatedmonoarthritiswhenallotherjointsstable – Swelling and tenderness in a patient with total joint replacement n RA patients may not mount a febrile response and the white blood cell count
may not be elevated in this setting •AcutedyspneaandcoughinapatientonMTXmayrepresentpneumonitis
VACCINATIONS AND DMARD THERAPY •Recommendedbeforetherapybegins –Influenzaandpneumococcalvaccinations –HepatitisBimmunizationifappropriate •Safe –Influenza(injection),tetanus,pneumococcus,meningococcus,hepatitisA,
hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV) •Avoid – Live virus vaccines such as intranasalinfluenza,mumps/measles/rubella(MMR),
yellow fever, and typhoid should be avoided in patients on immunomodulators –Waitatleast2weeksaftergivingthesevaccinesbeforeinitiatingimmunomodulators – Zoster vaccine, should be avoided in patients on biologic agents, but can be
giventopatientstakingMTXandprednisone<20mg/day
DeaneK.J Musculoskel Med.2006;23(supplNov):S24-S31.RavikumarR,etal.Curr Rheumatol Rep.2007;9:407-415;CDC.MMWR.2004;53:Q1-Q4;AveryRK.Rheum Dis Clin North Am.1999;25:567-584;ChalmersA,etal.J Rheumatol.1994;21:1203-1206;HarpazR,etal.MMWR Recomm Rep.2008;57 (RR-5):1-30;ACR.Herpeszoster(shingles)vaccineguidelinesforimmunocompromisedpatients.Availableat:http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp.AccessedOctober1,2010.
Issue date: February 2011 • Expiration date: February 29, 2012
OVERVIEwThispocketeducatorisdesignedtoaidprimarycareproviders(PCPs)inrecognizingtheearly signs of rheumatoid arthritis (RA) and determining when to refer a patient to a rheumatologist.SideAdiscussestheroleofthePCPintheearlydiagnosisofRAanddescribes how the PCP can work in tandem with the patient’s rheumatologist to effectively managethisdisease.SideBisdesignedtohelppatientsunderstandRA.LEARNING OBjECTIVES•IdentifypatientswhohaveprobableearlyRAandshouldbereferredtoarheumatologist•EmploythesqueezetesttoassistwithdiagnosisofRA•OrderappropriatelaboratorytestswhenRAissuspectedINTENDED AUDIENCEThistoolisintendedforPCPs.FACULTYClifton O. Bingham III, MD Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, Johns Hopkins University, Baltimore, MarylandJoyce P. Carlone, MN, RN, FNP-BC, CCRC NursePractitioner,DivisionofRheumatology,EmoryUniversity,Atlanta,GeorgiaMary Suzanne Cleveland, JD (Patient/Patient Educator) SeniorAnalyst,KansasHealthInstitute,Topeka,KansasLauren G. Collins, MD AssistantProfessorofFamilyandCommunityMedicine,JeffersonMedicalCollegeofThomas Jefferson University, Philadelphia, PennsylvaniaSTEERING COMMITTEE Michael E. Weinblatt, MD–Co-Chair JohnR.andEileenK.RiedmanProfessorofMedicine,HarvardMedicalSchool,Co-Director,ClinicalRheumatology,DivisionofRheumatology,Immunology,andAllergy,BrighamandWomen’sHospital,Boston,MassachusettsLauren G. Collins, MD–Co-ChairClifton O. Bingham III, MDJoyce P. Carlone, MN, RN, FNP-BC, CCRC Mary Suzanne Cleveland, JD (Patient/Patient Educator)Jeanne G. Cole, MS Director,OfficeofCME,JeffersonMedicalCollegeofThomasJeffersonUniversity,Philadelphia, PennsylvaniaKaren H. Costenbader, MD, MPH AssociatePhysician,DivisionofRheumatology,ImmunologyandAllergy,BrighamandWomen’sHospital, Assistant Professor of Medicine, Harvard Medical School, Boston, MassachusettsPaul P. Doghramji, MD, FAAFP MedicalDirectorforHealthServicesatUrsinusCollege,FamilyPhysician,CollegevilleFamilyPractice,Collegeville,PennsylvaniaDaniel Duch, PhD MedicalDirector,CuratioCMEInstitute,Exton,PennsylvaniaDavid S. Kountz, MD, MBA, FACP Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical Center,AssociateProfessorofMedicine,RobertWoodJohnsonMedicalSchool,NewBrunswick,NewJersey
2A 3A 4A 5A 6A 7A 8A 9A
�Osteoporosis 6–9��Seriousinfection rate
CVD10 years earlier
2��Rate ofmalignancy
�Pulmonarydisease
�GI bleeding
Jo
int destruction
Pain
D
is
abilit
y
RA symptom onset
Bony erosions70%–80%
Long-term disability80%
Rheumatologists:• Await early referral• Confirm diagnosis• Initiate DMARD/ biologics treatment
Rheumatologists:Long-termmanagementof RA
PCP:• Suspect diagnosis• “Immediate” referral• Baseline labs
PCP:• Surveillance• Comorbidity management• CVD risk reduction
4 Months
2 Years
10–20 Years
Immune responsedevelops
Joint destruction
Lymphomas
ComplicationsComorbidities
RAClinicalonset
EnvironmentGenes
Time
Pathologic inflammatoryresponse
CVD
Primary Care• Provisional diagnosis• Immediate referral to rheumatologist• Monitor for toxicities and disease progression• Address CVD risk and extra- articular issues
Rheumatologist• Confirm diagnosis• Initiate early, aggressive DMARD therapy• Monitor for toxicities and disease progression
Collaboration
Swelling on the proximal interphalangeal (PIP) joints
ReprintedfromTheLancet373,KlareskogLetal.Rheumatoidarthritis,659-672.Copyright2009,withpermissionfromElsevier.
Squeeze test
Participation in this activity includes reviewing the clinician educator and completing a posttest and evaluation. For additional information,
and to obtain 0.5 CME credits for participating in this activity, please visit http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
ACCREDITATION AND DESIGNATIONThis activity has been planned and implemented in accordance with the Essential Areas andPoliciesoftheAccreditationCouncilforContinuingMedicalEducation(ACCME).Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to providecontinuingmedicaleducationforphysicians.JeffersonMedicalCollegeofThomasJeffersonUniversitydesignatesthisenduringmaterialforamaximumof0.5AMA PRA Category 1 Credit™.Physiciansshouldclaimonlythecreditcommensuratewiththeextentoftheirparticipationintheactivity.DISCLOSUREJefferson Medical College of Thomas Jefferson University endorses the Standards of the ACCMEandtheGuidelinesforCommercialSupport.Thefollowingindividualshavedeclarednofinancialinterestsand/oraffiliations:Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; Jonathan S. Simmons, ELSThefollowingindividualshavedeclaredfinancialinterestsand/oraffiliations:Clifton O. Bingham III, MD Grant/Research Support: BMS, Genentech, UCB, Roche Consultant: Genentech,Roche,CentocorOrthoBiotech,Merck,UCB,Flexion,CelgeneJoyce P. Carlone, MN, RN, FNP-BC, CCRC Consultant, Product/Speakers Bureau, Other: UCBDavid S. Kountz, MD, MBA, FACPConsultant:NiCox,NovartisMichael E. Weinblatt, MDGrant/Research Support: AbbottConsultant:Abbott,CentocorOrthoBiotech,Pfizer/WyethCONTENT DISCLAIMER The information presented in this enduring material is for continuing medical education purposes only and is not meant to substitute for the independent medical judgment of a physicianregardingdiagnosisandtreatmentofaspecificpatient’smedicalcondition.The views or opinions expressed in the resources provided do not necessarily reflect those of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson HealthSystemorstaff.
ThisprogramissupportedbyeducationalgrantsfromAbbott,CentocorOrthoBiotechInc.,andPfizer.
Youcandownloadafree barcode reader app for your smartphone by searchingforQRCODESCANNERin the iPhone App Store, Android Market,orBlackberryAppWorld.
©2
010
Amer
ican
Col
lege
ofR
heum
atol
ogy.
Used
with
per
mis
sion
.
QR Code
31316/
3 34/
3 1316/3 13
16/3 1316/3 13
16/3 1316/3 13
16/
332/
3 1116/
6 14/
34 18/
C L I N I C I A N E D U C A T O R V O L U M E 4
Rheumatoid Arthrit is: Primary care Initiative for improved D iagnosis and outcomes
Co-sponsored by
SIDE A is for clinicians FREE CME
See panel 2A
SIDE B is for patients
RHEUMATOID ARTHRITIS FACTSRA is a chronic, progressive, systemic inflammatory disease •Characterizedby: – Progressive destruction of synovial joints with bony erosions and
loss of cartilage – Symptoms usually begin in the small joints of the fingers, wrists, and
feet – Swollen, tender joints are painful and difficult to move – Loss of physical function and quality of life – Decreased work productivity and increased disability and job loss •1.3millionadultAmericanshavebeendiagnosedwithRA •Peakageofonset:30to60years •2to4timesmorecommoninwomenthanmen •RApatients7timesaslikelytohavegreater-than-moderatedisability
than age- or sex-matched individuals •Ifundertreated,lifeexpectancyisreducedby5to15years –RAaccountsfor22%ofalldeathsfromarthritisandother
rheumatic conditions
It is never too late to stop further damage.
HochbergMC,SilmanAJ,SmolenJS,etal.eds.Rheumatology.3rded.NewYork,NY:Mosby;2003.AmericanCollegeofRheumatology.Factsheet.Availableat:http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/ra.asp.AccessedOctober1,2010.MacLeanCH,LouieR,LeakeB,etal.Qualityofcareforpatientswithrheumatoidarthritis.JAMA.2000;284:984-992.
RA IS A DISEASE OF THE ENTIRE BODYHeart:Cardiovasculardisease(CVD)occursonaverage10yearsearlierinRA patients than in the general population •AcceleratedatherosclerosisLungs:Increasedriskofmultiplepulmonarycomorbidities •Pleuritismayoccur • InterstitiallungdiseasesGastrointestinal (GI):RApatientshaveahighincidenceofGIbleeding,which may be attributable to use of nonsteroidal anti-inflammatory drugs (NSAIDs)andsteroidsduringtherapyNervous system: The deformity and damage to joints in RA may lead to entrapment of nerves •PatientmaypresentwithcarpaltunnelsyndromeOsteoporosis: Generalizedbonelossmayresultfromimmobility,theinflammatoryprocess,and/ortreatmentssuchassteroids • PeriarticulardemineralizationmayresultfrommediatorsofinflammationInfections:RApatientshavea6-to9-foldincreaseintherateofseriousinfections, including tuberculosis (TB) Malignancy: RA doubles the risk of some malignancies, particularly lymphoma
DeaneK.ManagingcomorbiditiesinRA.J Musculoskel Med.2006;23(suppl):S24-S31.BöttcherJ,PfeilA.DiagnosisofperiarticularosteoporosisinrheumatoidarthritisusingdigitalX-rayradiogrammetry.Arthritis Res Ther.2008;10:103.
PRIMARY CARE: EARLY DETECTION IS CRITICALTo prevent the progressive destruction of synovial joints and improve long-termoutcomes,RAmustbedetectedandtreatedearly. •Jointdamagecanberapid;withouttreatment,bonyerosionsmaybe
detectablebymagneticresonanceimaging(MRI)within4monthsofdisease onset
•Rateofx-rayprogressionismorerapidinthefirstyearthaninthesecond and third
•Withoutoptimaltreatment,mostpatientsdevelopbonyerosionswithin2years,and~80%ofthesepatientsdeveloplong-termdisability
•Successfullong-termmanagementrequiresapartnershipbetweenthe PCP and the rheumatologist, the patient, and other health care team members
Benefits of early detection: •DecreasedRAseverity,disability,andmortalitywitheffectivetreat-
ments, such as disease-modifying antirheumatic drugs (DMARDs) •LowerratesofRAcomplications •Lowerratesoflower-extremityorthopedicsurgicalprocedures •Decreasedcardiacriskswithcontrolofinflammation
McQueenFM,StewartN,CrabbeJ,etal.Magneticresonanceimagingofthewristinearlyrheumatoidarthritisrevealsahighprevalenceoferosionsatfourmonthsaftersymptomonset.Ann Rheum Dis.1998;57:350-356.BykerkVP,KeystoneEC.RAinprimarycare:20clinicalpearls.J Musculoskelet Med.2004;21:133-146.
PROVISIONAL DIAGNOSIS OF RAPatientswhohaveatleast1jointwithdefinitiveclinicalsynovitis(swelling)and in whom the synovitis is not better explained by another disease shouldbeexaminedforRA.MAkE THE DIAGNOSIS Does your patient have: 3 Swollen or tender joints –Either>1largeor≥1smalljointofthehandsorfeet,or –Positivesqueezetest(painwhengentlysqueezingacrossthe
metacarpophalangeal/metatarsophalangealjoints) 3 Symptoms lasting ≥6weeks
If patient has swollen joints or a positive squeeze test as above for ≥6 weeks, refer to a rheumatologist for provisional RA.
If the patient does not meet these criteria but has at least 1 swollen or tender joint and a positive RF or anti-CCP test, he or she should be referred to a rheumatologist.
A rheumatologist will make a definitive diagnosis of RA based on the followingcriteria: 1.Clinicalsignsandsymptoms 2.Patternandnumbersofjointsinvolved 3.Laboratorymeasures(RFandanti-CCPantibody) 4.Radiographicfindings 5.Rulingoutothercausesofinflammatoryarthritis
AletahaD,NeogiT,SilmanAJ.2010rheumatoidarthritisclassificationcriteria:anAmericanCollegeofRheumatology/ EuropeanLeagueAgainstRheumatismcollaborativeinitiative.Arthritis Rheum.2010Sept;62:2569-2581.
COLLABORATION BETwEEN PRIMARY CARE AND RHEUMATOLOGY ENSURES OPTIMAL CARESuccessfulmanagementofRArequireslong-termteaminvolvement.Inthe first stages, the PCP is responsible for identifying possible cases of RA,providingearlyreferraltoarheumatologistandearlypaincontrol.TherheumatologistconfirmsthediagnosisandinitiatesDMARDtherapy. •EarlyreferraltoarheumatologistiscriticaltoearlyinitiationofDMARD
therapy and to stop joint damage •Tofacilitatetheevaluationofthepatientbytherheumatologist,itis
advisabletoobtain: –Rheumatoidfactor(RF) n30%–70%ofRApatientsarepositive,althoughpositiveRFcan
be caused by many conditions – Anti-CCP antibody n40%–60%ofRApatientsarepositive(maybeyearsbefore
clinical manifestation) nMaybedetectableearlierthanRF n Extremely high specificity for RA – C-reactive protein, erythrocyte sedimentation rate –Completebloodcount(CBC),liverfunctiontests(LFTs) –Optionalx-raysofthehands,wrists,andfeet •Monitorforalarmsigns(infection,dyspnea,neckpain,rheumatoideye
disease, painful red eye) •EarlytreatmentbythePCPisintendedtorelievepainandenhance
mobility –NSAIDs,shortcourseoflow-doseprednisone;rarely,opioidsfor
severe pain
A patient who is RF and anti-CCP negative may still have RA.
BridgesSL.SpottingaggressiveRAearly:thephysicalexamination,testing,andimaging.J Musculoskelet Med.2006;23(supplNov):S10-S14.
LONG-TERM MANAGEMENT OF RA PATIENTSCVD: Patients with RA and persistent inflammation may have additional risk for CVD and require more aggressive cholesterol lowering •MinimizeCVDriskfactors(eg,smoking,lipids,bloodpressure) •MaintainhighindexofsuspicionforCVDFever and infections:RApatientsonsteroids,methotrexate(MTX),leflunomide,orbiologic agents are at increased risk of serious infection •AssessRApatientswithfever,suspectedinfection – Prompt and thorough evaluation of symptoms, antibiotics if warranted – Biologics may need to be held until infection is resolved – Prompt initiation of antibiotics (especially for patients on biologics) nAvoiduseoftrimethoprim/sulfamethoxazoleinpatientsonMTX •Ifpatientsonimmunosuppressiveagentsandbiologicsdonotrespondrapidlytoinitial
treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc) •Considersepticarthritiswhenthereis –Isolatedmonoarthritiswhenallotherjointsstable – Swelling and tenderness in a patient with total joint replacement n RA patients may not mount a febrile response and the white blood cell count
may not be elevated in this setting •AcutedyspneaandcoughinapatientonMTXmayrepresentpneumonitis
VACCINATIONS AND DMARD THERAPY •Recommendedbeforetherapybegins –Influenzaandpneumococcalvaccinations –HepatitisBimmunizationifappropriate •Safe –Influenza(injection),tetanus,pneumococcus,meningococcus,hepatitisA,
hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV) •Avoid – Live virus vaccines such as intranasalinfluenza,mumps/measles/rubella(MMR),
yellow fever, and typhoid should be avoided in patients on immunomodulators –Waitatleast2weeksaftergivingthesevaccinesbeforeinitiatingimmunomodulators – Zoster vaccine, should be avoided in patients on biologic agents, but can be
giventopatientstakingMTXandprednisone<20mg/day
DeaneK.J Musculoskel Med.2006;23(supplNov):S24-S31.RavikumarR,etal.Curr Rheumatol Rep.2007;9:407-415;CDC.MMWR.2004;53:Q1-Q4;AveryRK.Rheum Dis Clin North Am.1999;25:567-584;ChalmersA,etal.J Rheumatol.1994;21:1203-1206;HarpazR,etal.MMWR Recomm Rep.2008;57 (RR-5):1-30;ACR.Herpeszoster(shingles)vaccineguidelinesforimmunocompromisedpatients.Availableat:http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp.AccessedOctober1,2010.
Issue date: February 2011 • Expiration date: February 29, 2012
OVERVIEwThispocketeducatorisdesignedtoaidprimarycareproviders(PCPs)inrecognizingtheearly signs of rheumatoid arthritis (RA) and determining when to refer a patient to a rheumatologist.SideAdiscussestheroleofthePCPintheearlydiagnosisofRAanddescribes how the PCP can work in tandem with the patient’s rheumatologist to effectively managethisdisease.SideBisdesignedtohelppatientsunderstandRA.LEARNING OBjECTIVES•IdentifypatientswhohaveprobableearlyRAandshouldbereferredtoarheumatologist•EmploythesqueezetesttoassistwithdiagnosisofRA•OrderappropriatelaboratorytestswhenRAissuspectedINTENDED AUDIENCEThistoolisintendedforPCPs.FACULTYClifton O. Bingham III, MD Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, Johns Hopkins University, Baltimore, MarylandJoyce P. Carlone, MN, RN, FNP-BC, CCRC NursePractitioner,DivisionofRheumatology,EmoryUniversity,Atlanta,GeorgiaMary Suzanne Cleveland, JD (Patient/Patient Educator) SeniorAnalyst,KansasHealthInstitute,Topeka,KansasLauren G. Collins, MD AssistantProfessorofFamilyandCommunityMedicine,JeffersonMedicalCollegeofThomas Jefferson University, Philadelphia, PennsylvaniaSTEERING COMMITTEE Michael E. Weinblatt, MD–Co-Chair JohnR.andEileenK.RiedmanProfessorofMedicine,HarvardMedicalSchool,Co-Director,ClinicalRheumatology,DivisionofRheumatology,Immunology,andAllergy,BrighamandWomen’sHospital,Boston,MassachusettsLauren G. Collins, MD–Co-ChairClifton O. Bingham III, MDJoyce P. Carlone, MN, RN, FNP-BC, CCRC Mary Suzanne Cleveland, JD (Patient/Patient Educator)Jeanne G. Cole, MS Director,OfficeofCME,JeffersonMedicalCollegeofThomasJeffersonUniversity,Philadelphia, PennsylvaniaKaren H. Costenbader, MD, MPH AssociatePhysician,DivisionofRheumatology,ImmunologyandAllergy,BrighamandWomen’sHospital, Assistant Professor of Medicine, Harvard Medical School, Boston, MassachusettsPaul P. Doghramji, MD, FAAFP MedicalDirectorforHealthServicesatUrsinusCollege,FamilyPhysician,CollegevilleFamilyPractice,Collegeville,PennsylvaniaDaniel Duch, PhD MedicalDirector,CuratioCMEInstitute,Exton,PennsylvaniaDavid S. Kountz, MD, MBA, FACP Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical Center,AssociateProfessorofMedicine,RobertWoodJohnsonMedicalSchool,NewBrunswick,NewJersey
2A 3A 4A 5A 6A 7A 8A 9A
�Osteoporosis 6–9��Seriousinfection rate
CVD10 years earlier
2��Rate ofmalignancy
�Pulmonarydisease
�GI bleeding
Jo
int destruction
Pain
D
is
abilit
y
RA symptom onset
Bony erosions70%–80%
Long-term disability80%
Rheumatologists:• Await early referral• Confirm diagnosis• Initiate DMARD/ biologics treatment
Rheumatologists:Long-termmanagementof RA
PCP:• Suspect diagnosis• “Immediate” referral• Baseline labs
PCP:• Surveillance• Comorbidity management• CVD risk reduction
4 Months
2 Years
10–20 Years
Immune responsedevelops
Joint destruction
Lymphomas
ComplicationsComorbidities
RAClinicalonset
EnvironmentGenes
Time
Pathologic inflammatoryresponse
CVD
Primary Care• Provisional diagnosis• Immediate referral to rheumatologist• Monitor for toxicities and disease progression• Address CVD risk and extra- articular issues
Rheumatologist• Confirm diagnosis• Initiate early, aggressive DMARD therapy• Monitor for toxicities and disease progression
Collaboration
Swelling on the proximal interphalangeal (PIP) joints
ReprintedfromTheLancet373,KlareskogLetal.Rheumatoidarthritis,659-672.Copyright2009,withpermissionfromElsevier.
Squeeze test
Participation in this activity includes reviewing the clinician educator and completing a posttest and evaluation. For additional information,
and to obtain 0.5 CME credits for participating in this activity, please visit http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
ACCREDITATION AND DESIGNATIONThis activity has been planned and implemented in accordance with the Essential Areas andPoliciesoftheAccreditationCouncilforContinuingMedicalEducation(ACCME).Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to providecontinuingmedicaleducationforphysicians.JeffersonMedicalCollegeofThomasJeffersonUniversitydesignatesthisenduringmaterialforamaximumof0.5AMA PRA Category 1 Credit™.Physiciansshouldclaimonlythecreditcommensuratewiththeextentoftheirparticipationintheactivity.DISCLOSUREJefferson Medical College of Thomas Jefferson University endorses the Standards of the ACCMEandtheGuidelinesforCommercialSupport.Thefollowingindividualshavedeclarednofinancialinterestsand/oraffiliations:Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; Jonathan S. Simmons, ELSThefollowingindividualshavedeclaredfinancialinterestsand/oraffiliations:Clifton O. Bingham III, MD Grant/Research Support: BMS, Genentech, UCB, Roche Consultant: Genentech,Roche,CentocorOrthoBiotech,Merck,UCB,Flexion,CelgeneJoyce P. Carlone, MN, RN, FNP-BC, CCRC Consultant, Product/Speakers Bureau, Other: UCBDavid S. Kountz, MD, MBA, FACPConsultant:NiCox,NovartisMichael E. Weinblatt, MDGrant/Research Support: AbbottConsultant:Abbott,CentocorOrthoBiotech,Pfizer/WyethCONTENT DISCLAIMER The information presented in this enduring material is for continuing medical education purposes only and is not meant to substitute for the independent medical judgment of a physicianregardingdiagnosisandtreatmentofaspecificpatient’smedicalcondition.The views or opinions expressed in the resources provided do not necessarily reflect those of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson HealthSystemorstaff.
ThisprogramissupportedbyeducationalgrantsfromAbbott,CentocorOrthoBiotechInc.,andPfizer.
Youcandownloadafree barcode reader app for your smartphone by searchingforQRCODESCANNERin the iPhone App Store, Android Market,orBlackberryAppWorld.
©2
010
Amer
ican
Col
lege
ofR
heum
atol
ogy.
Used
with
per
mis
sion
.
QR Code
31316/
3 34/
3 1316/3 13
16/3 1316/3 13
16/3 1316/3 13
16/
332/
3 1116/
6 14/
34 18/
C L I N I C I A N E D U C A T O R V O L U M E 4
Rheumatoid Arthrit is: Primary care Initiative for improved D iagnosis and outcomes
Co-sponsored by
SIDE A is for clinicians FREE CME
See panel 2A
SIDE B is for patients
RHEUMATOID ARTHRITIS FACTSRA is a chronic, progressive, systemic inflammatory disease •Characterizedby: – Progressive destruction of synovial joints with bony erosions and
loss of cartilage – Symptoms usually begin in the small joints of the fingers, wrists, and
feet – Swollen, tender joints are painful and difficult to move – Loss of physical function and quality of life – Decreased work productivity and increased disability and job loss •1.3millionadultAmericanshavebeendiagnosedwithRA •Peakageofonset:30to60years •2to4timesmorecommoninwomenthanmen •RApatients7timesaslikelytohavegreater-than-moderatedisability
than age- or sex-matched individuals •Ifundertreated,lifeexpectancyisreducedby5to15years –RAaccountsfor22%ofalldeathsfromarthritisandother
rheumatic conditions
It is never too late to stop further damage.
HochbergMC,SilmanAJ,SmolenJS,etal.eds.Rheumatology.3rded.NewYork,NY:Mosby;2003.AmericanCollegeofRheumatology.Factsheet.Availableat:http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/ra.asp.AccessedOctober1,2010.MacLeanCH,LouieR,LeakeB,etal.Qualityofcareforpatientswithrheumatoidarthritis.JAMA.2000;284:984-992.
RA IS A DISEASE OF THE ENTIRE BODYHeart:Cardiovasculardisease(CVD)occursonaverage10yearsearlierinRA patients than in the general population •AcceleratedatherosclerosisLungs:Increasedriskofmultiplepulmonarycomorbidities •Pleuritismayoccur • InterstitiallungdiseasesGastrointestinal (GI):RApatientshaveahighincidenceofGIbleeding,which may be attributable to use of nonsteroidal anti-inflammatory drugs (NSAIDs)andsteroidsduringtherapyNervous system: The deformity and damage to joints in RA may lead to entrapment of nerves •PatientmaypresentwithcarpaltunnelsyndromeOsteoporosis: Generalizedbonelossmayresultfromimmobility,theinflammatoryprocess,and/ortreatmentssuchassteroids • PeriarticulardemineralizationmayresultfrommediatorsofinflammationInfections:RApatientshavea6-to9-foldincreaseintherateofseriousinfections, including tuberculosis (TB) Malignancy: RA doubles the risk of some malignancies, particularly lymphoma
DeaneK.ManagingcomorbiditiesinRA.J Musculoskel Med.2006;23(suppl):S24-S31.BöttcherJ,PfeilA.DiagnosisofperiarticularosteoporosisinrheumatoidarthritisusingdigitalX-rayradiogrammetry.Arthritis Res Ther.2008;10:103.
PRIMARY CARE: EARLY DETECTION IS CRITICALTo prevent the progressive destruction of synovial joints and improve long-termoutcomes,RAmustbedetectedandtreatedearly. •Jointdamagecanberapid;withouttreatment,bonyerosionsmaybe
detectablebymagneticresonanceimaging(MRI)within4monthsofdisease onset
•Rateofx-rayprogressionismorerapidinthefirstyearthaninthesecond and third
•Withoutoptimaltreatment,mostpatientsdevelopbonyerosionswithin2years,and~80%ofthesepatientsdeveloplong-termdisability
•Successfullong-termmanagementrequiresapartnershipbetweenthe PCP and the rheumatologist, the patient, and other health care team members
Benefits of early detection: •DecreasedRAseverity,disability,andmortalitywitheffectivetreat-
ments, such as disease-modifying antirheumatic drugs (DMARDs) •LowerratesofRAcomplications •Lowerratesoflower-extremityorthopedicsurgicalprocedures •Decreasedcardiacriskswithcontrolofinflammation
McQueenFM,StewartN,CrabbeJ,etal.Magneticresonanceimagingofthewristinearlyrheumatoidarthritisrevealsahighprevalenceoferosionsatfourmonthsaftersymptomonset.Ann Rheum Dis.1998;57:350-356.BykerkVP,KeystoneEC.RAinprimarycare:20clinicalpearls.J Musculoskelet Med.2004;21:133-146.
PROVISIONAL DIAGNOSIS OF RAPatientswhohaveatleast1jointwithdefinitiveclinicalsynovitis(swelling)and in whom the synovitis is not better explained by another disease shouldbeexaminedforRA.MAkE THE DIAGNOSIS Does your patient have: 3 Swollen or tender joints –Either>1largeor≥1smalljointofthehandsorfeet,or –Positivesqueezetest(painwhengentlysqueezingacrossthe
metacarpophalangeal/metatarsophalangealjoints) 3 Symptoms lasting ≥6weeks
If patient has swollen joints or a positive squeeze test as above for ≥6 weeks, refer to a rheumatologist for provisional RA.
If the patient does not meet these criteria but has at least 1 swollen or tender joint and a positive RF or anti-CCP test, he or she should be referred to a rheumatologist.
A rheumatologist will make a definitive diagnosis of RA based on the followingcriteria: 1.Clinicalsignsandsymptoms 2.Patternandnumbersofjointsinvolved 3.Laboratorymeasures(RFandanti-CCPantibody) 4.Radiographicfindings 5.Rulingoutothercausesofinflammatoryarthritis
AletahaD,NeogiT,SilmanAJ.2010rheumatoidarthritisclassificationcriteria:anAmericanCollegeofRheumatology/ EuropeanLeagueAgainstRheumatismcollaborativeinitiative.Arthritis Rheum.2010Sept;62:2569-2581.
COLLABORATION BETwEEN PRIMARY CARE AND RHEUMATOLOGY ENSURES OPTIMAL CARESuccessfulmanagementofRArequireslong-termteaminvolvement.Inthe first stages, the PCP is responsible for identifying possible cases of RA,providingearlyreferraltoarheumatologistandearlypaincontrol.TherheumatologistconfirmsthediagnosisandinitiatesDMARDtherapy. •EarlyreferraltoarheumatologistiscriticaltoearlyinitiationofDMARD
therapy and to stop joint damage •Tofacilitatetheevaluationofthepatientbytherheumatologist,itis
advisabletoobtain: –Rheumatoidfactor(RF) n30%–70%ofRApatientsarepositive,althoughpositiveRFcan
be caused by many conditions – Anti-CCP antibody n40%–60%ofRApatientsarepositive(maybeyearsbefore
clinical manifestation) nMaybedetectableearlierthanRF n Extremely high specificity for RA – C-reactive protein, erythrocyte sedimentation rate –Completebloodcount(CBC),liverfunctiontests(LFTs) –Optionalx-raysofthehands,wrists,andfeet •Monitorforalarmsigns(infection,dyspnea,neckpain,rheumatoideye
disease, painful red eye) •EarlytreatmentbythePCPisintendedtorelievepainandenhance
mobility –NSAIDs,shortcourseoflow-doseprednisone;rarely,opioidsfor
severe pain
A patient who is RF and anti-CCP negative may still have RA.
BridgesSL.SpottingaggressiveRAearly:thephysicalexamination,testing,andimaging.J Musculoskelet Med.2006;23(supplNov):S10-S14.
LONG-TERM MANAGEMENT OF RA PATIENTSCVD: Patients with RA and persistent inflammation may have additional risk for CVD and require more aggressive cholesterol lowering •MinimizeCVDriskfactors(eg,smoking,lipids,bloodpressure) •MaintainhighindexofsuspicionforCVDFever and infections:RApatientsonsteroids,methotrexate(MTX),leflunomide,orbiologic agents are at increased risk of serious infection •AssessRApatientswithfever,suspectedinfection – Prompt and thorough evaluation of symptoms, antibiotics if warranted – Biologics may need to be held until infection is resolved – Prompt initiation of antibiotics (especially for patients on biologics) nAvoiduseoftrimethoprim/sulfamethoxazoleinpatientsonMTX •Ifpatientsonimmunosuppressiveagentsandbiologicsdonotrespondrapidlytoinitial
treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc) •Considersepticarthritiswhenthereis –Isolatedmonoarthritiswhenallotherjointsstable – Swelling and tenderness in a patient with total joint replacement n RA patients may not mount a febrile response and the white blood cell count
may not be elevated in this setting •AcutedyspneaandcoughinapatientonMTXmayrepresentpneumonitis
VACCINATIONS AND DMARD THERAPY •Recommendedbeforetherapybegins –Influenzaandpneumococcalvaccinations –HepatitisBimmunizationifappropriate •Safe –Influenza(injection),tetanus,pneumococcus,meningococcus,hepatitisA,
hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV) •Avoid – Live virus vaccines such as intranasalinfluenza,mumps/measles/rubella(MMR),
yellow fever, and typhoid should be avoided in patients on immunomodulators –Waitatleast2weeksaftergivingthesevaccinesbeforeinitiatingimmunomodulators – Zoster vaccine, should be avoided in patients on biologic agents, but can be
giventopatientstakingMTXandprednisone<20mg/day
DeaneK.J Musculoskel Med.2006;23(supplNov):S24-S31.RavikumarR,etal.Curr Rheumatol Rep.2007;9:407-415;CDC.MMWR.2004;53:Q1-Q4;AveryRK.Rheum Dis Clin North Am.1999;25:567-584;ChalmersA,etal.J Rheumatol.1994;21:1203-1206;HarpazR,etal.MMWR Recomm Rep.2008;57 (RR-5):1-30;ACR.Herpeszoster(shingles)vaccineguidelinesforimmunocompromisedpatients.Availableat:http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp.AccessedOctober1,2010.
Issue date: February 2011 • Expiration date: February 29, 2012
OVERVIEwThispocketeducatorisdesignedtoaidprimarycareproviders(PCPs)inrecognizingtheearly signs of rheumatoid arthritis (RA) and determining when to refer a patient to a rheumatologist.SideAdiscussestheroleofthePCPintheearlydiagnosisofRAanddescribes how the PCP can work in tandem with the patient’s rheumatologist to effectively managethisdisease.SideBisdesignedtohelppatientsunderstandRA.LEARNING OBjECTIVES•IdentifypatientswhohaveprobableearlyRAandshouldbereferredtoarheumatologist•EmploythesqueezetesttoassistwithdiagnosisofRA•OrderappropriatelaboratorytestswhenRAissuspectedINTENDED AUDIENCEThistoolisintendedforPCPs.FACULTYClifton O. Bingham III, MD Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, Johns Hopkins University, Baltimore, MarylandJoyce P. Carlone, MN, RN, FNP-BC, CCRC NursePractitioner,DivisionofRheumatology,EmoryUniversity,Atlanta,GeorgiaMary Suzanne Cleveland, JD (Patient/Patient Educator) SeniorAnalyst,KansasHealthInstitute,Topeka,KansasLauren G. Collins, MD AssistantProfessorofFamilyandCommunityMedicine,JeffersonMedicalCollegeofThomas Jefferson University, Philadelphia, PennsylvaniaSTEERING COMMITTEE Michael E. Weinblatt, MD–Co-Chair JohnR.andEileenK.RiedmanProfessorofMedicine,HarvardMedicalSchool,Co-Director,ClinicalRheumatology,DivisionofRheumatology,Immunology,andAllergy,BrighamandWomen’sHospital,Boston,MassachusettsLauren G. Collins, MD–Co-ChairClifton O. Bingham III, MDJoyce P. Carlone, MN, RN, FNP-BC, CCRC Mary Suzanne Cleveland, JD (Patient/Patient Educator)Jeanne G. Cole, MS Director,OfficeofCME,JeffersonMedicalCollegeofThomasJeffersonUniversity,Philadelphia, PennsylvaniaKaren H. Costenbader, MD, MPH AssociatePhysician,DivisionofRheumatology,ImmunologyandAllergy,BrighamandWomen’sHospital, Assistant Professor of Medicine, Harvard Medical School, Boston, MassachusettsPaul P. Doghramji, MD, FAAFP MedicalDirectorforHealthServicesatUrsinusCollege,FamilyPhysician,CollegevilleFamilyPractice,Collegeville,PennsylvaniaDaniel Duch, PhD MedicalDirector,CuratioCMEInstitute,Exton,PennsylvaniaDavid S. Kountz, MD, MBA, FACP Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical Center,AssociateProfessorofMedicine,RobertWoodJohnsonMedicalSchool,NewBrunswick,NewJersey
2A 3A 4A 5A 6A 7A 8A 9A
�Osteoporosis 6–9��Seriousinfection rate
CVD10 years earlier
2��Rate ofmalignancy
�Pulmonarydisease
�GI bleeding
Jo
int destruction
Pain
D
is
abilit
y
RA symptom onset
Bony erosions70%–80%
Long-term disability80%
Rheumatologists:• Await early referral• Confirm diagnosis• Initiate DMARD/ biologics treatment
Rheumatologists:Long-termmanagementof RA
PCP:• Suspect diagnosis• “Immediate” referral• Baseline labs
PCP:• Surveillance• Comorbidity management• CVD risk reduction
4 Months
2 Years
10–20 Years
Immune responsedevelops
Joint destruction
Lymphomas
ComplicationsComorbidities
RAClinicalonset
EnvironmentGenes
Time
Pathologic inflammatoryresponse
CVD
Primary Care• Provisional diagnosis• Immediate referral to rheumatologist• Monitor for toxicities and disease progression• Address CVD risk and extra- articular issues
Rheumatologist• Confirm diagnosis• Initiate early, aggressive DMARD therapy• Monitor for toxicities and disease progression
Collaboration
Swelling on the proximal interphalangeal (PIP) joints
ReprintedfromTheLancet373,KlareskogLetal.Rheumatoidarthritis,659-672.Copyright2009,withpermissionfromElsevier.
Squeeze test
Participation in this activity includes reviewing the clinician educator and completing a posttest and evaluation. For additional information,
and to obtain 0.5 CME credits for participating in this activity, please visit http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
ACCREDITATION AND DESIGNATIONThis activity has been planned and implemented in accordance with the Essential Areas andPoliciesoftheAccreditationCouncilforContinuingMedicalEducation(ACCME).Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to providecontinuingmedicaleducationforphysicians.JeffersonMedicalCollegeofThomasJeffersonUniversitydesignatesthisenduringmaterialforamaximumof0.5AMA PRA Category 1 Credit™.Physiciansshouldclaimonlythecreditcommensuratewiththeextentoftheirparticipationintheactivity.DISCLOSUREJefferson Medical College of Thomas Jefferson University endorses the Standards of the ACCMEandtheGuidelinesforCommercialSupport.Thefollowingindividualshavedeclarednofinancialinterestsand/oraffiliations:Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; Jonathan S. Simmons, ELSThefollowingindividualshavedeclaredfinancialinterestsand/oraffiliations:Clifton O. Bingham III, MD Grant/Research Support: BMS, Genentech, UCB, Roche Consultant: Genentech,Roche,CentocorOrthoBiotech,Merck,UCB,Flexion,CelgeneJoyce P. Carlone, MN, RN, FNP-BC, CCRC Consultant, Product/Speakers Bureau, Other: UCBDavid S. Kountz, MD, MBA, FACPConsultant:NiCox,NovartisMichael E. Weinblatt, MDGrant/Research Support: AbbottConsultant:Abbott,CentocorOrthoBiotech,Pfizer/WyethCONTENT DISCLAIMER The information presented in this enduring material is for continuing medical education purposes only and is not meant to substitute for the independent medical judgment of a physicianregardingdiagnosisandtreatmentofaspecificpatient’smedicalcondition.The views or opinions expressed in the resources provided do not necessarily reflect those of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson HealthSystemorstaff.
ThisprogramissupportedbyeducationalgrantsfromAbbott,CentocorOrthoBiotechInc.,andPfizer.
Youcandownloadafree barcode reader app for your smartphone by searchingforQRCODESCANNERin the iPhone App Store, Android Market,orBlackberryAppWorld.
©2
010
Amer
ican
Col
lege
ofR
heum
atol
ogy.
Used
with
per
mis
sion
.
QR Code
31316/
3 34/
3 1316/3 13
16/3 1316/3 13
16/3 1316/3 13
16/
332/
3 1116/
6 14/
34 18/
C L I N I C I A N E D U C A T O R V O L U M E 4
Rheumatoid Arthrit is: Primary care Initiative for improved D iagnosis and outcomes
Co-sponsored by
SIDE A is for clinicians FREE CME
See panel 2A
SIDE B is for patients
RHEUMATOID ARTHRITIS FACTSRA is a chronic, progressive, systemic inflammatory disease •Characterizedby: – Progressive destruction of synovial joints with bony erosions and
loss of cartilage – Symptoms usually begin in the small joints of the fingers, wrists, and
feet – Swollen, tender joints are painful and difficult to move – Loss of physical function and quality of life – Decreased work productivity and increased disability and job loss •1.3millionadultAmericanshavebeendiagnosedwithRA •Peakageofonset:30to60years •2to4timesmorecommoninwomenthanmen •RApatients7timesaslikelytohavegreater-than-moderatedisability
than age- or sex-matched individuals •Ifundertreated,lifeexpectancyisreducedby5to15years –RAaccountsfor22%ofalldeathsfromarthritisandother
rheumatic conditions
It is never too late to stop further damage.
HochbergMC,SilmanAJ,SmolenJS,etal.eds.Rheumatology.3rded.NewYork,NY:Mosby;2003.AmericanCollegeofRheumatology.Factsheet.Availableat:http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/ra.asp.AccessedOctober1,2010.MacLeanCH,LouieR,LeakeB,etal.Qualityofcareforpatientswithrheumatoidarthritis.JAMA.2000;284:984-992.
RA IS A DISEASE OF THE ENTIRE BODYHeart:Cardiovasculardisease(CVD)occursonaverage10yearsearlierinRA patients than in the general population •AcceleratedatherosclerosisLungs:Increasedriskofmultiplepulmonarycomorbidities •Pleuritismayoccur • InterstitiallungdiseasesGastrointestinal (GI):RApatientshaveahighincidenceofGIbleeding,which may be attributable to use of nonsteroidal anti-inflammatory drugs (NSAIDs)andsteroidsduringtherapyNervous system: The deformity and damage to joints in RA may lead to entrapment of nerves •PatientmaypresentwithcarpaltunnelsyndromeOsteoporosis: Generalizedbonelossmayresultfromimmobility,theinflammatoryprocess,and/ortreatmentssuchassteroids • PeriarticulardemineralizationmayresultfrommediatorsofinflammationInfections:RApatientshavea6-to9-foldincreaseintherateofseriousinfections, including tuberculosis (TB) Malignancy: RA doubles the risk of some malignancies, particularly lymphoma
DeaneK.ManagingcomorbiditiesinRA.J Musculoskel Med.2006;23(suppl):S24-S31.BöttcherJ,PfeilA.DiagnosisofperiarticularosteoporosisinrheumatoidarthritisusingdigitalX-rayradiogrammetry.Arthritis Res Ther.2008;10:103.
PRIMARY CARE: EARLY DETECTION IS CRITICALTo prevent the progressive destruction of synovial joints and improve long-termoutcomes,RAmustbedetectedandtreatedearly. •Jointdamagecanberapid;withouttreatment,bonyerosionsmaybe
detectablebymagneticresonanceimaging(MRI)within4monthsofdisease onset
•Rateofx-rayprogressionismorerapidinthefirstyearthaninthesecond and third
•Withoutoptimaltreatment,mostpatientsdevelopbonyerosionswithin2years,and~80%ofthesepatientsdeveloplong-termdisability
•Successfullong-termmanagementrequiresapartnershipbetweenthe PCP and the rheumatologist, the patient, and other health care team members
Benefits of early detection: •DecreasedRAseverity,disability,andmortalitywitheffectivetreat-
ments, such as disease-modifying antirheumatic drugs (DMARDs) •LowerratesofRAcomplications •Lowerratesoflower-extremityorthopedicsurgicalprocedures •Decreasedcardiacriskswithcontrolofinflammation
McQueenFM,StewartN,CrabbeJ,etal.Magneticresonanceimagingofthewristinearlyrheumatoidarthritisrevealsahighprevalenceoferosionsatfourmonthsaftersymptomonset.Ann Rheum Dis.1998;57:350-356.BykerkVP,KeystoneEC.RAinprimarycare:20clinicalpearls.J Musculoskelet Med.2004;21:133-146.
PROVISIONAL DIAGNOSIS OF RAPatientswhohaveatleast1jointwithdefinitiveclinicalsynovitis(swelling)and in whom the synovitis is not better explained by another disease shouldbeexaminedforRA.MAkE THE DIAGNOSIS Does your patient have: 3 Swollen or tender joints –Either>1largeor≥1smalljointofthehandsorfeet,or –Positivesqueezetest(painwhengentlysqueezingacrossthe
metacarpophalangeal/metatarsophalangealjoints) 3 Symptoms lasting ≥6weeks
If patient has swollen joints or a positive squeeze test as above for ≥6 weeks, refer to a rheumatologist for provisional RA.
If the patient does not meet these criteria but has at least 1 swollen or tender joint and a positive RF or anti-CCP test, he or she should be referred to a rheumatologist.
A rheumatologist will make a definitive diagnosis of RA based on the followingcriteria: 1.Clinicalsignsandsymptoms 2.Patternandnumbersofjointsinvolved 3.Laboratorymeasures(RFandanti-CCPantibody) 4.Radiographicfindings 5.Rulingoutothercausesofinflammatoryarthritis
AletahaD,NeogiT,SilmanAJ.2010rheumatoidarthritisclassificationcriteria:anAmericanCollegeofRheumatology/ EuropeanLeagueAgainstRheumatismcollaborativeinitiative.Arthritis Rheum.2010Sept;62:2569-2581.
COLLABORATION BETwEEN PRIMARY CARE AND RHEUMATOLOGY ENSURES OPTIMAL CARESuccessfulmanagementofRArequireslong-termteaminvolvement.Inthe first stages, the PCP is responsible for identifying possible cases of RA,providingearlyreferraltoarheumatologistandearlypaincontrol.TherheumatologistconfirmsthediagnosisandinitiatesDMARDtherapy. •EarlyreferraltoarheumatologistiscriticaltoearlyinitiationofDMARD
therapy and to stop joint damage •Tofacilitatetheevaluationofthepatientbytherheumatologist,itis
advisabletoobtain: –Rheumatoidfactor(RF) n30%–70%ofRApatientsarepositive,althoughpositiveRFcan
be caused by many conditions – Anti-CCP antibody n40%–60%ofRApatientsarepositive(maybeyearsbefore
clinical manifestation) nMaybedetectableearlierthanRF n Extremely high specificity for RA – C-reactive protein, erythrocyte sedimentation rate –Completebloodcount(CBC),liverfunctiontests(LFTs) –Optionalx-raysofthehands,wrists,andfeet •Monitorforalarmsigns(infection,dyspnea,neckpain,rheumatoideye
disease, painful red eye) •EarlytreatmentbythePCPisintendedtorelievepainandenhance
mobility –NSAIDs,shortcourseoflow-doseprednisone;rarely,opioidsfor
severe pain
A patient who is RF and anti-CCP negative may still have RA.
BridgesSL.SpottingaggressiveRAearly:thephysicalexamination,testing,andimaging.J Musculoskelet Med.2006;23(supplNov):S10-S14.
LONG-TERM MANAGEMENT OF RA PATIENTSCVD: Patients with RA and persistent inflammation may have additional risk for CVD and require more aggressive cholesterol lowering •MinimizeCVDriskfactors(eg,smoking,lipids,bloodpressure) •MaintainhighindexofsuspicionforCVDFever and infections:RApatientsonsteroids,methotrexate(MTX),leflunomide,orbiologic agents are at increased risk of serious infection •AssessRApatientswithfever,suspectedinfection – Prompt and thorough evaluation of symptoms, antibiotics if warranted – Biologics may need to be held until infection is resolved – Prompt initiation of antibiotics (especially for patients on biologics) nAvoiduseoftrimethoprim/sulfamethoxazoleinpatientsonMTX •Ifpatientsonimmunosuppressiveagentsandbiologicsdonotrespondrapidlytoinitial
treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc) •Considersepticarthritiswhenthereis –Isolatedmonoarthritiswhenallotherjointsstable – Swelling and tenderness in a patient with total joint replacement n RA patients may not mount a febrile response and the white blood cell count
may not be elevated in this setting •AcutedyspneaandcoughinapatientonMTXmayrepresentpneumonitis
VACCINATIONS AND DMARD THERAPY •Recommendedbeforetherapybegins –Influenzaandpneumococcalvaccinations –HepatitisBimmunizationifappropriate •Safe –Influenza(injection),tetanus,pneumococcus,meningococcus,hepatitisA,
hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV) •Avoid – Live virus vaccines such as intranasalinfluenza,mumps/measles/rubella(MMR),
yellow fever, and typhoid should be avoided in patients on immunomodulators –Waitatleast2weeksaftergivingthesevaccinesbeforeinitiatingimmunomodulators – Zoster vaccine, should be avoided in patients on biologic agents, but can be
giventopatientstakingMTXandprednisone<20mg/day
DeaneK.J Musculoskel Med.2006;23(supplNov):S24-S31.RavikumarR,etal.Curr Rheumatol Rep.2007;9:407-415;CDC.MMWR.2004;53:Q1-Q4;AveryRK.Rheum Dis Clin North Am.1999;25:567-584;ChalmersA,etal.J Rheumatol.1994;21:1203-1206;HarpazR,etal.MMWR Recomm Rep.2008;57 (RR-5):1-30;ACR.Herpeszoster(shingles)vaccineguidelinesforimmunocompromisedpatients.Availableat:http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp.AccessedOctober1,2010.
Issue date: February 2011 • Expiration date: February 29, 2012
OVERVIEwThispocketeducatorisdesignedtoaidprimarycareproviders(PCPs)inrecognizingtheearly signs of rheumatoid arthritis (RA) and determining when to refer a patient to a rheumatologist.SideAdiscussestheroleofthePCPintheearlydiagnosisofRAanddescribes how the PCP can work in tandem with the patient’s rheumatologist to effectively managethisdisease.SideBisdesignedtohelppatientsunderstandRA.LEARNING OBjECTIVES•IdentifypatientswhohaveprobableearlyRAandshouldbereferredtoarheumatologist•EmploythesqueezetesttoassistwithdiagnosisofRA•OrderappropriatelaboratorytestswhenRAissuspectedINTENDED AUDIENCEThistoolisintendedforPCPs.FACULTYClifton O. Bingham III, MD Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, Johns Hopkins University, Baltimore, MarylandJoyce P. Carlone, MN, RN, FNP-BC, CCRC NursePractitioner,DivisionofRheumatology,EmoryUniversity,Atlanta,GeorgiaMary Suzanne Cleveland, JD (Patient/Patient Educator) SeniorAnalyst,KansasHealthInstitute,Topeka,KansasLauren G. Collins, MD AssistantProfessorofFamilyandCommunityMedicine,JeffersonMedicalCollegeofThomas Jefferson University, Philadelphia, PennsylvaniaSTEERING COMMITTEE Michael E. Weinblatt, MD–Co-Chair JohnR.andEileenK.RiedmanProfessorofMedicine,HarvardMedicalSchool,Co-Director,ClinicalRheumatology,DivisionofRheumatology,Immunology,andAllergy,BrighamandWomen’sHospital,Boston,MassachusettsLauren G. Collins, MD–Co-ChairClifton O. Bingham III, MDJoyce P. Carlone, MN, RN, FNP-BC, CCRC Mary Suzanne Cleveland, JD (Patient/Patient Educator)Jeanne G. Cole, MS Director,OfficeofCME,JeffersonMedicalCollegeofThomasJeffersonUniversity,Philadelphia, PennsylvaniaKaren H. Costenbader, MD, MPH AssociatePhysician,DivisionofRheumatology,ImmunologyandAllergy,BrighamandWomen’sHospital, Assistant Professor of Medicine, Harvard Medical School, Boston, MassachusettsPaul P. Doghramji, MD, FAAFP MedicalDirectorforHealthServicesatUrsinusCollege,FamilyPhysician,CollegevilleFamilyPractice,Collegeville,PennsylvaniaDaniel Duch, PhD MedicalDirector,CuratioCMEInstitute,Exton,PennsylvaniaDavid S. Kountz, MD, MBA, FACP Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical Center,AssociateProfessorofMedicine,RobertWoodJohnsonMedicalSchool,NewBrunswick,NewJersey
2A 3A 4A 5A 6A 7A 8A 9A
�Osteoporosis 6–9��Seriousinfection rate
CVD10 years earlier
2��Rate ofmalignancy
�Pulmonarydisease
�GI bleeding
Jo
int destruction
Pain
D
is
abilit
y
RA symptom onset
Bony erosions70%–80%
Long-term disability80%
Rheumatologists:• Await early referral• Confirm diagnosis• Initiate DMARD/ biologics treatment
Rheumatologists:Long-termmanagementof RA
PCP:• Suspect diagnosis• “Immediate” referral• Baseline labs
PCP:• Surveillance• Comorbidity management• CVD risk reduction
4 Months
2 Years
10–20 Years
Immune responsedevelops
Joint destruction
Lymphomas
ComplicationsComorbidities
RAClinicalonset
EnvironmentGenes
Time
Pathologic inflammatoryresponse
CVD
Primary Care• Provisional diagnosis• Immediate referral to rheumatologist• Monitor for toxicities and disease progression• Address CVD risk and extra- articular issues
Rheumatologist• Confirm diagnosis• Initiate early, aggressive DMARD therapy• Monitor for toxicities and disease progression
Collaboration
Swelling on the proximal interphalangeal (PIP) joints
ReprintedfromTheLancet373,KlareskogLetal.Rheumatoidarthritis,659-672.Copyright2009,withpermissionfromElsevier.
Squeeze test
Participation in this activity includes reviewing the clinician educator and completing a posttest and evaluation. For additional information,
and to obtain 0.5 CME credits for participating in this activity, please visit http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
ACCREDITATION AND DESIGNATIONThis activity has been planned and implemented in accordance with the Essential Areas andPoliciesoftheAccreditationCouncilforContinuingMedicalEducation(ACCME).Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to providecontinuingmedicaleducationforphysicians.JeffersonMedicalCollegeofThomasJeffersonUniversitydesignatesthisenduringmaterialforamaximumof0.5AMA PRA Category 1 Credit™.Physiciansshouldclaimonlythecreditcommensuratewiththeextentoftheirparticipationintheactivity.DISCLOSUREJefferson Medical College of Thomas Jefferson University endorses the Standards of the ACCMEandtheGuidelinesforCommercialSupport.Thefollowingindividualshavedeclarednofinancialinterestsand/oraffiliations:Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; Jonathan S. Simmons, ELSThefollowingindividualshavedeclaredfinancialinterestsand/oraffiliations:Clifton O. Bingham III, MD Grant/Research Support: BMS, Genentech, UCB, Roche Consultant: Genentech,Roche,CentocorOrthoBiotech,Merck,UCB,Flexion,CelgeneJoyce P. Carlone, MN, RN, FNP-BC, CCRC Consultant, Product/Speakers Bureau, Other: UCBDavid S. Kountz, MD, MBA, FACPConsultant:NiCox,NovartisMichael E. Weinblatt, MDGrant/Research Support: AbbottConsultant:Abbott,CentocorOrthoBiotech,Pfizer/WyethCONTENT DISCLAIMER The information presented in this enduring material is for continuing medical education purposes only and is not meant to substitute for the independent medical judgment of a physicianregardingdiagnosisandtreatmentofaspecificpatient’smedicalcondition.The views or opinions expressed in the resources provided do not necessarily reflect those of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson HealthSystemorstaff.
ThisprogramissupportedbyeducationalgrantsfromAbbott,CentocorOrthoBiotechInc.,andPfizer.
Youcandownloadafree barcode reader app for your smartphone by searchingforQRCODESCANNERin the iPhone App Store, Android Market,orBlackberryAppWorld.
©2
010
Amer
ican
Col
lege
ofR
heum
atol
ogy.
Used
with
per
mis
sion
.
QR Code
31316/
3 34/
3 1316/3 13
16/3 1316/3 13
16/3 1316/3 13
16/
332/
3 1116/
6 14/
34 18/
C L I N I C I A N E D U C A T O R V O L U M E 4
Rheumatoid Arthrit is: Primary care Initiative for improved D iagnosis and outcomes
Co-sponsored by
SIDE A is for clinicians FREE CME
See panel 2A
SIDE B is for patients
RHEUMATOID ARTHRITIS FACTSRA is a chronic, progressive, systemic inflammatory disease •Characterizedby: – Progressive destruction of synovial joints with bony erosions and
loss of cartilage – Symptoms usually begin in the small joints of the fingers, wrists, and
feet – Swollen, tender joints are painful and difficult to move – Loss of physical function and quality of life – Decreased work productivity and increased disability and job loss •1.3millionadultAmericanshavebeendiagnosedwithRA •Peakageofonset:30to60years •2to4timesmorecommoninwomenthanmen •RApatients7timesaslikelytohavegreater-than-moderatedisability
than age- or sex-matched individuals •Ifundertreated,lifeexpectancyisreducedby5to15years –RAaccountsfor22%ofalldeathsfromarthritisandother
rheumatic conditions
It is never too late to stop further damage.
HochbergMC,SilmanAJ,SmolenJS,etal.eds.Rheumatology.3rded.NewYork,NY:Mosby;2003.AmericanCollegeofRheumatology.Factsheet.Availableat:http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/ra.asp.AccessedOctober1,2010.MacLeanCH,LouieR,LeakeB,etal.Qualityofcareforpatientswithrheumatoidarthritis.JAMA.2000;284:984-992.
RA IS A DISEASE OF THE ENTIRE BODYHeart:Cardiovasculardisease(CVD)occursonaverage10yearsearlierinRA patients than in the general population •AcceleratedatherosclerosisLungs:Increasedriskofmultiplepulmonarycomorbidities •Pleuritismayoccur • InterstitiallungdiseasesGastrointestinal (GI):RApatientshaveahighincidenceofGIbleeding,which may be attributable to use of nonsteroidal anti-inflammatory drugs (NSAIDs)andsteroidsduringtherapyNervous system: The deformity and damage to joints in RA may lead to entrapment of nerves •PatientmaypresentwithcarpaltunnelsyndromeOsteoporosis: Generalizedbonelossmayresultfromimmobility,theinflammatoryprocess,and/ortreatmentssuchassteroids • PeriarticulardemineralizationmayresultfrommediatorsofinflammationInfections:RApatientshavea6-to9-foldincreaseintherateofseriousinfections, including tuberculosis (TB) Malignancy: RA doubles the risk of some malignancies, particularly lymphoma
DeaneK.ManagingcomorbiditiesinRA.J Musculoskel Med.2006;23(suppl):S24-S31.BöttcherJ,PfeilA.DiagnosisofperiarticularosteoporosisinrheumatoidarthritisusingdigitalX-rayradiogrammetry.Arthritis Res Ther.2008;10:103.
PRIMARY CARE: EARLY DETECTION IS CRITICALTo prevent the progressive destruction of synovial joints and improve long-termoutcomes,RAmustbedetectedandtreatedearly. •Jointdamagecanberapid;withouttreatment,bonyerosionsmaybe
detectablebymagneticresonanceimaging(MRI)within4monthsofdisease onset
•Rateofx-rayprogressionismorerapidinthefirstyearthaninthesecond and third
•Withoutoptimaltreatment,mostpatientsdevelopbonyerosionswithin2years,and~80%ofthesepatientsdeveloplong-termdisability
•Successfullong-termmanagementrequiresapartnershipbetweenthe PCP and the rheumatologist, the patient, and other health care team members
Benefits of early detection: •DecreasedRAseverity,disability,andmortalitywitheffectivetreat-
ments, such as disease-modifying antirheumatic drugs (DMARDs) •LowerratesofRAcomplications •Lowerratesoflower-extremityorthopedicsurgicalprocedures •Decreasedcardiacriskswithcontrolofinflammation
McQueenFM,StewartN,CrabbeJ,etal.Magneticresonanceimagingofthewristinearlyrheumatoidarthritisrevealsahighprevalenceoferosionsatfourmonthsaftersymptomonset.Ann Rheum Dis.1998;57:350-356.BykerkVP,KeystoneEC.RAinprimarycare:20clinicalpearls.J Musculoskelet Med.2004;21:133-146.
PROVISIONAL DIAGNOSIS OF RAPatientswhohaveatleast1jointwithdefinitiveclinicalsynovitis(swelling)and in whom the synovitis is not better explained by another disease shouldbeexaminedforRA.MAkE THE DIAGNOSIS Does your patient have: 3 Swollen or tender joints –Either>1largeor≥1smalljointofthehandsorfeet,or –Positivesqueezetest(painwhengentlysqueezingacrossthe
metacarpophalangeal/metatarsophalangealjoints) 3 Symptoms lasting ≥6weeks
If patient has swollen joints or a positive squeeze test as above for ≥6 weeks, refer to a rheumatologist for provisional RA.
If the patient does not meet these criteria but has at least 1 swollen or tender joint and a positive RF or anti-CCP test, he or she should be referred to a rheumatologist.
A rheumatologist will make a definitive diagnosis of RA based on the followingcriteria: 1.Clinicalsignsandsymptoms 2.Patternandnumbersofjointsinvolved 3.Laboratorymeasures(RFandanti-CCPantibody) 4.Radiographicfindings 5.Rulingoutothercausesofinflammatoryarthritis
AletahaD,NeogiT,SilmanAJ.2010rheumatoidarthritisclassificationcriteria:anAmericanCollegeofRheumatology/ EuropeanLeagueAgainstRheumatismcollaborativeinitiative.Arthritis Rheum.2010Sept;62:2569-2581.
COLLABORATION BETwEEN PRIMARY CARE AND RHEUMATOLOGY ENSURES OPTIMAL CARESuccessfulmanagementofRArequireslong-termteaminvolvement.Inthe first stages, the PCP is responsible for identifying possible cases of RA,providingearlyreferraltoarheumatologistandearlypaincontrol.TherheumatologistconfirmsthediagnosisandinitiatesDMARDtherapy. •EarlyreferraltoarheumatologistiscriticaltoearlyinitiationofDMARD
therapy and to stop joint damage •Tofacilitatetheevaluationofthepatientbytherheumatologist,itis
advisabletoobtain: –Rheumatoidfactor(RF) n30%–70%ofRApatientsarepositive,althoughpositiveRFcan
be caused by many conditions – Anti-CCP antibody n40%–60%ofRApatientsarepositive(maybeyearsbefore
clinical manifestation) nMaybedetectableearlierthanRF n Extremely high specificity for RA – C-reactive protein, erythrocyte sedimentation rate –Completebloodcount(CBC),liverfunctiontests(LFTs) –Optionalx-raysofthehands,wrists,andfeet •Monitorforalarmsigns(infection,dyspnea,neckpain,rheumatoideye
disease, painful red eye) •EarlytreatmentbythePCPisintendedtorelievepainandenhance
mobility –NSAIDs,shortcourseoflow-doseprednisone;rarely,opioidsfor
severe pain
A patient who is RF and anti-CCP negative may still have RA.
BridgesSL.SpottingaggressiveRAearly:thephysicalexamination,testing,andimaging.J Musculoskelet Med.2006;23(supplNov):S10-S14.
LONG-TERM MANAGEMENT OF RA PATIENTSCVD: Patients with RA and persistent inflammation may have additional risk for CVD and require more aggressive cholesterol lowering •MinimizeCVDriskfactors(eg,smoking,lipids,bloodpressure) •MaintainhighindexofsuspicionforCVDFever and infections:RApatientsonsteroids,methotrexate(MTX),leflunomide,orbiologic agents are at increased risk of serious infection •AssessRApatientswithfever,suspectedinfection – Prompt and thorough evaluation of symptoms, antibiotics if warranted – Biologics may need to be held until infection is resolved – Prompt initiation of antibiotics (especially for patients on biologics) nAvoiduseoftrimethoprim/sulfamethoxazoleinpatientsonMTX •Ifpatientsonimmunosuppressiveagentsandbiologicsdonotrespondrapidlytoinitial
treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc) •Considersepticarthritiswhenthereis –Isolatedmonoarthritiswhenallotherjointsstable – Swelling and tenderness in a patient with total joint replacement n RA patients may not mount a febrile response and the white blood cell count
may not be elevated in this setting •AcutedyspneaandcoughinapatientonMTXmayrepresentpneumonitis
VACCINATIONS AND DMARD THERAPY •Recommendedbeforetherapybegins –Influenzaandpneumococcalvaccinations –HepatitisBimmunizationifappropriate •Safe –Influenza(injection),tetanus,pneumococcus,meningococcus,hepatitisA,
hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV) •Avoid – Live virus vaccines such as intranasalinfluenza,mumps/measles/rubella(MMR),
yellow fever, and typhoid should be avoided in patients on immunomodulators –Waitatleast2weeksaftergivingthesevaccinesbeforeinitiatingimmunomodulators – Zoster vaccine, should be avoided in patients on biologic agents, but can be
giventopatientstakingMTXandprednisone<20mg/day
DeaneK.J Musculoskel Med.2006;23(supplNov):S24-S31.RavikumarR,etal.Curr Rheumatol Rep.2007;9:407-415;CDC.MMWR.2004;53:Q1-Q4;AveryRK.Rheum Dis Clin North Am.1999;25:567-584;ChalmersA,etal.J Rheumatol.1994;21:1203-1206;HarpazR,etal.MMWR Recomm Rep.2008;57 (RR-5):1-30;ACR.Herpeszoster(shingles)vaccineguidelinesforimmunocompromisedpatients.Availableat:http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp.AccessedOctober1,2010.
Issue date: February 2011 • Expiration date: February 29, 2012
OVERVIEwThispocketeducatorisdesignedtoaidprimarycareproviders(PCPs)inrecognizingtheearly signs of rheumatoid arthritis (RA) and determining when to refer a patient to a rheumatologist.SideAdiscussestheroleofthePCPintheearlydiagnosisofRAanddescribes how the PCP can work in tandem with the patient’s rheumatologist to effectively managethisdisease.SideBisdesignedtohelppatientsunderstandRA.LEARNING OBjECTIVES•IdentifypatientswhohaveprobableearlyRAandshouldbereferredtoarheumatologist•EmploythesqueezetesttoassistwithdiagnosisofRA•OrderappropriatelaboratorytestswhenRAissuspectedINTENDED AUDIENCEThistoolisintendedforPCPs.FACULTYClifton O. Bingham III, MD Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, Johns Hopkins University, Baltimore, MarylandJoyce P. Carlone, MN, RN, FNP-BC, CCRC NursePractitioner,DivisionofRheumatology,EmoryUniversity,Atlanta,GeorgiaMary Suzanne Cleveland, JD (Patient/Patient Educator) SeniorAnalyst,KansasHealthInstitute,Topeka,KansasLauren G. Collins, MD AssistantProfessorofFamilyandCommunityMedicine,JeffersonMedicalCollegeofThomas Jefferson University, Philadelphia, PennsylvaniaSTEERING COMMITTEE Michael E. Weinblatt, MD–Co-Chair JohnR.andEileenK.RiedmanProfessorofMedicine,HarvardMedicalSchool,Co-Director,ClinicalRheumatology,DivisionofRheumatology,Immunology,andAllergy,BrighamandWomen’sHospital,Boston,MassachusettsLauren G. Collins, MD–Co-ChairClifton O. Bingham III, MDJoyce P. Carlone, MN, RN, FNP-BC, CCRC Mary Suzanne Cleveland, JD (Patient/Patient Educator)Jeanne G. Cole, MS Director,OfficeofCME,JeffersonMedicalCollegeofThomasJeffersonUniversity,Philadelphia, PennsylvaniaKaren H. Costenbader, MD, MPH AssociatePhysician,DivisionofRheumatology,ImmunologyandAllergy,BrighamandWomen’sHospital, Assistant Professor of Medicine, Harvard Medical School, Boston, MassachusettsPaul P. Doghramji, MD, FAAFP MedicalDirectorforHealthServicesatUrsinusCollege,FamilyPhysician,CollegevilleFamilyPractice,Collegeville,PennsylvaniaDaniel Duch, PhD MedicalDirector,CuratioCMEInstitute,Exton,PennsylvaniaDavid S. Kountz, MD, MBA, FACP Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical Center,AssociateProfessorofMedicine,RobertWoodJohnsonMedicalSchool,NewBrunswick,NewJersey
2A 3A 4A 5A 6A 7A 8A 9A
�Osteoporosis 6–9��Seriousinfection rate
CVD10 years earlier
2��Rate ofmalignancy
�Pulmonarydisease
�GI bleeding
Jo
int destruction
Pain
D
is
abilit
y
RA symptom onset
Bony erosions70%–80%
Long-term disability80%
Rheumatologists:• Await early referral• Confirm diagnosis• Initiate DMARD/ biologics treatment
Rheumatologists:Long-termmanagementof RA
PCP:• Suspect diagnosis• “Immediate” referral• Baseline labs
PCP:• Surveillance• Comorbidity management• CVD risk reduction
4 Months
2 Years
10–20 Years
Immune responsedevelops
Joint destruction
Lymphomas
ComplicationsComorbidities
RAClinicalonset
EnvironmentGenes
Time
Pathologic inflammatoryresponse
CVD
Primary Care• Provisional diagnosis• Immediate referral to rheumatologist• Monitor for toxicities and disease progression• Address CVD risk and extra- articular issues
Rheumatologist• Confirm diagnosis• Initiate early, aggressive DMARD therapy• Monitor for toxicities and disease progression
Collaboration
Swelling on the proximal interphalangeal (PIP) joints
ReprintedfromTheLancet373,KlareskogLetal.Rheumatoidarthritis,659-672.Copyright2009,withpermissionfromElsevier.
Squeeze test
Participation in this activity includes reviewing the clinician educator and completing a posttest and evaluation. For additional information,
and to obtain 0.5 CME credits for participating in this activity, please visit http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
ACCREDITATION AND DESIGNATIONThis activity has been planned and implemented in accordance with the Essential Areas andPoliciesoftheAccreditationCouncilforContinuingMedicalEducation(ACCME).Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to providecontinuingmedicaleducationforphysicians.JeffersonMedicalCollegeofThomasJeffersonUniversitydesignatesthisenduringmaterialforamaximumof0.5AMA PRA Category 1 Credit™.Physiciansshouldclaimonlythecreditcommensuratewiththeextentoftheirparticipationintheactivity.DISCLOSUREJefferson Medical College of Thomas Jefferson University endorses the Standards of the ACCMEandtheGuidelinesforCommercialSupport.Thefollowingindividualshavedeclarednofinancialinterestsand/oraffiliations:Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; Jonathan S. Simmons, ELSThefollowingindividualshavedeclaredfinancialinterestsand/oraffiliations:Clifton O. Bingham III, MD Grant/Research Support: BMS, Genentech, UCB, Roche Consultant: Genentech,Roche,CentocorOrthoBiotech,Merck,UCB,Flexion,CelgeneJoyce P. Carlone, MN, RN, FNP-BC, CCRC Consultant, Product/Speakers Bureau, Other: UCBDavid S. Kountz, MD, MBA, FACPConsultant:NiCox,NovartisMichael E. Weinblatt, MDGrant/Research Support: AbbottConsultant:Abbott,CentocorOrthoBiotech,Pfizer/WyethCONTENT DISCLAIMER The information presented in this enduring material is for continuing medical education purposes only and is not meant to substitute for the independent medical judgment of a physicianregardingdiagnosisandtreatmentofaspecificpatient’smedicalcondition.The views or opinions expressed in the resources provided do not necessarily reflect those of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson HealthSystemorstaff.
ThisprogramissupportedbyeducationalgrantsfromAbbott,CentocorOrthoBiotechInc.,andPfizer.
Youcandownloadafree barcode reader app for your smartphone by searchingforQRCODESCANNERin the iPhone App Store, Android Market,orBlackberryAppWorld.
©2
010
Amer
ican
Col
lege
ofR
heum
atol
ogy.
Used
with
per
mis
sion
.
QR Code
31316/
3 34/
3 1316/3 13
16/3 1316/3 13
16/3 1316/3 13
16/
332/
3 1116/
6 14/
34 18/
C L I N I C I A N E D U C A T O R V O L U M E 4
Rheumatoid Arthrit is: Primary care Initiative for improved D iagnosis and outcomes
Co-sponsored by
SIDE A is for clinicians FREE CME
See panel 2A
SIDE B is for patients
RHEUMATOID ARTHRITIS FACTSRA is a chronic, progressive, systemic inflammatory disease •Characterizedby: – Progressive destruction of synovial joints with bony erosions and
loss of cartilage – Symptoms usually begin in the small joints of the fingers, wrists, and
feet – Swollen, tender joints are painful and difficult to move – Loss of physical function and quality of life – Decreased work productivity and increased disability and job loss •1.3millionadultAmericanshavebeendiagnosedwithRA •Peakageofonset:30to60years •2to4timesmorecommoninwomenthanmen •RApatients7timesaslikelytohavegreater-than-moderatedisability
than age- or sex-matched individuals •Ifundertreated,lifeexpectancyisreducedby5to15years –RAaccountsfor22%ofalldeathsfromarthritisandother
rheumatic conditions
It is never too late to stop further damage.
HochbergMC,SilmanAJ,SmolenJS,etal.eds.Rheumatology.3rded.NewYork,NY:Mosby;2003.AmericanCollegeofRheumatology.Factsheet.Availableat:http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/ra.asp.AccessedOctober1,2010.MacLeanCH,LouieR,LeakeB,etal.Qualityofcareforpatientswithrheumatoidarthritis.JAMA.2000;284:984-992.
RA IS A DISEASE OF THE ENTIRE BODYHeart:Cardiovasculardisease(CVD)occursonaverage10yearsearlierinRA patients than in the general population •AcceleratedatherosclerosisLungs:Increasedriskofmultiplepulmonarycomorbidities •Pleuritismayoccur • InterstitiallungdiseasesGastrointestinal (GI):RApatientshaveahighincidenceofGIbleeding,which may be attributable to use of nonsteroidal anti-inflammatory drugs (NSAIDs)andsteroidsduringtherapyNervous system: The deformity and damage to joints in RA may lead to entrapment of nerves •PatientmaypresentwithcarpaltunnelsyndromeOsteoporosis: Generalizedbonelossmayresultfromimmobility,theinflammatoryprocess,and/ortreatmentssuchassteroids • PeriarticulardemineralizationmayresultfrommediatorsofinflammationInfections:RApatientshavea6-to9-foldincreaseintherateofseriousinfections, including tuberculosis (TB) Malignancy: RA doubles the risk of some malignancies, particularly lymphoma
DeaneK.ManagingcomorbiditiesinRA.J Musculoskel Med.2006;23(suppl):S24-S31.BöttcherJ,PfeilA.DiagnosisofperiarticularosteoporosisinrheumatoidarthritisusingdigitalX-rayradiogrammetry.Arthritis Res Ther.2008;10:103.
PRIMARY CARE: EARLY DETECTION IS CRITICALTo prevent the progressive destruction of synovial joints and improve long-termoutcomes,RAmustbedetectedandtreatedearly. •Jointdamagecanberapid;withouttreatment,bonyerosionsmaybe
detectablebymagneticresonanceimaging(MRI)within4monthsofdisease onset
•Rateofx-rayprogressionismorerapidinthefirstyearthaninthesecond and third
•Withoutoptimaltreatment,mostpatientsdevelopbonyerosionswithin2years,and~80%ofthesepatientsdeveloplong-termdisability
•Successfullong-termmanagementrequiresapartnershipbetweenthe PCP and the rheumatologist, the patient, and other health care team members
Benefits of early detection: •DecreasedRAseverity,disability,andmortalitywitheffectivetreat-
ments, such as disease-modifying antirheumatic drugs (DMARDs) •LowerratesofRAcomplications •Lowerratesoflower-extremityorthopedicsurgicalprocedures •Decreasedcardiacriskswithcontrolofinflammation
McQueenFM,StewartN,CrabbeJ,etal.Magneticresonanceimagingofthewristinearlyrheumatoidarthritisrevealsahighprevalenceoferosionsatfourmonthsaftersymptomonset.Ann Rheum Dis.1998;57:350-356.BykerkVP,KeystoneEC.RAinprimarycare:20clinicalpearls.J Musculoskelet Med.2004;21:133-146.
PROVISIONAL DIAGNOSIS OF RAPatientswhohaveatleast1jointwithdefinitiveclinicalsynovitis(swelling)and in whom the synovitis is not better explained by another disease shouldbeexaminedforRA.MAkE THE DIAGNOSIS Does your patient have: 3 Swollen or tender joints –Either>1largeor≥1smalljointofthehandsorfeet,or –Positivesqueezetest(painwhengentlysqueezingacrossthe
metacarpophalangeal/metatarsophalangealjoints) 3 Symptoms lasting ≥6weeks
If patient has swollen joints or a positive squeeze test as above for ≥6 weeks, refer to a rheumatologist for provisional RA.
If the patient does not meet these criteria but has at least 1 swollen or tender joint and a positive RF or anti-CCP test, he or she should be referred to a rheumatologist.
A rheumatologist will make a definitive diagnosis of RA based on the followingcriteria: 1.Clinicalsignsandsymptoms 2.Patternandnumbersofjointsinvolved 3.Laboratorymeasures(RFandanti-CCPantibody) 4.Radiographicfindings 5.Rulingoutothercausesofinflammatoryarthritis
AletahaD,NeogiT,SilmanAJ.2010rheumatoidarthritisclassificationcriteria:anAmericanCollegeofRheumatology/ EuropeanLeagueAgainstRheumatismcollaborativeinitiative.Arthritis Rheum.2010Sept;62:2569-2581.
COLLABORATION BETwEEN PRIMARY CARE AND RHEUMATOLOGY ENSURES OPTIMAL CARESuccessfulmanagementofRArequireslong-termteaminvolvement.Inthe first stages, the PCP is responsible for identifying possible cases of RA,providingearlyreferraltoarheumatologistandearlypaincontrol.TherheumatologistconfirmsthediagnosisandinitiatesDMARDtherapy. •EarlyreferraltoarheumatologistiscriticaltoearlyinitiationofDMARD
therapy and to stop joint damage •Tofacilitatetheevaluationofthepatientbytherheumatologist,itis
advisabletoobtain: –Rheumatoidfactor(RF) n30%–70%ofRApatientsarepositive,althoughpositiveRFcan
be caused by many conditions – Anti-CCP antibody n40%–60%ofRApatientsarepositive(maybeyearsbefore
clinical manifestation) nMaybedetectableearlierthanRF n Extremely high specificity for RA – C-reactive protein, erythrocyte sedimentation rate –Completebloodcount(CBC),liverfunctiontests(LFTs) –Optionalx-raysofthehands,wrists,andfeet •Monitorforalarmsigns(infection,dyspnea,neckpain,rheumatoideye
disease, painful red eye) •EarlytreatmentbythePCPisintendedtorelievepainandenhance
mobility –NSAIDs,shortcourseoflow-doseprednisone;rarely,opioidsfor
severe pain
A patient who is RF and anti-CCP negative may still have RA.
BridgesSL.SpottingaggressiveRAearly:thephysicalexamination,testing,andimaging.J Musculoskelet Med.2006;23(supplNov):S10-S14.
LONG-TERM MANAGEMENT OF RA PATIENTSCVD: Patients with RA and persistent inflammation may have additional risk for CVD and require more aggressive cholesterol lowering •MinimizeCVDriskfactors(eg,smoking,lipids,bloodpressure) •MaintainhighindexofsuspicionforCVDFever and infections:RApatientsonsteroids,methotrexate(MTX),leflunomide,orbiologic agents are at increased risk of serious infection •AssessRApatientswithfever,suspectedinfection – Prompt and thorough evaluation of symptoms, antibiotics if warranted – Biologics may need to be held until infection is resolved – Prompt initiation of antibiotics (especially for patients on biologics) nAvoiduseoftrimethoprim/sulfamethoxazoleinpatientsonMTX •Ifpatientsonimmunosuppressiveagentsandbiologicsdonotrespondrapidlytoinitial
treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc) •Considersepticarthritiswhenthereis –Isolatedmonoarthritiswhenallotherjointsstable – Swelling and tenderness in a patient with total joint replacement n RA patients may not mount a febrile response and the white blood cell count
may not be elevated in this setting •AcutedyspneaandcoughinapatientonMTXmayrepresentpneumonitis
VACCINATIONS AND DMARD THERAPY •Recommendedbeforetherapybegins –Influenzaandpneumococcalvaccinations –HepatitisBimmunizationifappropriate •Safe –Influenza(injection),tetanus,pneumococcus,meningococcus,hepatitisA,
hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV) •Avoid – Live virus vaccines such as intranasalinfluenza,mumps/measles/rubella(MMR),
yellow fever, and typhoid should be avoided in patients on immunomodulators –Waitatleast2weeksaftergivingthesevaccinesbeforeinitiatingimmunomodulators – Zoster vaccine, should be avoided in patients on biologic agents, but can be
giventopatientstakingMTXandprednisone<20mg/day
DeaneK.J Musculoskel Med.2006;23(supplNov):S24-S31.RavikumarR,etal.Curr Rheumatol Rep.2007;9:407-415;CDC.MMWR.2004;53:Q1-Q4;AveryRK.Rheum Dis Clin North Am.1999;25:567-584;ChalmersA,etal.J Rheumatol.1994;21:1203-1206;HarpazR,etal.MMWR Recomm Rep.2008;57 (RR-5):1-30;ACR.Herpeszoster(shingles)vaccineguidelinesforimmunocompromisedpatients.Availableat:http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp.AccessedOctober1,2010.
Issue date: February 2011 • Expiration date: February 29, 2012
OVERVIEwThispocketeducatorisdesignedtoaidprimarycareproviders(PCPs)inrecognizingtheearly signs of rheumatoid arthritis (RA) and determining when to refer a patient to a rheumatologist.SideAdiscussestheroleofthePCPintheearlydiagnosisofRAanddescribes how the PCP can work in tandem with the patient’s rheumatologist to effectively managethisdisease.SideBisdesignedtohelppatientsunderstandRA.LEARNING OBjECTIVES•IdentifypatientswhohaveprobableearlyRAandshouldbereferredtoarheumatologist•EmploythesqueezetesttoassistwithdiagnosisofRA•OrderappropriatelaboratorytestswhenRAissuspectedINTENDED AUDIENCEThistoolisintendedforPCPs.FACULTYClifton O. Bingham III, MD Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, Johns Hopkins University, Baltimore, MarylandJoyce P. Carlone, MN, RN, FNP-BC, CCRC NursePractitioner,DivisionofRheumatology,EmoryUniversity,Atlanta,GeorgiaMary Suzanne Cleveland, JD (Patient/Patient Educator) SeniorAnalyst,KansasHealthInstitute,Topeka,KansasLauren G. Collins, MD AssistantProfessorofFamilyandCommunityMedicine,JeffersonMedicalCollegeofThomas Jefferson University, Philadelphia, PennsylvaniaSTEERING COMMITTEE Michael E. Weinblatt, MD–Co-Chair JohnR.andEileenK.RiedmanProfessorofMedicine,HarvardMedicalSchool,Co-Director,ClinicalRheumatology,DivisionofRheumatology,Immunology,andAllergy,BrighamandWomen’sHospital,Boston,MassachusettsLauren G. Collins, MD–Co-ChairClifton O. Bingham III, MDJoyce P. Carlone, MN, RN, FNP-BC, CCRC Mary Suzanne Cleveland, JD (Patient/Patient Educator)Jeanne G. Cole, MS Director,OfficeofCME,JeffersonMedicalCollegeofThomasJeffersonUniversity,Philadelphia, PennsylvaniaKaren H. Costenbader, MD, MPH AssociatePhysician,DivisionofRheumatology,ImmunologyandAllergy,BrighamandWomen’sHospital, Assistant Professor of Medicine, Harvard Medical School, Boston, MassachusettsPaul P. Doghramji, MD, FAAFP MedicalDirectorforHealthServicesatUrsinusCollege,FamilyPhysician,CollegevilleFamilyPractice,Collegeville,PennsylvaniaDaniel Duch, PhD MedicalDirector,CuratioCMEInstitute,Exton,PennsylvaniaDavid S. Kountz, MD, MBA, FACP Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical Center,AssociateProfessorofMedicine,RobertWoodJohnsonMedicalSchool,NewBrunswick,NewJersey
2A 3A 4A 5A 6A 7A 8A 9A
�Osteoporosis 6–9��Seriousinfection rate
CVD10 years earlier
2��Rate ofmalignancy
�Pulmonarydisease
�GI bleeding
Jo
int destruction
Pain
D
is
abilit
y
RA symptom onset
Bony erosions70%–80%
Long-term disability80%
Rheumatologists:• Await early referral• Confirm diagnosis• Initiate DMARD/ biologics treatment
Rheumatologists:Long-termmanagementof RA
PCP:• Suspect diagnosis• “Immediate” referral• Baseline labs
PCP:• Surveillance• Comorbidity management• CVD risk reduction
4 Months
2 Years
10–20 Years
Immune responsedevelops
Joint destruction
Lymphomas
ComplicationsComorbidities
RAClinicalonset
EnvironmentGenes
Time
Pathologic inflammatoryresponse
CVD
Primary Care• Provisional diagnosis• Immediate referral to rheumatologist• Monitor for toxicities and disease progression• Address CVD risk and extra- articular issues
Rheumatologist• Confirm diagnosis• Initiate early, aggressive DMARD therapy• Monitor for toxicities and disease progression
Collaboration
Swelling on the proximal interphalangeal (PIP) joints
ReprintedfromTheLancet373,KlareskogLetal.Rheumatoidarthritis,659-672.Copyright2009,withpermissionfromElsevier.
Squeeze test
Participation in this activity includes reviewing the clinician educator and completing a posttest and evaluation. For additional information,
and to obtain 0.5 CME credits for participating in this activity, please visit http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
ACCREDITATION AND DESIGNATIONThis activity has been planned and implemented in accordance with the Essential Areas andPoliciesoftheAccreditationCouncilforContinuingMedicalEducation(ACCME).Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to providecontinuingmedicaleducationforphysicians.JeffersonMedicalCollegeofThomasJeffersonUniversitydesignatesthisenduringmaterialforamaximumof0.5AMA PRA Category 1 Credit™.Physiciansshouldclaimonlythecreditcommensuratewiththeextentoftheirparticipationintheactivity.DISCLOSUREJefferson Medical College of Thomas Jefferson University endorses the Standards of the ACCMEandtheGuidelinesforCommercialSupport.Thefollowingindividualshavedeclarednofinancialinterestsand/oraffiliations:Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; Jonathan S. Simmons, ELSThefollowingindividualshavedeclaredfinancialinterestsand/oraffiliations:Clifton O. Bingham III, MD Grant/Research Support: BMS, Genentech, UCB, Roche Consultant: Genentech,Roche,CentocorOrthoBiotech,Merck,UCB,Flexion,CelgeneJoyce P. Carlone, MN, RN, FNP-BC, CCRC Consultant, Product/Speakers Bureau, Other: UCBDavid S. Kountz, MD, MBA, FACPConsultant:NiCox,NovartisMichael E. Weinblatt, MDGrant/Research Support: AbbottConsultant:Abbott,CentocorOrthoBiotech,Pfizer/WyethCONTENT DISCLAIMER The information presented in this enduring material is for continuing medical education purposes only and is not meant to substitute for the independent medical judgment of a physicianregardingdiagnosisandtreatmentofaspecificpatient’smedicalcondition.The views or opinions expressed in the resources provided do not necessarily reflect those of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson HealthSystemorstaff.
ThisprogramissupportedbyeducationalgrantsfromAbbott,CentocorOrthoBiotechInc.,andPfizer.
Youcandownloadafree barcode reader app for your smartphone by searchingforQRCODESCANNERin the iPhone App Store, Android Market,orBlackberryAppWorld.
©2
010
Amer
ican
Col
lege
ofR
heum
atol
ogy.
Used
with
per
mis
sion
.
QR Code
31316/
3 34/
3 1316/3 13
16/3 1316/3 13
16/3 1316/3 13
16/
332/
3 1116/
6 14/
34 18/
C L I N I C I A N E D U C A T O R V O L U M E 4
Rheumatoid Arthrit is: Primary care Initiative for improved D iagnosis and outcomes
Co-sponsored by
SIDE A is for clinicians FREE CME
See panel 2A
SIDE B is for patients
RHEUMATOID ARTHRITIS FACTSRA is a chronic, progressive, systemic inflammatory disease •Characterizedby: – Progressive destruction of synovial joints with bony erosions and
loss of cartilage – Symptoms usually begin in the small joints of the fingers, wrists, and
feet – Swollen, tender joints are painful and difficult to move – Loss of physical function and quality of life – Decreased work productivity and increased disability and job loss •1.3millionadultAmericanshavebeendiagnosedwithRA •Peakageofonset:30to60years •2to4timesmorecommoninwomenthanmen •RApatients7timesaslikelytohavegreater-than-moderatedisability
than age- or sex-matched individuals •Ifundertreated,lifeexpectancyisreducedby5to15years –RAaccountsfor22%ofalldeathsfromarthritisandother
rheumatic conditions
It is never too late to stop further damage.
HochbergMC,SilmanAJ,SmolenJS,etal.eds.Rheumatology.3rded.NewYork,NY:Mosby;2003.AmericanCollegeofRheumatology.Factsheet.Availableat:http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/ra.asp.AccessedOctober1,2010.MacLeanCH,LouieR,LeakeB,etal.Qualityofcareforpatientswithrheumatoidarthritis.JAMA.2000;284:984-992.
RA IS A DISEASE OF THE ENTIRE BODYHeart:Cardiovasculardisease(CVD)occursonaverage10yearsearlierinRA patients than in the general population •AcceleratedatherosclerosisLungs:Increasedriskofmultiplepulmonarycomorbidities •Pleuritismayoccur • InterstitiallungdiseasesGastrointestinal (GI):RApatientshaveahighincidenceofGIbleeding,which may be attributable to use of nonsteroidal anti-inflammatory drugs (NSAIDs)andsteroidsduringtherapyNervous system: The deformity and damage to joints in RA may lead to entrapment of nerves •PatientmaypresentwithcarpaltunnelsyndromeOsteoporosis: Generalizedbonelossmayresultfromimmobility,theinflammatoryprocess,and/ortreatmentssuchassteroids • PeriarticulardemineralizationmayresultfrommediatorsofinflammationInfections:RApatientshavea6-to9-foldincreaseintherateofseriousinfections, including tuberculosis (TB) Malignancy: RA doubles the risk of some malignancies, particularly lymphoma
DeaneK.ManagingcomorbiditiesinRA.J Musculoskel Med.2006;23(suppl):S24-S31.BöttcherJ,PfeilA.DiagnosisofperiarticularosteoporosisinrheumatoidarthritisusingdigitalX-rayradiogrammetry.Arthritis Res Ther.2008;10:103.
PRIMARY CARE: EARLY DETECTION IS CRITICALTo prevent the progressive destruction of synovial joints and improve long-termoutcomes,RAmustbedetectedandtreatedearly. •Jointdamagecanberapid;withouttreatment,bonyerosionsmaybe
detectablebymagneticresonanceimaging(MRI)within4monthsofdisease onset
•Rateofx-rayprogressionismorerapidinthefirstyearthaninthesecond and third
•Withoutoptimaltreatment,mostpatientsdevelopbonyerosionswithin2years,and~80%ofthesepatientsdeveloplong-termdisability
•Successfullong-termmanagementrequiresapartnershipbetweenthe PCP and the rheumatologist, the patient, and other health care team members
Benefits of early detection: •DecreasedRAseverity,disability,andmortalitywitheffectivetreat-
ments, such as disease-modifying antirheumatic drugs (DMARDs) •LowerratesofRAcomplications •Lowerratesoflower-extremityorthopedicsurgicalprocedures •Decreasedcardiacriskswithcontrolofinflammation
McQueenFM,StewartN,CrabbeJ,etal.Magneticresonanceimagingofthewristinearlyrheumatoidarthritisrevealsahighprevalenceoferosionsatfourmonthsaftersymptomonset.Ann Rheum Dis.1998;57:350-356.BykerkVP,KeystoneEC.RAinprimarycare:20clinicalpearls.J Musculoskelet Med.2004;21:133-146.
PROVISIONAL DIAGNOSIS OF RAPatientswhohaveatleast1jointwithdefinitiveclinicalsynovitis(swelling)and in whom the synovitis is not better explained by another disease shouldbeexaminedforRA.MAkE THE DIAGNOSIS Does your patient have: 3 Swollen or tender joints –Either>1largeor≥1smalljointofthehandsorfeet,or –Positivesqueezetest(painwhengentlysqueezingacrossthe
metacarpophalangeal/metatarsophalangealjoints) 3 Symptoms lasting ≥6weeks
If patient has swollen joints or a positive squeeze test as above for ≥6 weeks, refer to a rheumatologist for provisional RA.
If the patient does not meet these criteria but has at least 1 swollen or tender joint and a positive RF or anti-CCP test, he or she should be referred to a rheumatologist.
A rheumatologist will make a definitive diagnosis of RA based on the followingcriteria: 1.Clinicalsignsandsymptoms 2.Patternandnumbersofjointsinvolved 3.Laboratorymeasures(RFandanti-CCPantibody) 4.Radiographicfindings 5.Rulingoutothercausesofinflammatoryarthritis
AletahaD,NeogiT,SilmanAJ.2010rheumatoidarthritisclassificationcriteria:anAmericanCollegeofRheumatology/ EuropeanLeagueAgainstRheumatismcollaborativeinitiative.Arthritis Rheum.2010Sept;62:2569-2581.
COLLABORATION BETwEEN PRIMARY CARE AND RHEUMATOLOGY ENSURES OPTIMAL CARESuccessfulmanagementofRArequireslong-termteaminvolvement.Inthe first stages, the PCP is responsible for identifying possible cases of RA,providingearlyreferraltoarheumatologistandearlypaincontrol.TherheumatologistconfirmsthediagnosisandinitiatesDMARDtherapy. •EarlyreferraltoarheumatologistiscriticaltoearlyinitiationofDMARD
therapy and to stop joint damage •Tofacilitatetheevaluationofthepatientbytherheumatologist,itis
advisabletoobtain: –Rheumatoidfactor(RF) n30%–70%ofRApatientsarepositive,althoughpositiveRFcan
be caused by many conditions – Anti-CCP antibody n40%–60%ofRApatientsarepositive(maybeyearsbefore
clinical manifestation) nMaybedetectableearlierthanRF n Extremely high specificity for RA – C-reactive protein, erythrocyte sedimentation rate –Completebloodcount(CBC),liverfunctiontests(LFTs) –Optionalx-raysofthehands,wrists,andfeet •Monitorforalarmsigns(infection,dyspnea,neckpain,rheumatoideye
disease, painful red eye) •EarlytreatmentbythePCPisintendedtorelievepainandenhance
mobility –NSAIDs,shortcourseoflow-doseprednisone;rarely,opioidsfor
severe pain
A patient who is RF and anti-CCP negative may still have RA.
BridgesSL.SpottingaggressiveRAearly:thephysicalexamination,testing,andimaging.J Musculoskelet Med.2006;23(supplNov):S10-S14.
LONG-TERM MANAGEMENT OF RA PATIENTSCVD: Patients with RA and persistent inflammation may have additional risk for CVD and require more aggressive cholesterol lowering •MinimizeCVDriskfactors(eg,smoking,lipids,bloodpressure) •MaintainhighindexofsuspicionforCVDFever and infections:RApatientsonsteroids,methotrexate(MTX),leflunomide,orbiologic agents are at increased risk of serious infection •AssessRApatientswithfever,suspectedinfection – Prompt and thorough evaluation of symptoms, antibiotics if warranted – Biologics may need to be held until infection is resolved – Prompt initiation of antibiotics (especially for patients on biologics) nAvoiduseoftrimethoprim/sulfamethoxazoleinpatientsonMTX •Ifpatientsonimmunosuppressiveagentsandbiologicsdonotrespondrapidlytoinitial
treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc) •Considersepticarthritiswhenthereis –Isolatedmonoarthritiswhenallotherjointsstable – Swelling and tenderness in a patient with total joint replacement n RA patients may not mount a febrile response and the white blood cell count
may not be elevated in this setting •AcutedyspneaandcoughinapatientonMTXmayrepresentpneumonitis
VACCINATIONS AND DMARD THERAPY •Recommendedbeforetherapybegins –Influenzaandpneumococcalvaccinations –HepatitisBimmunizationifappropriate •Safe –Influenza(injection),tetanus,pneumococcus,meningococcus,hepatitisA,
hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV) •Avoid – Live virus vaccines such as intranasalinfluenza,mumps/measles/rubella(MMR),
yellow fever, and typhoid should be avoided in patients on immunomodulators –Waitatleast2weeksaftergivingthesevaccinesbeforeinitiatingimmunomodulators – Zoster vaccine, should be avoided in patients on biologic agents, but can be
giventopatientstakingMTXandprednisone<20mg/day
DeaneK.J Musculoskel Med.2006;23(supplNov):S24-S31.RavikumarR,etal.Curr Rheumatol Rep.2007;9:407-415;CDC.MMWR.2004;53:Q1-Q4;AveryRK.Rheum Dis Clin North Am.1999;25:567-584;ChalmersA,etal.J Rheumatol.1994;21:1203-1206;HarpazR,etal.MMWR Recomm Rep.2008;57 (RR-5):1-30;ACR.Herpeszoster(shingles)vaccineguidelinesforimmunocompromisedpatients.Availableat:http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp.AccessedOctober1,2010.
Issue date: February 2011 • Expiration date: February 29, 2012
OVERVIEwThispocketeducatorisdesignedtoaidprimarycareproviders(PCPs)inrecognizingtheearly signs of rheumatoid arthritis (RA) and determining when to refer a patient to a rheumatologist.SideAdiscussestheroleofthePCPintheearlydiagnosisofRAanddescribes how the PCP can work in tandem with the patient’s rheumatologist to effectively managethisdisease.SideBisdesignedtohelppatientsunderstandRA.LEARNING OBjECTIVES•IdentifypatientswhohaveprobableearlyRAandshouldbereferredtoarheumatologist•EmploythesqueezetesttoassistwithdiagnosisofRA•OrderappropriatelaboratorytestswhenRAissuspectedINTENDED AUDIENCEThistoolisintendedforPCPs.FACULTYClifton O. Bingham III, MD Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, Johns Hopkins University, Baltimore, MarylandJoyce P. Carlone, MN, RN, FNP-BC, CCRC NursePractitioner,DivisionofRheumatology,EmoryUniversity,Atlanta,GeorgiaMary Suzanne Cleveland, JD (Patient/Patient Educator) SeniorAnalyst,KansasHealthInstitute,Topeka,KansasLauren G. Collins, MD AssistantProfessorofFamilyandCommunityMedicine,JeffersonMedicalCollegeofThomas Jefferson University, Philadelphia, PennsylvaniaSTEERING COMMITTEE Michael E. Weinblatt, MD–Co-Chair JohnR.andEileenK.RiedmanProfessorofMedicine,HarvardMedicalSchool,Co-Director,ClinicalRheumatology,DivisionofRheumatology,Immunology,andAllergy,BrighamandWomen’sHospital,Boston,MassachusettsLauren G. Collins, MD–Co-ChairClifton O. Bingham III, MDJoyce P. Carlone, MN, RN, FNP-BC, CCRC Mary Suzanne Cleveland, JD (Patient/Patient Educator)Jeanne G. Cole, MS Director,OfficeofCME,JeffersonMedicalCollegeofThomasJeffersonUniversity,Philadelphia, PennsylvaniaKaren H. Costenbader, MD, MPH AssociatePhysician,DivisionofRheumatology,ImmunologyandAllergy,BrighamandWomen’sHospital, Assistant Professor of Medicine, Harvard Medical School, Boston, MassachusettsPaul P. Doghramji, MD, FAAFP MedicalDirectorforHealthServicesatUrsinusCollege,FamilyPhysician,CollegevilleFamilyPractice,Collegeville,PennsylvaniaDaniel Duch, PhD MedicalDirector,CuratioCMEInstitute,Exton,PennsylvaniaDavid S. Kountz, MD, MBA, FACP Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical Center,AssociateProfessorofMedicine,RobertWoodJohnsonMedicalSchool,NewBrunswick,NewJersey
2A 3A 4A 5A 6A 7A 8A 9A
�Osteoporosis 6–9��Seriousinfection rate
CVD10 years earlier
2��Rate ofmalignancy
�Pulmonarydisease
�GI bleeding
Jo
int destruction
Pain
D
is
abilit
y
RA symptom onset
Bony erosions70%–80%
Long-term disability80%
Rheumatologists:• Await early referral• Confirm diagnosis• Initiate DMARD/ biologics treatment
Rheumatologists:Long-termmanagementof RA
PCP:• Suspect diagnosis• “Immediate” referral• Baseline labs
PCP:• Surveillance• Comorbidity management• CVD risk reduction
4 Months
2 Years
10–20 Years
Immune responsedevelops
Joint destruction
Lymphomas
ComplicationsComorbidities
RAClinicalonset
EnvironmentGenes
Time
Pathologic inflammatoryresponse
CVD
Primary Care• Provisional diagnosis• Immediate referral to rheumatologist• Monitor for toxicities and disease progression• Address CVD risk and extra- articular issues
Rheumatologist• Confirm diagnosis• Initiate early, aggressive DMARD therapy• Monitor for toxicities and disease progression
Collaboration
Swelling on the proximal interphalangeal (PIP) joints
ReprintedfromTheLancet373,KlareskogLetal.Rheumatoidarthritis,659-672.Copyright2009,withpermissionfromElsevier.
Squeeze test
Participation in this activity includes reviewing the clinician educator and completing a posttest and evaluation. For additional information,
and to obtain 0.5 CME credits for participating in this activity, please visit http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
ACCREDITATION AND DESIGNATIONThis activity has been planned and implemented in accordance with the Essential Areas andPoliciesoftheAccreditationCouncilforContinuingMedicalEducation(ACCME).Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to providecontinuingmedicaleducationforphysicians.JeffersonMedicalCollegeofThomasJeffersonUniversitydesignatesthisenduringmaterialforamaximumof0.5AMA PRA Category 1 Credit™.Physiciansshouldclaimonlythecreditcommensuratewiththeextentoftheirparticipationintheactivity.DISCLOSUREJefferson Medical College of Thomas Jefferson University endorses the Standards of the ACCMEandtheGuidelinesforCommercialSupport.Thefollowingindividualshavedeclarednofinancialinterestsand/oraffiliations:Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; Jonathan S. Simmons, ELSThefollowingindividualshavedeclaredfinancialinterestsand/oraffiliations:Clifton O. Bingham III, MD Grant/Research Support: BMS, Genentech, UCB, Roche Consultant: Genentech,Roche,CentocorOrthoBiotech,Merck,UCB,Flexion,CelgeneJoyce P. Carlone, MN, RN, FNP-BC, CCRC Consultant, Product/Speakers Bureau, Other: UCBDavid S. Kountz, MD, MBA, FACPConsultant:NiCox,NovartisMichael E. Weinblatt, MDGrant/Research Support: AbbottConsultant:Abbott,CentocorOrthoBiotech,Pfizer/WyethCONTENT DISCLAIMER The information presented in this enduring material is for continuing medical education purposes only and is not meant to substitute for the independent medical judgment of a physicianregardingdiagnosisandtreatmentofaspecificpatient’smedicalcondition.The views or opinions expressed in the resources provided do not necessarily reflect those of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson HealthSystemorstaff.
ThisprogramissupportedbyeducationalgrantsfromAbbott,CentocorOrthoBiotechInc.,andPfizer.
Youcandownloadafree barcode reader app for your smartphone by searchingforQRCODESCANNERin the iPhone App Store, Android Market,orBlackberryAppWorld.
©2
010
Amer
ican
Col
lege
ofR
heum
atol
ogy.
Used
with
per
mis
sion
.
QR Code
31316/
3 34/
3 1316/3 13
16/3 1316/3 13
16/3 1316/3 13
16/
332/
3 1116/
6 14/
34 18/
C L I N I C I A N E D U C A T O R V O L U M E 4
Rheumatoid Arthrit is: Primary care Initiative for improved D iagnosis and outcomes
Co-sponsored by
SIDE A is for clinicians FREE CME
See panel 2A
SIDE B is for patients
RHEUMATOID ARTHRITIS FACTSRA is a chronic, progressive, systemic inflammatory disease •Characterizedby: – Progressive destruction of synovial joints with bony erosions and
loss of cartilage – Symptoms usually begin in the small joints of the fingers, wrists, and
feet – Swollen, tender joints are painful and difficult to move – Loss of physical function and quality of life – Decreased work productivity and increased disability and job loss •1.3millionadultAmericanshavebeendiagnosedwithRA •Peakageofonset:30to60years •2to4timesmorecommoninwomenthanmen •RApatients7timesaslikelytohavegreater-than-moderatedisability
than age- or sex-matched individuals •Ifundertreated,lifeexpectancyisreducedby5to15years –RAaccountsfor22%ofalldeathsfromarthritisandother
rheumatic conditions
It is never too late to stop further damage.
HochbergMC,SilmanAJ,SmolenJS,etal.eds.Rheumatology.3rded.NewYork,NY:Mosby;2003.AmericanCollegeofRheumatology.Factsheet.Availableat:http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/ra.asp.AccessedOctober1,2010.MacLeanCH,LouieR,LeakeB,etal.Qualityofcareforpatientswithrheumatoidarthritis.JAMA.2000;284:984-992.
RA IS A DISEASE OF THE ENTIRE BODYHeart:Cardiovasculardisease(CVD)occursonaverage10yearsearlierinRA patients than in the general population •AcceleratedatherosclerosisLungs:Increasedriskofmultiplepulmonarycomorbidities •Pleuritismayoccur • InterstitiallungdiseasesGastrointestinal (GI):RApatientshaveahighincidenceofGIbleeding,which may be attributable to use of nonsteroidal anti-inflammatory drugs (NSAIDs)andsteroidsduringtherapyNervous system: The deformity and damage to joints in RA may lead to entrapment of nerves •PatientmaypresentwithcarpaltunnelsyndromeOsteoporosis: Generalizedbonelossmayresultfromimmobility,theinflammatoryprocess,and/ortreatmentssuchassteroids • PeriarticulardemineralizationmayresultfrommediatorsofinflammationInfections:RApatientshavea6-to9-foldincreaseintherateofseriousinfections, including tuberculosis (TB) Malignancy: RA doubles the risk of some malignancies, particularly lymphoma
DeaneK.ManagingcomorbiditiesinRA.J Musculoskel Med.2006;23(suppl):S24-S31.BöttcherJ,PfeilA.DiagnosisofperiarticularosteoporosisinrheumatoidarthritisusingdigitalX-rayradiogrammetry.Arthritis Res Ther.2008;10:103.
PRIMARY CARE: EARLY DETECTION IS CRITICALTo prevent the progressive destruction of synovial joints and improve long-termoutcomes,RAmustbedetectedandtreatedearly. •Jointdamagecanberapid;withouttreatment,bonyerosionsmaybe
detectablebymagneticresonanceimaging(MRI)within4monthsofdisease onset
•Rateofx-rayprogressionismorerapidinthefirstyearthaninthesecond and third
•Withoutoptimaltreatment,mostpatientsdevelopbonyerosionswithin2years,and~80%ofthesepatientsdeveloplong-termdisability
•Successfullong-termmanagementrequiresapartnershipbetweenthe PCP and the rheumatologist, the patient, and other health care team members
Benefits of early detection: •DecreasedRAseverity,disability,andmortalitywitheffectivetreat-
ments, such as disease-modifying antirheumatic drugs (DMARDs) •LowerratesofRAcomplications •Lowerratesoflower-extremityorthopedicsurgicalprocedures •Decreasedcardiacriskswithcontrolofinflammation
McQueenFM,StewartN,CrabbeJ,etal.Magneticresonanceimagingofthewristinearlyrheumatoidarthritisrevealsahighprevalenceoferosionsatfourmonthsaftersymptomonset.Ann Rheum Dis.1998;57:350-356.BykerkVP,KeystoneEC.RAinprimarycare:20clinicalpearls.J Musculoskelet Med.2004;21:133-146.
PROVISIONAL DIAGNOSIS OF RAPatientswhohaveatleast1jointwithdefinitiveclinicalsynovitis(swelling)and in whom the synovitis is not better explained by another disease shouldbeexaminedforRA.MAkE THE DIAGNOSIS Does your patient have: 3 Swollen or tender joints –Either>1largeor≥1smalljointofthehandsorfeet,or –Positivesqueezetest(painwhengentlysqueezingacrossthe
metacarpophalangeal/metatarsophalangealjoints) 3 Symptoms lasting ≥6weeks
If patient has swollen joints or a positive squeeze test as above for ≥6 weeks, refer to a rheumatologist for provisional RA.
If the patient does not meet these criteria but has at least 1 swollen or tender joint and a positive RF or anti-CCP test, he or she should be referred to a rheumatologist.
A rheumatologist will make a definitive diagnosis of RA based on the followingcriteria: 1.Clinicalsignsandsymptoms 2.Patternandnumbersofjointsinvolved 3.Laboratorymeasures(RFandanti-CCPantibody) 4.Radiographicfindings 5.Rulingoutothercausesofinflammatoryarthritis
AletahaD,NeogiT,SilmanAJ.2010rheumatoidarthritisclassificationcriteria:anAmericanCollegeofRheumatology/ EuropeanLeagueAgainstRheumatismcollaborativeinitiative.Arthritis Rheum.2010Sept;62:2569-2581.
COLLABORATION BETwEEN PRIMARY CARE AND RHEUMATOLOGY ENSURES OPTIMAL CARESuccessfulmanagementofRArequireslong-termteaminvolvement.Inthe first stages, the PCP is responsible for identifying possible cases of RA,providingearlyreferraltoarheumatologistandearlypaincontrol.TherheumatologistconfirmsthediagnosisandinitiatesDMARDtherapy. •EarlyreferraltoarheumatologistiscriticaltoearlyinitiationofDMARD
therapy and to stop joint damage •Tofacilitatetheevaluationofthepatientbytherheumatologist,itis
advisabletoobtain: –Rheumatoidfactor(RF) n30%–70%ofRApatientsarepositive,althoughpositiveRFcan
be caused by many conditions – Anti-CCP antibody n40%–60%ofRApatientsarepositive(maybeyearsbefore
clinical manifestation) nMaybedetectableearlierthanRF n Extremely high specificity for RA – C-reactive protein, erythrocyte sedimentation rate –Completebloodcount(CBC),liverfunctiontests(LFTs) –Optionalx-raysofthehands,wrists,andfeet •Monitorforalarmsigns(infection,dyspnea,neckpain,rheumatoideye
disease, painful red eye) •EarlytreatmentbythePCPisintendedtorelievepainandenhance
mobility –NSAIDs,shortcourseoflow-doseprednisone;rarely,opioidsfor
severe pain
A patient who is RF and anti-CCP negative may still have RA.
BridgesSL.SpottingaggressiveRAearly:thephysicalexamination,testing,andimaging.J Musculoskelet Med.2006;23(supplNov):S10-S14.
LONG-TERM MANAGEMENT OF RA PATIENTSCVD: Patients with RA and persistent inflammation may have additional risk for CVD and require more aggressive cholesterol lowering •MinimizeCVDriskfactors(eg,smoking,lipids,bloodpressure) •MaintainhighindexofsuspicionforCVDFever and infections:RApatientsonsteroids,methotrexate(MTX),leflunomide,orbiologic agents are at increased risk of serious infection •AssessRApatientswithfever,suspectedinfection – Prompt and thorough evaluation of symptoms, antibiotics if warranted – Biologics may need to be held until infection is resolved – Prompt initiation of antibiotics (especially for patients on biologics) nAvoiduseoftrimethoprim/sulfamethoxazoleinpatientsonMTX •Ifpatientsonimmunosuppressiveagentsandbiologicsdonotrespondrapidlytoinitial
treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc) •Considersepticarthritiswhenthereis –Isolatedmonoarthritiswhenallotherjointsstable – Swelling and tenderness in a patient with total joint replacement n RA patients may not mount a febrile response and the white blood cell count
may not be elevated in this setting •AcutedyspneaandcoughinapatientonMTXmayrepresentpneumonitis
VACCINATIONS AND DMARD THERAPY •Recommendedbeforetherapybegins –Influenzaandpneumococcalvaccinations –HepatitisBimmunizationifappropriate •Safe –Influenza(injection),tetanus,pneumococcus,meningococcus,hepatitisA,
hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV) •Avoid – Live virus vaccines such as intranasalinfluenza,mumps/measles/rubella(MMR),
yellow fever, and typhoid should be avoided in patients on immunomodulators –Waitatleast2weeksaftergivingthesevaccinesbeforeinitiatingimmunomodulators – Zoster vaccine, should be avoided in patients on biologic agents, but can be
giventopatientstakingMTXandprednisone<20mg/day
DeaneK.J Musculoskel Med.2006;23(supplNov):S24-S31.RavikumarR,etal.Curr Rheumatol Rep.2007;9:407-415;CDC.MMWR.2004;53:Q1-Q4;AveryRK.Rheum Dis Clin North Am.1999;25:567-584;ChalmersA,etal.J Rheumatol.1994;21:1203-1206;HarpazR,etal.MMWR Recomm Rep.2008;57 (RR-5):1-30;ACR.Herpeszoster(shingles)vaccineguidelinesforimmunocompromisedpatients.Availableat:http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp.AccessedOctober1,2010.
Issue date: February 2011 • Expiration date: February 29, 2012
OVERVIEwThispocketeducatorisdesignedtoaidprimarycareproviders(PCPs)inrecognizingtheearly signs of rheumatoid arthritis (RA) and determining when to refer a patient to a rheumatologist.SideAdiscussestheroleofthePCPintheearlydiagnosisofRAanddescribes how the PCP can work in tandem with the patient’s rheumatologist to effectively managethisdisease.SideBisdesignedtohelppatientsunderstandRA.LEARNING OBjECTIVES•IdentifypatientswhohaveprobableearlyRAandshouldbereferredtoarheumatologist•EmploythesqueezetesttoassistwithdiagnosisofRA•OrderappropriatelaboratorytestswhenRAissuspectedINTENDED AUDIENCEThistoolisintendedforPCPs.FACULTYClifton O. Bingham III, MD Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, Johns Hopkins University, Baltimore, MarylandJoyce P. Carlone, MN, RN, FNP-BC, CCRC NursePractitioner,DivisionofRheumatology,EmoryUniversity,Atlanta,GeorgiaMary Suzanne Cleveland, JD (Patient/Patient Educator) SeniorAnalyst,KansasHealthInstitute,Topeka,KansasLauren G. Collins, MD AssistantProfessorofFamilyandCommunityMedicine,JeffersonMedicalCollegeofThomas Jefferson University, Philadelphia, PennsylvaniaSTEERING COMMITTEE Michael E. Weinblatt, MD–Co-Chair JohnR.andEileenK.RiedmanProfessorofMedicine,HarvardMedicalSchool,Co-Director,ClinicalRheumatology,DivisionofRheumatology,Immunology,andAllergy,BrighamandWomen’sHospital,Boston,MassachusettsLauren G. Collins, MD–Co-ChairClifton O. Bingham III, MDJoyce P. Carlone, MN, RN, FNP-BC, CCRC Mary Suzanne Cleveland, JD (Patient/Patient Educator)Jeanne G. Cole, MS Director,OfficeofCME,JeffersonMedicalCollegeofThomasJeffersonUniversity,Philadelphia, PennsylvaniaKaren H. Costenbader, MD, MPH AssociatePhysician,DivisionofRheumatology,ImmunologyandAllergy,BrighamandWomen’sHospital, Assistant Professor of Medicine, Harvard Medical School, Boston, MassachusettsPaul P. Doghramji, MD, FAAFP MedicalDirectorforHealthServicesatUrsinusCollege,FamilyPhysician,CollegevilleFamilyPractice,Collegeville,PennsylvaniaDaniel Duch, PhD MedicalDirector,CuratioCMEInstitute,Exton,PennsylvaniaDavid S. Kountz, MD, MBA, FACP Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical Center,AssociateProfessorofMedicine,RobertWoodJohnsonMedicalSchool,NewBrunswick,NewJersey
2A 3A 4A 5A 6A 7A 8A 9A
�Osteoporosis 6–9��Seriousinfection rate
CVD10 years earlier
2��Rate ofmalignancy
�Pulmonarydisease
�GI bleeding
Jo
int destruction
Pain
D
is
abilit
y
RA symptom onset
Bony erosions70%–80%
Long-term disability80%
Rheumatologists:• Await early referral• Confirm diagnosis• Initiate DMARD/ biologics treatment
Rheumatologists:Long-termmanagementof RA
PCP:• Suspect diagnosis• “Immediate” referral• Baseline labs
PCP:• Surveillance• Comorbidity management• CVD risk reduction
4 Months
2 Years
10–20 Years
Immune responsedevelops
Joint destruction
Lymphomas
ComplicationsComorbidities
RAClinicalonset
EnvironmentGenes
Time
Pathologic inflammatoryresponse
CVD
Primary Care• Provisional diagnosis• Immediate referral to rheumatologist• Monitor for toxicities and disease progression• Address CVD risk and extra- articular issues
Rheumatologist• Confirm diagnosis• Initiate early, aggressive DMARD therapy• Monitor for toxicities and disease progression
Collaboration
Swelling on the proximal interphalangeal (PIP) joints
ReprintedfromTheLancet373,KlareskogLetal.Rheumatoidarthritis,659-672.Copyright2009,withpermissionfromElsevier.
Squeeze test
Participation in this activity includes reviewing the clinician educator and completing a posttest and evaluation. For additional information,
and to obtain 0.5 CME credits for participating in this activity, please visit http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
ACCREDITATION AND DESIGNATIONThis activity has been planned and implemented in accordance with the Essential Areas andPoliciesoftheAccreditationCouncilforContinuingMedicalEducation(ACCME).Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to providecontinuingmedicaleducationforphysicians.JeffersonMedicalCollegeofThomasJeffersonUniversitydesignatesthisenduringmaterialforamaximumof0.5AMA PRA Category 1 Credit™.Physiciansshouldclaimonlythecreditcommensuratewiththeextentoftheirparticipationintheactivity.DISCLOSUREJefferson Medical College of Thomas Jefferson University endorses the Standards of the ACCMEandtheGuidelinesforCommercialSupport.Thefollowingindividualshavedeclarednofinancialinterestsand/oraffiliations:Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; Jonathan S. Simmons, ELSThefollowingindividualshavedeclaredfinancialinterestsand/oraffiliations:Clifton O. Bingham III, MD Grant/Research Support: BMS, Genentech, UCB, Roche Consultant: Genentech,Roche,CentocorOrthoBiotech,Merck,UCB,Flexion,CelgeneJoyce P. Carlone, MN, RN, FNP-BC, CCRC Consultant, Product/Speakers Bureau, Other: UCBDavid S. Kountz, MD, MBA, FACPConsultant:NiCox,NovartisMichael E. Weinblatt, MDGrant/Research Support: AbbottConsultant:Abbott,CentocorOrthoBiotech,Pfizer/WyethCONTENT DISCLAIMER The information presented in this enduring material is for continuing medical education purposes only and is not meant to substitute for the independent medical judgment of a physicianregardingdiagnosisandtreatmentofaspecificpatient’smedicalcondition.The views or opinions expressed in the resources provided do not necessarily reflect those of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson HealthSystemorstaff.
ThisprogramissupportedbyeducationalgrantsfromAbbott,CentocorOrthoBiotechInc.,andPfizer.
Youcandownloadafree barcode reader app for your smartphone by searchingforQRCODESCANNERin the iPhone App Store, Android Market,orBlackberryAppWorld.
©2
010
Amer
ican
Col
lege
ofR
heum
atol
ogy.
Used
with
per
mis
sion
.
QR Code
31316 /
334/
31316 / 313
16 / 31316 / 313
16 / 31316 / 313
16 /
332 /
31116 /
614/
3418/
what is rheumatoid arthritis (RA)?•RAisachronicconditionthatdamagesthejointsofthe
body.Chronicconditionsarelonglasting(greaterthan3months)anddonotgoawayeasilyorquickly.RAaffectswomenmorethantwiceasmuchasmen.Althoughitmayoccur at any age, it usually starts in patients when they arebetween30and60yearsold.RAcausescontinuingjointdamageandassociatedconditionsformanypatients.To reduce complications, RA should be diagnosed and treatedearlyandoptimallymanagedthroughoutlife.
what are the symptoms?EarlysignsofRAinclude:•Swelling,stiffness,aching,orpaininoneormorejoints•Morningstiffnessthatlastsforatleast30minutesand
often for several hours•Difficultygraspingobjectsasstronglyasyouusedto
RA commonly affects the small joints of the fingers, wrists, and feet, but it may also affect other joints as the disease progresses, includingtheankles,knees,hips,elbows,andshoulders.
1B 2B 3B 4B 5B 6B 7B 8B
what causes RA?•ItisnotknownwhatcausesRA,butitisanautoimmune
disease.Thismeansthatthebodyattacksitself
•Thebody’simmunesystemfightsoffinfectionscausedbyinvading bacteria and viruses
•InautoimmunediseaseslikeRA,thebodyrespondsasifitsnormal cells are foreign cells and attacks them
•GeneticsmayplayapartinthedevelopmentofRA,butmany people who get RA do not have any relatives with the condition
what happens when RA causes an autoimmune response? Whenanimmuneresponseistriggered,inflammationoccursintheareasthatareattackedbytheimmunesystem.
•Inflammationcausesrednessandwarmth,swelling,stiffness, and pain in the affected joints
•Iftheautoimmuneresponseisnotslowedorstopped,itcan permanently damage the affected joints and other tissues over time
Can RA be prevented?Because we do not know why RA happens, there is no known waytopreventthedisease.However, early diagnosis and early treatment are the best ways to fight RA.
•Treatmentisfirstfocusedonreducinginflammationandrelieving pain
•WhenadiagnosisofRAisconfirmed,treatmentalsoaimsatstopping or slowing joint damage and damage to other parts of the body
How can RA be controlled?TherehasbeengreatimprovementinthedrugsusedtotreatRA.
•Aclassofdrugsreferredtoas“DMARDs” acts to slow or stop the progression of RA to more advanced stages of the disease
•Ifyoulookatthegraphabove,youwillseethatwhenaDMARD is not used (the red line), the problems caused by RAincreaserapidly,especiallyinthefirst2years
•However,whentreatedwithDMARDs(theblueline),thedisease progresses much more slowly, and fewer problems occur
•DMARDssuchasmethotrexate,hydroxychloroquine,sulfasalazine,orbiologicDMARDsaremostoftenusedtocontrol RA
I have some pain in my joints. How can I tell if I have RA?•IfyouthinkyoumayhaveRA,youneedtotellyourhealthcare
provider.Heorshewillexamineyouandaskthefollowingquestions:
–Whathurtsasyougetoutofbedinthemorning? – How long does it take to feel as limber as you’re going to
feelfortheday? –Whenisyourpaintheworst(AMorPM)? –DoanymembersofyourfamilyhaveRA? –Isitdifficultforyouto: n Turnfaucethandles? n Holdahairbrush/toothbrush? n Dress/batheindependently? n Fixyourownbreakfast? n Walkoutdoorsonflatground? –Howisyourenergylevel? –Doyousmoke? –Signsthatmaysuggestotherreasonsforyourpain: n Fever n Nightsweats n Unexpected weight loss n Rash, tick exposure n Recent contact with sick children
Youmayalsofilloutthequestionnaireonpanel8B,whichwillhelpidentifythecauseofyourdiscomfort.
what happens next?•IfyourhealthcareproviderthinksyoumayhaveRA,he
or she will prescribe medication to reduce the pain and inflammationinthejoints.Heorshewillalsoreferyoutoarheumatologist,whichisadoctorwhospecializesinRAandrelateddiseases.
•The rheumatologist will confirm the diagnosis of RA and prescribe appropriate medication to slow or stop the autoimmuneprocessandjointdamage.
•Depending on the extent of injury caused by RA, you may be referred to a physical or occupational therapist, a podiatrist, orotherspecialists,suchasanorthopedicsurgeon.
Rheumatoid Arthritis Resources and InformationThe American College of Rheumatology http://www.rheumatology.org/The Arthritis Foundation http://www.arthritis.org/The National Library of Medicine/Medline Plus http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
Healthy joint Damaged joint
Destruction of cartilage
Cutaway view
Joints affected:Jaw
Elbow
Hip
Wrist,hand, fingers
Knee
Ankle, foot, toes
Shoulder
Spine
Other organs that may be affected if RA is not treated early:
Eyes: dryness and damage to delicate structures
Lungs: much greater risk of getting serious infections and other complications
Heart disease: may occurabout10years sooner than in people without RA
Stomach: high risk of bleeding
Double the risk of some types of cancer, so increased screening is advisable
Early diagnosis and treatment may prevent these complications.
Med
ical
Illu
stra
tion
Copy
right
© 2
010
Nucl
eus
Med
ical
Med
ia,
All r
ight
s re
serv
ed. w
ww
.nuc
leus
inc.
com
Are other parts of the body affected besides the joints?
Se
lf-R
ep
ort
Qu
estio
nn
air
e f
or
Rh
eu
ma
toid
Art
hri
tis
Plea
se c
heck
(3)t
heO
NEb
esta
nsw
erfo
ryou
rabi
litie
s.
If w
e as
ked
som
eone
who
spe
nds
a go
od d
eal o
f tim
e w
ith
you,
wou
ld th
ey s
ay th
at y
ou h
ave
diffi
culty
with
:
With
out
any
di
fficu
lty
With
so
me
diffi
culty
With
m
uch
diffi
culty
Unab
le
to d
o
1.D
ress
ing
your
self,
incl
udin
gty
ing
shoe
lace
san
ddo
ing
butto
ns?
2.G
ettin
gin
and
out
ofb
ed?
3.L
iftin
ga
full
cup
org
lass
toy
ourm
outh
?
4.W
alki
ngo
utdo
ors
onfl
atg
roun
d?
5.W
ashi
nga
ndd
ryin
gyo
ure
ntire
bod
y?
6.B
endi
ngd
own
top
ick
upc
loth
ing
from
the
floor
?
7.T
urni
ngre
gula
rfau
cets
(tap
s)o
nan
dof
f?
8.G
ettin
gin
and
out
ofa
car
?
Shar
eyo
ura
nsw
ers
with
you
rprim
ary
care
pro
vider
.
70
60
50
40
30
20
10
00 4321 5
Years of Disease
Dise
ase
Prog
ress
Without DMARDs, problems increase rapidly
With DMARDs, fewer problems
Treatment With Disease-Modifiying Antirheumatic Drugs(DMARDs) Improves Long-Term Outcomes
Immune cell
Target cell
ALSO AVAILABLE
An interactive version of this Rheumatoid Arthritis: Primary care Initiative for improved Diagnosis and outcomes (RAPID) clinician educator is now available as an iPhone app. The enhanced app version includes the following features:
• VideodemonstrationofthesqueezetestandprovisionalRAdiagnosis
• Videodiscussionofpatientpointofviewtowardsprimarycareproviders and the need for early diagnosis
• VideodiscussionofrecommendedvaccinationsforRApatientsand the presence of comorbid conditions
The free iPhone app is available in either of the following ways:
• Downloadtheappat http://www.curatiocme.com/RAPID/iphone
• UsingthecameraonyouriPhone,scantheQRcodebelow
Published in Rheumatology,3rded.GordonDA,HastingsDE.Clinicalfeaturesofrheumatoidarthritis,765-780.CopyrightElsevier2003.
Publ
ishe
d in
Rhe
umat
olog
y,3
rde
d.G
ordo
nDA
,Has
tings
DE.
Clin
ical
feat
ures
ofr
heum
atoi
dar
thrit
is,7
65-7
80.C
opyr
ight
Els
evie
r200
3.
31316 /
334/
31316 / 313
16 / 31316 / 313
16 / 31316 / 313
16 /
332 /
31116 /
614/
3418/
what is rheumatoid arthritis (RA)?•RAisachronicconditionthatdamagesthejointsofthe
body.Chronicconditionsarelonglasting(greaterthan3months)anddonotgoawayeasilyorquickly.RAaffectswomenmorethantwiceasmuchasmen.Althoughitmayoccur at any age, it usually starts in patients when they arebetween30and60yearsold.RAcausescontinuingjointdamageandassociatedconditionsformanypatients.To reduce complications, RA should be diagnosed and treatedearlyandoptimallymanagedthroughoutlife.
what are the symptoms?EarlysignsofRAinclude:•Swelling,stiffness,aching,orpaininoneormorejoints•Morningstiffnessthatlastsforatleast30minutesand
often for several hours•Difficultygraspingobjectsasstronglyasyouusedto
RA commonly affects the small joints of the fingers, wrists, and feet, but it may also affect other joints as the disease progresses, includingtheankles,knees,hips,elbows,andshoulders.
1B 2B 3B 4B 5B 6B 7B 8B
what causes RA?•ItisnotknownwhatcausesRA,butitisanautoimmune
disease.Thismeansthatthebodyattacksitself
•Thebody’simmunesystemfightsoffinfectionscausedbyinvading bacteria and viruses
•InautoimmunediseaseslikeRA,thebodyrespondsasifitsnormal cells are foreign cells and attacks them
•GeneticsmayplayapartinthedevelopmentofRA,butmany people who get RA do not have any relatives with the condition
what happens when RA causes an autoimmune response? Whenanimmuneresponseistriggered,inflammationoccursintheareasthatareattackedbytheimmunesystem.
•Inflammationcausesrednessandwarmth,swelling,stiffness, and pain in the affected joints
•Iftheautoimmuneresponseisnotslowedorstopped,itcan permanently damage the affected joints and other tissues over time
Can RA be prevented?Because we do not know why RA happens, there is no known waytopreventthedisease.However, early diagnosis and early treatment are the best ways to fight RA.
•Treatmentisfirstfocusedonreducinginflammationandrelieving pain
•WhenadiagnosisofRAisconfirmed,treatmentalsoaimsatstopping or slowing joint damage and damage to other parts of the body
How can RA be controlled?TherehasbeengreatimprovementinthedrugsusedtotreatRA.
•Aclassofdrugsreferredtoas“DMARDs” acts to slow or stop the progression of RA to more advanced stages of the disease
•Ifyoulookatthegraphabove,youwillseethatwhenaDMARD is not used (the red line), the problems caused by RAincreaserapidly,especiallyinthefirst2years
•However,whentreatedwithDMARDs(theblueline),thedisease progresses much more slowly, and fewer problems occur
•DMARDssuchasmethotrexate,hydroxychloroquine,sulfasalazine,orbiologicDMARDsaremostoftenusedtocontrol RA
I have some pain in my joints. How can I tell if I have RA?•IfyouthinkyoumayhaveRA,youneedtotellyourhealthcare
provider.Heorshewillexamineyouandaskthefollowingquestions:
–Whathurtsasyougetoutofbedinthemorning? – How long does it take to feel as limber as you’re going to
feelfortheday? –Whenisyourpaintheworst(AMorPM)? –DoanymembersofyourfamilyhaveRA? –Isitdifficultforyouto: n Turnfaucethandles? n Holdahairbrush/toothbrush? n Dress/batheindependently? n Fixyourownbreakfast? n Walkoutdoorsonflatground? –Howisyourenergylevel? –Doyousmoke? –Signsthatmaysuggestotherreasonsforyourpain: n Fever n Nightsweats n Unexpected weight loss n Rash, tick exposure n Recent contact with sick children
Youmayalsofilloutthequestionnaireonpanel8B,whichwillhelpidentifythecauseofyourdiscomfort.
what happens next?•IfyourhealthcareproviderthinksyoumayhaveRA,he
or she will prescribe medication to reduce the pain and inflammationinthejoints.Heorshewillalsoreferyoutoarheumatologist,whichisadoctorwhospecializesinRAandrelateddiseases.
•The rheumatologist will confirm the diagnosis of RA and prescribe appropriate medication to slow or stop the autoimmuneprocessandjointdamage.
•Depending on the extent of injury caused by RA, you may be referred to a physical or occupational therapist, a podiatrist, orotherspecialists,suchasanorthopedicsurgeon.
Rheumatoid Arthritis Resources and InformationThe American College of Rheumatology http://www.rheumatology.org/The Arthritis Foundation http://www.arthritis.org/The National Library of Medicine/Medline Plus http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
Healthy joint Damaged joint
Destruction of cartilage
Cutaway view
Joints affected:Jaw
Elbow
Hip
Wrist,hand, fingers
Knee
Ankle, foot, toes
Shoulder
Spine
Other organs that may be affected if RA is not treated early:
Eyes: dryness and damage to delicate structures
Lungs: much greater risk of getting serious infections and other complications
Heart disease: may occurabout10years sooner than in people without RA
Stomach: high risk of bleeding
Double the risk of some types of cancer, so increased screening is advisable
Early diagnosis and treatment may prevent these complications.
Med
ical
Illu
stra
tion
Copy
right
© 2
010
Nucl
eus
Med
ical
Med
ia,
All r
ight
s re
serv
ed. w
ww
.nuc
leus
inc.
com
Are other parts of the body affected besides the joints?
Se
lf-R
ep
ort
Qu
estio
nn
air
e f
or
Rh
eu
ma
toid
Art
hri
tis
Plea
se c
heck
(3)t
heO
NEb
esta
nsw
erfo
ryou
rabi
litie
s.
If w
e as
ked
som
eone
who
spe
nds
a go
od d
eal o
f tim
e w
ith
you,
wou
ld th
ey s
ay th
at y
ou h
ave
diffi
culty
with
:
With
out
any
di
fficu
lty
With
so
me
diffi
culty
With
m
uch
diffi
culty
Unab
le
to d
o
1.D
ress
ing
your
self,
incl
udin
gty
ing
shoe
lace
san
ddo
ing
butto
ns?
2.G
ettin
gin
and
out
ofb
ed?
3.L
iftin
ga
full
cup
org
lass
toy
ourm
outh
?
4.W
alki
ngo
utdo
ors
onfl
atg
roun
d?
5.W
ashi
nga
ndd
ryin
gyo
ure
ntire
bod
y?
6.B
endi
ngd
own
top
ick
upc
loth
ing
from
the
floor
?
7.T
urni
ngre
gula
rfau
cets
(tap
s)o
nan
dof
f?
8.G
ettin
gin
and
out
ofa
car
?
Shar
eyo
ura
nsw
ers
with
you
rprim
ary
care
pro
vider
.
70
60
50
40
30
20
10
00 4321 5
Years of Disease
Dise
ase
Prog
ress
Without DMARDs, problems increase rapidly
With DMARDs, fewer problems
Treatment With Disease-Modifiying Antirheumatic Drugs(DMARDs) Improves Long-Term Outcomes
Immune cell
Target cell
ALSO AVAILABLE
An interactive version of this Rheumatoid Arthritis: Primary care Initiative for improved Diagnosis and outcomes (RAPID) clinician educator is now available as an iPhone app. The enhanced app version includes the following features:
• VideodemonstrationofthesqueezetestandprovisionalRAdiagnosis
• Videodiscussionofpatientpointofviewtowardsprimarycareproviders and the need for early diagnosis
• VideodiscussionofrecommendedvaccinationsforRApatientsand the presence of comorbid conditions
The free iPhone app is available in either of the following ways:
• Downloadtheappat http://www.curatiocme.com/RAPID/iphone
• UsingthecameraonyouriPhone,scantheQRcodebelow
Published in Rheumatology,3rded.GordonDA,HastingsDE.Clinicalfeaturesofrheumatoidarthritis,765-780.CopyrightElsevier2003.
Publ
ishe
d in
Rhe
umat
olog
y,3
rde
d.G
ordo
nDA
,Has
tings
DE.
Clin
ical
feat
ures
ofr
heum
atoi
dar
thrit
is,7
65-7
80.C
opyr
ight
Els
evie
r200
3.
31316 /
334/
31316 / 313
16 / 31316 / 313
16 / 31316 / 313
16 /
332 /
31116 /
614/
3418/
what is rheumatoid arthritis (RA)?•RAisachronicconditionthatdamagesthejointsofthe
body.Chronicconditionsarelonglasting(greaterthan3months)anddonotgoawayeasilyorquickly.RAaffectswomenmorethantwiceasmuchasmen.Althoughitmayoccur at any age, it usually starts in patients when they arebetween30and60yearsold.RAcausescontinuingjointdamageandassociatedconditionsformanypatients.To reduce complications, RA should be diagnosed and treatedearlyandoptimallymanagedthroughoutlife.
what are the symptoms?EarlysignsofRAinclude:•Swelling,stiffness,aching,orpaininoneormorejoints•Morningstiffnessthatlastsforatleast30minutesand
often for several hours•Difficultygraspingobjectsasstronglyasyouusedto
RA commonly affects the small joints of the fingers, wrists, and feet, but it may also affect other joints as the disease progresses, includingtheankles,knees,hips,elbows,andshoulders.
1B 2B 3B 4B 5B 6B 7B 8B
what causes RA?•ItisnotknownwhatcausesRA,butitisanautoimmune
disease.Thismeansthatthebodyattacksitself
•Thebody’simmunesystemfightsoffinfectionscausedbyinvading bacteria and viruses
•InautoimmunediseaseslikeRA,thebodyrespondsasifitsnormal cells are foreign cells and attacks them
•GeneticsmayplayapartinthedevelopmentofRA,butmany people who get RA do not have any relatives with the condition
what happens when RA causes an autoimmune response? Whenanimmuneresponseistriggered,inflammationoccursintheareasthatareattackedbytheimmunesystem.
•Inflammationcausesrednessandwarmth,swelling,stiffness, and pain in the affected joints
•Iftheautoimmuneresponseisnotslowedorstopped,itcan permanently damage the affected joints and other tissues over time
Can RA be prevented?Because we do not know why RA happens, there is no known waytopreventthedisease.However, early diagnosis and early treatment are the best ways to fight RA.
•Treatmentisfirstfocusedonreducinginflammationandrelieving pain
•WhenadiagnosisofRAisconfirmed,treatmentalsoaimsatstopping or slowing joint damage and damage to other parts of the body
How can RA be controlled?TherehasbeengreatimprovementinthedrugsusedtotreatRA.
•Aclassofdrugsreferredtoas“DMARDs” acts to slow or stop the progression of RA to more advanced stages of the disease
•Ifyoulookatthegraphabove,youwillseethatwhenaDMARD is not used (the red line), the problems caused by RAincreaserapidly,especiallyinthefirst2years
•However,whentreatedwithDMARDs(theblueline),thedisease progresses much more slowly, and fewer problems occur
•DMARDssuchasmethotrexate,hydroxychloroquine,sulfasalazine,orbiologicDMARDsaremostoftenusedtocontrol RA
I have some pain in my joints. How can I tell if I have RA?•IfyouthinkyoumayhaveRA,youneedtotellyourhealthcare
provider.Heorshewillexamineyouandaskthefollowingquestions:
–Whathurtsasyougetoutofbedinthemorning? – How long does it take to feel as limber as you’re going to
feelfortheday? –Whenisyourpaintheworst(AMorPM)? –DoanymembersofyourfamilyhaveRA? –Isitdifficultforyouto: n Turnfaucethandles? n Holdahairbrush/toothbrush? n Dress/batheindependently? n Fixyourownbreakfast? n Walkoutdoorsonflatground? –Howisyourenergylevel? –Doyousmoke? –Signsthatmaysuggestotherreasonsforyourpain: n Fever n Nightsweats n Unexpected weight loss n Rash, tick exposure n Recent contact with sick children
Youmayalsofilloutthequestionnaireonpanel8B,whichwillhelpidentifythecauseofyourdiscomfort.
what happens next?•IfyourhealthcareproviderthinksyoumayhaveRA,he
or she will prescribe medication to reduce the pain and inflammationinthejoints.Heorshewillalsoreferyoutoarheumatologist,whichisadoctorwhospecializesinRAandrelateddiseases.
•The rheumatologist will confirm the diagnosis of RA and prescribe appropriate medication to slow or stop the autoimmuneprocessandjointdamage.
•Depending on the extent of injury caused by RA, you may be referred to a physical or occupational therapist, a podiatrist, orotherspecialists,suchasanorthopedicsurgeon.
Rheumatoid Arthritis Resources and InformationThe American College of Rheumatology http://www.rheumatology.org/The Arthritis Foundation http://www.arthritis.org/The National Library of Medicine/Medline Plus http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
Healthy joint Damaged joint
Destruction of cartilage
Cutaway view
Joints affected:Jaw
Elbow
Hip
Wrist,hand, fingers
Knee
Ankle, foot, toes
Shoulder
Spine
Other organs that may be affected if RA is not treated early:
Eyes: dryness and damage to delicate structures
Lungs: much greater risk of getting serious infections and other complications
Heart disease: may occurabout10years sooner than in people without RA
Stomach: high risk of bleeding
Double the risk of some types of cancer, so increased screening is advisable
Early diagnosis and treatment may prevent these complications.
Med
ical
Illu
stra
tion
Copy
right
© 2
010
Nucl
eus
Med
ical
Med
ia,
All r
ight
s re
serv
ed. w
ww
.nuc
leus
inc.
com
Are other parts of the body affected besides the joints?
Se
lf-R
ep
ort
Qu
estio
nn
air
e f
or
Rh
eu
ma
toid
Art
hri
tis
Plea
se c
heck
(3)t
heO
NEb
esta
nsw
erfo
ryou
rabi
litie
s.
If w
e as
ked
som
eone
who
spe
nds
a go
od d
eal o
f tim
e w
ith
you,
wou
ld th
ey s
ay th
at y
ou h
ave
diffi
culty
with
:
With
out
any
di
fficu
lty
With
so
me
diffi
culty
With
m
uch
diffi
culty
Unab
le
to d
o
1.D
ress
ing
your
self,
incl
udin
gty
ing
shoe
lace
san
ddo
ing
butto
ns?
2.G
ettin
gin
and
out
ofb
ed?
3.L
iftin
ga
full
cup
org
lass
toy
ourm
outh
?
4.W
alki
ngo
utdo
ors
onfl
atg
roun
d?
5.W
ashi
nga
ndd
ryin
gyo
ure
ntire
bod
y?
6.B
endi
ngd
own
top
ick
upc
loth
ing
from
the
floor
?
7.T
urni
ngre
gula
rfau
cets
(tap
s)o
nan
dof
f?
8.G
ettin
gin
and
out
ofa
car
?
Shar
eyo
ura
nsw
ers
with
you
rprim
ary
care
pro
vider
.
70
60
50
40
30
20
10
00 4321 5
Years of Disease
Dise
ase
Prog
ress
Without DMARDs, problems increase rapidly
With DMARDs, fewer problems
Treatment With Disease-Modifiying Antirheumatic Drugs(DMARDs) Improves Long-Term Outcomes
Immune cell
Target cell
ALSO AVAILABLE
An interactive version of this Rheumatoid Arthritis: Primary care Initiative for improved Diagnosis and outcomes (RAPID) clinician educator is now available as an iPhone app. The enhanced app version includes the following features:
• VideodemonstrationofthesqueezetestandprovisionalRAdiagnosis
• Videodiscussionofpatientpointofviewtowardsprimarycareproviders and the need for early diagnosis
• VideodiscussionofrecommendedvaccinationsforRApatientsand the presence of comorbid conditions
The free iPhone app is available in either of the following ways:
• Downloadtheappat http://www.curatiocme.com/RAPID/iphone
• UsingthecameraonyouriPhone,scantheQRcodebelow
Published in Rheumatology,3rded.GordonDA,HastingsDE.Clinicalfeaturesofrheumatoidarthritis,765-780.CopyrightElsevier2003.
Publ
ishe
d in
Rhe
umat
olog
y,3
rde
d.G
ordo
nDA
,Has
tings
DE.
Clin
ical
feat
ures
ofr
heum
atoi
dar
thrit
is,7
65-7
80.C
opyr
ight
Els
evie
r200
3.
31316 /
334/
31316 / 313
16 / 31316 / 313
16 / 31316 / 313
16 /
332 /
31116 /
614/
3418/
what is rheumatoid arthritis (RA)?•RAisachronicconditionthatdamagesthejointsofthe
body.Chronicconditionsarelonglasting(greaterthan3months)anddonotgoawayeasilyorquickly.RAaffectswomenmorethantwiceasmuchasmen.Althoughitmayoccur at any age, it usually starts in patients when they arebetween30and60yearsold.RAcausescontinuingjointdamageandassociatedconditionsformanypatients.To reduce complications, RA should be diagnosed and treatedearlyandoptimallymanagedthroughoutlife.
what are the symptoms?EarlysignsofRAinclude:•Swelling,stiffness,aching,orpaininoneormorejoints•Morningstiffnessthatlastsforatleast30minutesand
often for several hours•Difficultygraspingobjectsasstronglyasyouusedto
RA commonly affects the small joints of the fingers, wrists, and feet, but it may also affect other joints as the disease progresses, includingtheankles,knees,hips,elbows,andshoulders.
1B 2B 3B 4B 5B 6B 7B 8B
what causes RA?•ItisnotknownwhatcausesRA,butitisanautoimmune
disease.Thismeansthatthebodyattacksitself
•Thebody’simmunesystemfightsoffinfectionscausedbyinvading bacteria and viruses
•InautoimmunediseaseslikeRA,thebodyrespondsasifitsnormal cells are foreign cells and attacks them
•GeneticsmayplayapartinthedevelopmentofRA,butmany people who get RA do not have any relatives with the condition
what happens when RA causes an autoimmune response? Whenanimmuneresponseistriggered,inflammationoccursintheareasthatareattackedbytheimmunesystem.
•Inflammationcausesrednessandwarmth,swelling,stiffness, and pain in the affected joints
•Iftheautoimmuneresponseisnotslowedorstopped,itcan permanently damage the affected joints and other tissues over time
Can RA be prevented?Because we do not know why RA happens, there is no known waytopreventthedisease.However, early diagnosis and early treatment are the best ways to fight RA.
•Treatmentisfirstfocusedonreducinginflammationandrelieving pain
•WhenadiagnosisofRAisconfirmed,treatmentalsoaimsatstopping or slowing joint damage and damage to other parts of the body
How can RA be controlled?TherehasbeengreatimprovementinthedrugsusedtotreatRA.
•Aclassofdrugsreferredtoas“DMARDs” acts to slow or stop the progression of RA to more advanced stages of the disease
•Ifyoulookatthegraphabove,youwillseethatwhenaDMARD is not used (the red line), the problems caused by RAincreaserapidly,especiallyinthefirst2years
•However,whentreatedwithDMARDs(theblueline),thedisease progresses much more slowly, and fewer problems occur
•DMARDssuchasmethotrexate,hydroxychloroquine,sulfasalazine,orbiologicDMARDsaremostoftenusedtocontrol RA
I have some pain in my joints. How can I tell if I have RA?•IfyouthinkyoumayhaveRA,youneedtotellyourhealthcare
provider.Heorshewillexamineyouandaskthefollowingquestions:
–Whathurtsasyougetoutofbedinthemorning? – How long does it take to feel as limber as you’re going to
feelfortheday? –Whenisyourpaintheworst(AMorPM)? –DoanymembersofyourfamilyhaveRA? –Isitdifficultforyouto: n Turnfaucethandles? n Holdahairbrush/toothbrush? n Dress/batheindependently? n Fixyourownbreakfast? n Walkoutdoorsonflatground? –Howisyourenergylevel? –Doyousmoke? –Signsthatmaysuggestotherreasonsforyourpain: n Fever n Nightsweats n Unexpected weight loss n Rash, tick exposure n Recent contact with sick children
Youmayalsofilloutthequestionnaireonpanel8B,whichwillhelpidentifythecauseofyourdiscomfort.
what happens next?•IfyourhealthcareproviderthinksyoumayhaveRA,he
or she will prescribe medication to reduce the pain and inflammationinthejoints.Heorshewillalsoreferyoutoarheumatologist,whichisadoctorwhospecializesinRAandrelateddiseases.
•The rheumatologist will confirm the diagnosis of RA and prescribe appropriate medication to slow or stop the autoimmuneprocessandjointdamage.
•Depending on the extent of injury caused by RA, you may be referred to a physical or occupational therapist, a podiatrist, orotherspecialists,suchasanorthopedicsurgeon.
Rheumatoid Arthritis Resources and InformationThe American College of Rheumatology http://www.rheumatology.org/The Arthritis Foundation http://www.arthritis.org/The National Library of Medicine/Medline Plus http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
Healthy joint Damaged joint
Destruction of cartilage
Cutaway view
Joints affected:Jaw
Elbow
Hip
Wrist,hand, fingers
Knee
Ankle, foot, toes
Shoulder
Spine
Other organs that may be affected if RA is not treated early:
Eyes: dryness and damage to delicate structures
Lungs: much greater risk of getting serious infections and other complications
Heart disease: may occurabout10years sooner than in people without RA
Stomach: high risk of bleeding
Double the risk of some types of cancer, so increased screening is advisable
Early diagnosis and treatment may prevent these complications.
Med
ical
Illu
stra
tion
Copy
right
© 2
010
Nucl
eus
Med
ical
Med
ia,
All r
ight
s re
serv
ed. w
ww
.nuc
leus
inc.
com
Are other parts of the body affected besides the joints?
Se
lf-R
ep
ort
Qu
estio
nn
air
e f
or
Rh
eu
ma
toid
Art
hri
tis
Plea
se c
heck
(3)t
heO
NEb
esta
nsw
erfo
ryou
rabi
litie
s.
If w
e as
ked
som
eone
who
spe
nds
a go
od d
eal o
f tim
e w
ith
you,
wou
ld th
ey s
ay th
at y
ou h
ave
diffi
culty
with
:
With
out
any
di
fficu
lty
With
so
me
diffi
culty
With
m
uch
diffi
culty
Unab
le
to d
o
1.D
ress
ing
your
self,
incl
udin
gty
ing
shoe
lace
san
ddo
ing
butto
ns?
2.G
ettin
gin
and
out
ofb
ed?
3.L
iftin
ga
full
cup
org
lass
toy
ourm
outh
?
4.W
alki
ngo
utdo
ors
onfl
atg
roun
d?
5.W
ashi
nga
ndd
ryin
gyo
ure
ntire
bod
y?
6.B
endi
ngd
own
top
ick
upc
loth
ing
from
the
floor
?
7.T
urni
ngre
gula
rfau
cets
(tap
s)o
nan
dof
f?
8.G
ettin
gin
and
out
ofa
car
?
Shar
eyo
ura
nsw
ers
with
you
rprim
ary
care
pro
vider
.
70
60
50
40
30
20
10
00 4321 5
Years of Disease
Dise
ase
Prog
ress
Without DMARDs, problems increase rapidly
With DMARDs, fewer problems
Treatment With Disease-Modifiying Antirheumatic Drugs(DMARDs) Improves Long-Term Outcomes
Immune cell
Target cell
ALSO AVAILABLE
An interactive version of this Rheumatoid Arthritis: Primary care Initiative for improved Diagnosis and outcomes (RAPID) clinician educator is now available as an iPhone app. The enhanced app version includes the following features:
• VideodemonstrationofthesqueezetestandprovisionalRAdiagnosis
• Videodiscussionofpatientpointofviewtowardsprimarycareproviders and the need for early diagnosis
• VideodiscussionofrecommendedvaccinationsforRApatientsand the presence of comorbid conditions
The free iPhone app is available in either of the following ways:
• Downloadtheappat http://www.curatiocme.com/RAPID/iphone
• UsingthecameraonyouriPhone,scantheQRcodebelow
Published in Rheumatology,3rded.GordonDA,HastingsDE.Clinicalfeaturesofrheumatoidarthritis,765-780.CopyrightElsevier2003.
Publ
ishe
d in
Rhe
umat
olog
y,3
rde
d.G
ordo
nDA
,Has
tings
DE.
Clin
ical
feat
ures
ofr
heum
atoi
dar
thrit
is,7
65-7
80.C
opyr
ight
Els
evie
r200
3.
31316 /
334/
31316 / 313
16 / 31316 / 313
16 / 31316 / 313
16 /
332 /
31116 /
614/
3418/
what is rheumatoid arthritis (RA)?•RAisachronicconditionthatdamagesthejointsofthe
body.Chronicconditionsarelonglasting(greaterthan3months)anddonotgoawayeasilyorquickly.RAaffectswomenmorethantwiceasmuchasmen.Althoughitmayoccur at any age, it usually starts in patients when they arebetween30and60yearsold.RAcausescontinuingjointdamageandassociatedconditionsformanypatients.To reduce complications, RA should be diagnosed and treatedearlyandoptimallymanagedthroughoutlife.
what are the symptoms?EarlysignsofRAinclude:•Swelling,stiffness,aching,orpaininoneormorejoints•Morningstiffnessthatlastsforatleast30minutesand
often for several hours•Difficultygraspingobjectsasstronglyasyouusedto
RA commonly affects the small joints of the fingers, wrists, and feet, but it may also affect other joints as the disease progresses, includingtheankles,knees,hips,elbows,andshoulders.
1B 2B 3B 4B 5B 6B 7B 8B
what causes RA?•ItisnotknownwhatcausesRA,butitisanautoimmune
disease.Thismeansthatthebodyattacksitself
•Thebody’simmunesystemfightsoffinfectionscausedbyinvading bacteria and viruses
•InautoimmunediseaseslikeRA,thebodyrespondsasifitsnormal cells are foreign cells and attacks them
•GeneticsmayplayapartinthedevelopmentofRA,butmany people who get RA do not have any relatives with the condition
what happens when RA causes an autoimmune response? Whenanimmuneresponseistriggered,inflammationoccursintheareasthatareattackedbytheimmunesystem.
•Inflammationcausesrednessandwarmth,swelling,stiffness, and pain in the affected joints
•Iftheautoimmuneresponseisnotslowedorstopped,itcan permanently damage the affected joints and other tissues over time
Can RA be prevented?Because we do not know why RA happens, there is no known waytopreventthedisease.However, early diagnosis and early treatment are the best ways to fight RA.
•Treatmentisfirstfocusedonreducinginflammationandrelieving pain
•WhenadiagnosisofRAisconfirmed,treatmentalsoaimsatstopping or slowing joint damage and damage to other parts of the body
How can RA be controlled?TherehasbeengreatimprovementinthedrugsusedtotreatRA.
•Aclassofdrugsreferredtoas“DMARDs” acts to slow or stop the progression of RA to more advanced stages of the disease
•Ifyoulookatthegraphabove,youwillseethatwhenaDMARD is not used (the red line), the problems caused by RAincreaserapidly,especiallyinthefirst2years
•However,whentreatedwithDMARDs(theblueline),thedisease progresses much more slowly, and fewer problems occur
•DMARDssuchasmethotrexate,hydroxychloroquine,sulfasalazine,orbiologicDMARDsaremostoftenusedtocontrol RA
I have some pain in my joints. How can I tell if I have RA?•IfyouthinkyoumayhaveRA,youneedtotellyourhealthcare
provider.Heorshewillexamineyouandaskthefollowingquestions:
–Whathurtsasyougetoutofbedinthemorning? – How long does it take to feel as limber as you’re going to
feelfortheday? –Whenisyourpaintheworst(AMorPM)? –DoanymembersofyourfamilyhaveRA? –Isitdifficultforyouto: n Turnfaucethandles? n Holdahairbrush/toothbrush? n Dress/batheindependently? n Fixyourownbreakfast? n Walkoutdoorsonflatground? –Howisyourenergylevel? –Doyousmoke? –Signsthatmaysuggestotherreasonsforyourpain: n Fever n Nightsweats n Unexpected weight loss n Rash, tick exposure n Recent contact with sick children
Youmayalsofilloutthequestionnaireonpanel8B,whichwillhelpidentifythecauseofyourdiscomfort.
what happens next?•IfyourhealthcareproviderthinksyoumayhaveRA,he
or she will prescribe medication to reduce the pain and inflammationinthejoints.Heorshewillalsoreferyoutoarheumatologist,whichisadoctorwhospecializesinRAandrelateddiseases.
•The rheumatologist will confirm the diagnosis of RA and prescribe appropriate medication to slow or stop the autoimmuneprocessandjointdamage.
•Depending on the extent of injury caused by RA, you may be referred to a physical or occupational therapist, a podiatrist, orotherspecialists,suchasanorthopedicsurgeon.
Rheumatoid Arthritis Resources and InformationThe American College of Rheumatology http://www.rheumatology.org/The Arthritis Foundation http://www.arthritis.org/The National Library of Medicine/Medline Plus http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
Healthy joint Damaged joint
Destruction of cartilage
Cutaway view
Joints affected:Jaw
Elbow
Hip
Wrist,hand, fingers
Knee
Ankle, foot, toes
Shoulder
Spine
Other organs that may be affected if RA is not treated early:
Eyes: dryness and damage to delicate structures
Lungs: much greater risk of getting serious infections and other complications
Heart disease: may occurabout10years sooner than in people without RA
Stomach: high risk of bleeding
Double the risk of some types of cancer, so increased screening is advisable
Early diagnosis and treatment may prevent these complications.
Med
ical
Illu
stra
tion
Copy
right
© 2
010
Nucl
eus
Med
ical
Med
ia,
All r
ight
s re
serv
ed. w
ww
.nuc
leus
inc.
com
Are other parts of the body affected besides the joints?
Se
lf-R
ep
ort
Qu
estio
nn
air
e f
or
Rh
eu
ma
toid
Art
hri
tis
Plea
se c
heck
(3)t
heO
NEb
esta
nsw
erfo
ryou
rabi
litie
s.
If w
e as
ked
som
eone
who
spe
nds
a go
od d
eal o
f tim
e w
ith
you,
wou
ld th
ey s
ay th
at y
ou h
ave
diffi
culty
with
:
With
out
any
di
fficu
lty
With
so
me
diffi
culty
With
m
uch
diffi
culty
Unab
le
to d
o
1.D
ress
ing
your
self,
incl
udin
gty
ing
shoe
lace
san
ddo
ing
butto
ns?
2.G
ettin
gin
and
out
ofb
ed?
3.L
iftin
ga
full
cup
org
lass
toy
ourm
outh
?
4.W
alki
ngo
utdo
ors
onfl
atg
roun
d?
5.W
ashi
nga
ndd
ryin
gyo
ure
ntire
bod
y?
6.B
endi
ngd
own
top
ick
upc
loth
ing
from
the
floor
?
7.T
urni
ngre
gula
rfau
cets
(tap
s)o
nan
dof
f?
8.G
ettin
gin
and
out
ofa
car
?
Shar
eyo
ura
nsw
ers
with
you
rprim
ary
care
pro
vider
.
70
60
50
40
30
20
10
00 4321 5
Years of Disease
Dise
ase
Prog
ress
Without DMARDs, problems increase rapidly
With DMARDs, fewer problems
Treatment With Disease-Modifiying Antirheumatic Drugs(DMARDs) Improves Long-Term Outcomes
Immune cell
Target cell
ALSO AVAILABLE
An interactive version of this Rheumatoid Arthritis: Primary care Initiative for improved Diagnosis and outcomes (RAPID) clinician educator is now available as an iPhone app. The enhanced app version includes the following features:
• VideodemonstrationofthesqueezetestandprovisionalRAdiagnosis
• Videodiscussionofpatientpointofviewtowardsprimarycareproviders and the need for early diagnosis
• VideodiscussionofrecommendedvaccinationsforRApatientsand the presence of comorbid conditions
The free iPhone app is available in either of the following ways:
• Downloadtheappat http://www.curatiocme.com/RAPID/iphone
• UsingthecameraonyouriPhone,scantheQRcodebelow
Published in Rheumatology,3rded.GordonDA,HastingsDE.Clinicalfeaturesofrheumatoidarthritis,765-780.CopyrightElsevier2003.
Publ
ishe
d in
Rhe
umat
olog
y,3
rde
d.G
ordo
nDA
,Has
tings
DE.
Clin
ical
feat
ures
ofr
heum
atoi
dar
thrit
is,7
65-7
80.C
opyr
ight
Els
evie
r200
3.
31316 /
334/
31316 / 313
16 / 31316 / 313
16 / 31316 / 313
16 /
332 /
31116 /
614/
3418/
what is rheumatoid arthritis (RA)?•RAisachronicconditionthatdamagesthejointsofthe
body.Chronicconditionsarelonglasting(greaterthan3months)anddonotgoawayeasilyorquickly.RAaffectswomenmorethantwiceasmuchasmen.Althoughitmayoccur at any age, it usually starts in patients when they arebetween30and60yearsold.RAcausescontinuingjointdamageandassociatedconditionsformanypatients.To reduce complications, RA should be diagnosed and treatedearlyandoptimallymanagedthroughoutlife.
what are the symptoms?EarlysignsofRAinclude:•Swelling,stiffness,aching,orpaininoneormorejoints•Morningstiffnessthatlastsforatleast30minutesand
often for several hours•Difficultygraspingobjectsasstronglyasyouusedto
RA commonly affects the small joints of the fingers, wrists, and feet, but it may also affect other joints as the disease progresses, includingtheankles,knees,hips,elbows,andshoulders.
1B 2B 3B 4B 5B 6B 7B 8B
what causes RA?•ItisnotknownwhatcausesRA,butitisanautoimmune
disease.Thismeansthatthebodyattacksitself
•Thebody’simmunesystemfightsoffinfectionscausedbyinvading bacteria and viruses
•InautoimmunediseaseslikeRA,thebodyrespondsasifitsnormal cells are foreign cells and attacks them
•GeneticsmayplayapartinthedevelopmentofRA,butmany people who get RA do not have any relatives with the condition
what happens when RA causes an autoimmune response? Whenanimmuneresponseistriggered,inflammationoccursintheareasthatareattackedbytheimmunesystem.
•Inflammationcausesrednessandwarmth,swelling,stiffness, and pain in the affected joints
•Iftheautoimmuneresponseisnotslowedorstopped,itcan permanently damage the affected joints and other tissues over time
Can RA be prevented?Because we do not know why RA happens, there is no known waytopreventthedisease.However, early diagnosis and early treatment are the best ways to fight RA.
•Treatmentisfirstfocusedonreducinginflammationandrelieving pain
•WhenadiagnosisofRAisconfirmed,treatmentalsoaimsatstopping or slowing joint damage and damage to other parts of the body
How can RA be controlled?TherehasbeengreatimprovementinthedrugsusedtotreatRA.
•Aclassofdrugsreferredtoas“DMARDs” acts to slow or stop the progression of RA to more advanced stages of the disease
•Ifyoulookatthegraphabove,youwillseethatwhenaDMARD is not used (the red line), the problems caused by RAincreaserapidly,especiallyinthefirst2years
•However,whentreatedwithDMARDs(theblueline),thedisease progresses much more slowly, and fewer problems occur
•DMARDssuchasmethotrexate,hydroxychloroquine,sulfasalazine,orbiologicDMARDsaremostoftenusedtocontrol RA
I have some pain in my joints. How can I tell if I have RA?•IfyouthinkyoumayhaveRA,youneedtotellyourhealthcare
provider.Heorshewillexamineyouandaskthefollowingquestions:
–Whathurtsasyougetoutofbedinthemorning? – How long does it take to feel as limber as you’re going to
feelfortheday? –Whenisyourpaintheworst(AMorPM)? –DoanymembersofyourfamilyhaveRA? –Isitdifficultforyouto: n Turnfaucethandles? n Holdahairbrush/toothbrush? n Dress/batheindependently? n Fixyourownbreakfast? n Walkoutdoorsonflatground? –Howisyourenergylevel? –Doyousmoke? –Signsthatmaysuggestotherreasonsforyourpain: n Fever n Nightsweats n Unexpected weight loss n Rash, tick exposure n Recent contact with sick children
Youmayalsofilloutthequestionnaireonpanel8B,whichwillhelpidentifythecauseofyourdiscomfort.
what happens next?•IfyourhealthcareproviderthinksyoumayhaveRA,he
or she will prescribe medication to reduce the pain and inflammationinthejoints.Heorshewillalsoreferyoutoarheumatologist,whichisadoctorwhospecializesinRAandrelateddiseases.
•The rheumatologist will confirm the diagnosis of RA and prescribe appropriate medication to slow or stop the autoimmuneprocessandjointdamage.
•Depending on the extent of injury caused by RA, you may be referred to a physical or occupational therapist, a podiatrist, orotherspecialists,suchasanorthopedicsurgeon.
Rheumatoid Arthritis Resources and InformationThe American College of Rheumatology http://www.rheumatology.org/The Arthritis Foundation http://www.arthritis.org/The National Library of Medicine/Medline Plus http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
Healthy joint Damaged joint
Destruction of cartilage
Cutaway view
Joints affected:Jaw
Elbow
Hip
Wrist,hand, fingers
Knee
Ankle, foot, toes
Shoulder
Spine
Other organs that may be affected if RA is not treated early:
Eyes: dryness and damage to delicate structures
Lungs: much greater risk of getting serious infections and other complications
Heart disease: may occurabout10years sooner than in people without RA
Stomach: high risk of bleeding
Double the risk of some types of cancer, so increased screening is advisable
Early diagnosis and treatment may prevent these complications.
Med
ical
Illu
stra
tion
Copy
right
© 2
010
Nucl
eus
Med
ical
Med
ia,
All r
ight
s re
serv
ed. w
ww
.nuc
leus
inc.
com
Are other parts of the body affected besides the joints?
Se
lf-R
ep
ort
Qu
estio
nn
air
e f
or
Rh
eu
ma
toid
Art
hri
tis
Plea
se c
heck
(3)t
heO
NEb
esta
nsw
erfo
ryou
rabi
litie
s.
If w
e as
ked
som
eone
who
spe
nds
a go
od d
eal o
f tim
e w
ith
you,
wou
ld th
ey s
ay th
at y
ou h
ave
diffi
culty
with
:
With
out
any
di
fficu
lty
With
so
me
diffi
culty
With
m
uch
diffi
culty
Unab
le
to d
o
1.D
ress
ing
your
self,
incl
udin
gty
ing
shoe
lace
san
ddo
ing
butto
ns?
2.G
ettin
gin
and
out
ofb
ed?
3.L
iftin
ga
full
cup
org
lass
toy
ourm
outh
?
4.W
alki
ngo
utdo
ors
onfl
atg
roun
d?
5.W
ashi
nga
ndd
ryin
gyo
ure
ntire
bod
y?
6.B
endi
ngd
own
top
ick
upc
loth
ing
from
the
floor
?
7.T
urni
ngre
gula
rfau
cets
(tap
s)o
nan
dof
f?
8.G
ettin
gin
and
out
ofa
car
?
Shar
eyo
ura
nsw
ers
with
you
rprim
ary
care
pro
vider
.
70
60
50
40
30
20
10
00 4321 5
Years of Disease
Dise
ase
Prog
ress
Without DMARDs, problems increase rapidly
With DMARDs, fewer problems
Treatment With Disease-Modifiying Antirheumatic Drugs(DMARDs) Improves Long-Term Outcomes
Immune cell
Target cell
ALSO AVAILABLE
An interactive version of this Rheumatoid Arthritis: Primary care Initiative for improved Diagnosis and outcomes (RAPID) clinician educator is now available as an iPhone app. The enhanced app version includes the following features:
• VideodemonstrationofthesqueezetestandprovisionalRAdiagnosis
• Videodiscussionofpatientpointofviewtowardsprimarycareproviders and the need for early diagnosis
• VideodiscussionofrecommendedvaccinationsforRApatientsand the presence of comorbid conditions
The free iPhone app is available in either of the following ways:
• Downloadtheappat http://www.curatiocme.com/RAPID/iphone
• UsingthecameraonyouriPhone,scantheQRcodebelow
Published in Rheumatology,3rded.GordonDA,HastingsDE.Clinicalfeaturesofrheumatoidarthritis,765-780.CopyrightElsevier2003.
Publ
ishe
d in
Rhe
umat
olog
y,3
rde
d.G
ordo
nDA
,Has
tings
DE.
Clin
ical
feat
ures
ofr
heum
atoi
dar
thrit
is,7
65-7
80.C
opyr
ight
Els
evie
r200
3.
31316 /
334/
31316 / 313
16 / 31316 / 313
16 / 31316 / 313
16 /
332 /
31116 /
614/
3418/
what is rheumatoid arthritis (RA)?•RAisachronicconditionthatdamagesthejointsofthe
body.Chronicconditionsarelonglasting(greaterthan3months)anddonotgoawayeasilyorquickly.RAaffectswomenmorethantwiceasmuchasmen.Althoughitmayoccur at any age, it usually starts in patients when they arebetween30and60yearsold.RAcausescontinuingjointdamageandassociatedconditionsformanypatients.To reduce complications, RA should be diagnosed and treatedearlyandoptimallymanagedthroughoutlife.
what are the symptoms?EarlysignsofRAinclude:•Swelling,stiffness,aching,orpaininoneormorejoints•Morningstiffnessthatlastsforatleast30minutesand
often for several hours•Difficultygraspingobjectsasstronglyasyouusedto
RA commonly affects the small joints of the fingers, wrists, and feet, but it may also affect other joints as the disease progresses, includingtheankles,knees,hips,elbows,andshoulders.
1B 2B 3B 4B 5B 6B 7B 8B
what causes RA?•ItisnotknownwhatcausesRA,butitisanautoimmune
disease.Thismeansthatthebodyattacksitself
•Thebody’simmunesystemfightsoffinfectionscausedbyinvading bacteria and viruses
•InautoimmunediseaseslikeRA,thebodyrespondsasifitsnormal cells are foreign cells and attacks them
•GeneticsmayplayapartinthedevelopmentofRA,butmany people who get RA do not have any relatives with the condition
what happens when RA causes an autoimmune response? Whenanimmuneresponseistriggered,inflammationoccursintheareasthatareattackedbytheimmunesystem.
•Inflammationcausesrednessandwarmth,swelling,stiffness, and pain in the affected joints
•Iftheautoimmuneresponseisnotslowedorstopped,itcan permanently damage the affected joints and other tissues over time
Can RA be prevented?Because we do not know why RA happens, there is no known waytopreventthedisease.However, early diagnosis and early treatment are the best ways to fight RA.
•Treatmentisfirstfocusedonreducinginflammationandrelieving pain
•WhenadiagnosisofRAisconfirmed,treatmentalsoaimsatstopping or slowing joint damage and damage to other parts of the body
How can RA be controlled?TherehasbeengreatimprovementinthedrugsusedtotreatRA.
•Aclassofdrugsreferredtoas“DMARDs” acts to slow or stop the progression of RA to more advanced stages of the disease
•Ifyoulookatthegraphabove,youwillseethatwhenaDMARD is not used (the red line), the problems caused by RAincreaserapidly,especiallyinthefirst2years
•However,whentreatedwithDMARDs(theblueline),thedisease progresses much more slowly, and fewer problems occur
•DMARDssuchasmethotrexate,hydroxychloroquine,sulfasalazine,orbiologicDMARDsaremostoftenusedtocontrol RA
I have some pain in my joints. How can I tell if I have RA?•IfyouthinkyoumayhaveRA,youneedtotellyourhealthcare
provider.Heorshewillexamineyouandaskthefollowingquestions:
–Whathurtsasyougetoutofbedinthemorning? – How long does it take to feel as limber as you’re going to
feelfortheday? –Whenisyourpaintheworst(AMorPM)? –DoanymembersofyourfamilyhaveRA? –Isitdifficultforyouto: n Turnfaucethandles? n Holdahairbrush/toothbrush? n Dress/batheindependently? n Fixyourownbreakfast? n Walkoutdoorsonflatground? –Howisyourenergylevel? –Doyousmoke? –Signsthatmaysuggestotherreasonsforyourpain: n Fever n Nightsweats n Unexpected weight loss n Rash, tick exposure n Recent contact with sick children
Youmayalsofilloutthequestionnaireonpanel8B,whichwillhelpidentifythecauseofyourdiscomfort.
what happens next?•IfyourhealthcareproviderthinksyoumayhaveRA,he
or she will prescribe medication to reduce the pain and inflammationinthejoints.Heorshewillalsoreferyoutoarheumatologist,whichisadoctorwhospecializesinRAandrelateddiseases.
•The rheumatologist will confirm the diagnosis of RA and prescribe appropriate medication to slow or stop the autoimmuneprocessandjointdamage.
•Depending on the extent of injury caused by RA, you may be referred to a physical or occupational therapist, a podiatrist, orotherspecialists,suchasanorthopedicsurgeon.
Rheumatoid Arthritis Resources and InformationThe American College of Rheumatology http://www.rheumatology.org/The Arthritis Foundation http://www.arthritis.org/The National Library of Medicine/Medline Plus http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
Healthy joint Damaged joint
Destruction of cartilage
Cutaway view
Joints affected:Jaw
Elbow
Hip
Wrist,hand, fingers
Knee
Ankle, foot, toes
Shoulder
Spine
Other organs that may be affected if RA is not treated early:
Eyes: dryness and damage to delicate structures
Lungs: much greater risk of getting serious infections and other complications
Heart disease: may occurabout10years sooner than in people without RA
Stomach: high risk of bleeding
Double the risk of some types of cancer, so increased screening is advisable
Early diagnosis and treatment may prevent these complications.
Med
ical
Illu
stra
tion
Copy
right
© 2
010
Nucl
eus
Med
ical
Med
ia,
All r
ight
s re
serv
ed. w
ww
.nuc
leus
inc.
com
Are other parts of the body affected besides the joints?
Se
lf-R
ep
ort
Qu
estio
nn
air
e f
or
Rh
eu
ma
toid
Art
hri
tis
Plea
se c
heck
(3)t
heO
NEb
esta
nsw
erfo
ryou
rabi
litie
s.
If w
e as
ked
som
eone
who
spe
nds
a go
od d
eal o
f tim
e w
ith
you,
wou
ld th
ey s
ay th
at y
ou h
ave
diffi
culty
with
:
With
out
any
di
fficu
lty
With
so
me
diffi
culty
With
m
uch
diffi
culty
Unab
le
to d
o
1.D
ress
ing
your
self,
incl
udin
gty
ing
shoe
lace
san
ddo
ing
butto
ns?
2.G
ettin
gin
and
out
ofb
ed?
3.L
iftin
ga
full
cup
org
lass
toy
ourm
outh
?
4.W
alki
ngo
utdo
ors
onfl
atg
roun
d?
5.W
ashi
nga
ndd
ryin
gyo
ure
ntire
bod
y?
6.B
endi
ngd
own
top
ick
upc
loth
ing
from
the
floor
?
7.T
urni
ngre
gula
rfau
cets
(tap
s)o
nan
dof
f?
8.G
ettin
gin
and
out
ofa
car
?
Shar
eyo
ura
nsw
ers
with
you
rprim
ary
care
pro
vider
.
70
60
50
40
30
20
10
00 4321 5
Years of Disease
Dise
ase
Prog
ress
Without DMARDs, problems increase rapidly
With DMARDs, fewer problems
Treatment With Disease-Modifiying Antirheumatic Drugs(DMARDs) Improves Long-Term Outcomes
Immune cell
Target cell
ALSO AVAILABLE
An interactive version of this Rheumatoid Arthritis: Primary care Initiative for improved Diagnosis and outcomes (RAPID) clinician educator is now available as an iPhone app. The enhanced app version includes the following features:
• VideodemonstrationofthesqueezetestandprovisionalRAdiagnosis
• Videodiscussionofpatientpointofviewtowardsprimarycareproviders and the need for early diagnosis
• VideodiscussionofrecommendedvaccinationsforRApatientsand the presence of comorbid conditions
The free iPhone app is available in either of the following ways:
• Downloadtheappat http://www.curatiocme.com/RAPID/iphone
• UsingthecameraonyouriPhone,scantheQRcodebelow
Published in Rheumatology,3rded.GordonDA,HastingsDE.Clinicalfeaturesofrheumatoidarthritis,765-780.CopyrightElsevier2003.
Publ
ishe
d in
Rhe
umat
olog
y,3
rde
d.G
ordo
nDA
,Has
tings
DE.
Clin
ical
feat
ures
ofr
heum
atoi
dar
thrit
is,7
65-7
80.C
opyr
ight
Els
evie
r200
3.
31316 /
334/
31316 / 313
16 / 31316 / 313
16 / 31316 / 313
16 /
332 /
31116 /
614/
3418/
what is rheumatoid arthritis (RA)?•RAisachronicconditionthatdamagesthejointsofthe
body.Chronicconditionsarelonglasting(greaterthan3months)anddonotgoawayeasilyorquickly.RAaffectswomenmorethantwiceasmuchasmen.Althoughitmayoccur at any age, it usually starts in patients when they arebetween30and60yearsold.RAcausescontinuingjointdamageandassociatedconditionsformanypatients.To reduce complications, RA should be diagnosed and treatedearlyandoptimallymanagedthroughoutlife.
what are the symptoms?EarlysignsofRAinclude:•Swelling,stiffness,aching,orpaininoneormorejoints•Morningstiffnessthatlastsforatleast30minutesand
often for several hours•Difficultygraspingobjectsasstronglyasyouusedto
RA commonly affects the small joints of the fingers, wrists, and feet, but it may also affect other joints as the disease progresses, includingtheankles,knees,hips,elbows,andshoulders.
1B 2B 3B 4B 5B 6B 7B 8B
what causes RA?•ItisnotknownwhatcausesRA,butitisanautoimmune
disease.Thismeansthatthebodyattacksitself
•Thebody’simmunesystemfightsoffinfectionscausedbyinvading bacteria and viruses
•InautoimmunediseaseslikeRA,thebodyrespondsasifitsnormal cells are foreign cells and attacks them
•GeneticsmayplayapartinthedevelopmentofRA,butmany people who get RA do not have any relatives with the condition
what happens when RA causes an autoimmune response? Whenanimmuneresponseistriggered,inflammationoccursintheareasthatareattackedbytheimmunesystem.
•Inflammationcausesrednessandwarmth,swelling,stiffness, and pain in the affected joints
•Iftheautoimmuneresponseisnotslowedorstopped,itcan permanently damage the affected joints and other tissues over time
Can RA be prevented?Because we do not know why RA happens, there is no known waytopreventthedisease.However, early diagnosis and early treatment are the best ways to fight RA.
•Treatmentisfirstfocusedonreducinginflammationandrelieving pain
•WhenadiagnosisofRAisconfirmed,treatmentalsoaimsatstopping or slowing joint damage and damage to other parts of the body
How can RA be controlled?TherehasbeengreatimprovementinthedrugsusedtotreatRA.
•Aclassofdrugsreferredtoas“DMARDs” acts to slow or stop the progression of RA to more advanced stages of the disease
•Ifyoulookatthegraphabove,youwillseethatwhenaDMARD is not used (the red line), the problems caused by RAincreaserapidly,especiallyinthefirst2years
•However,whentreatedwithDMARDs(theblueline),thedisease progresses much more slowly, and fewer problems occur
•DMARDssuchasmethotrexate,hydroxychloroquine,sulfasalazine,orbiologicDMARDsaremostoftenusedtocontrol RA
I have some pain in my joints. How can I tell if I have RA?•IfyouthinkyoumayhaveRA,youneedtotellyourhealthcare
provider.Heorshewillexamineyouandaskthefollowingquestions:
–Whathurtsasyougetoutofbedinthemorning? – How long does it take to feel as limber as you’re going to
feelfortheday? –Whenisyourpaintheworst(AMorPM)? –DoanymembersofyourfamilyhaveRA? –Isitdifficultforyouto: n Turnfaucethandles? n Holdahairbrush/toothbrush? n Dress/batheindependently? n Fixyourownbreakfast? n Walkoutdoorsonflatground? –Howisyourenergylevel? –Doyousmoke? –Signsthatmaysuggestotherreasonsforyourpain: n Fever n Nightsweats n Unexpected weight loss n Rash, tick exposure n Recent contact with sick children
Youmayalsofilloutthequestionnaireonpanel8B,whichwillhelpidentifythecauseofyourdiscomfort.
what happens next?•IfyourhealthcareproviderthinksyoumayhaveRA,he
or she will prescribe medication to reduce the pain and inflammationinthejoints.Heorshewillalsoreferyoutoarheumatologist,whichisadoctorwhospecializesinRAandrelateddiseases.
•The rheumatologist will confirm the diagnosis of RA and prescribe appropriate medication to slow or stop the autoimmuneprocessandjointdamage.
•Depending on the extent of injury caused by RA, you may be referred to a physical or occupational therapist, a podiatrist, orotherspecialists,suchasanorthopedicsurgeon.
Rheumatoid Arthritis Resources and InformationThe American College of Rheumatology http://www.rheumatology.org/The Arthritis Foundation http://www.arthritis.org/The National Library of Medicine/Medline Plus http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
Healthy joint Damaged joint
Destruction of cartilage
Cutaway view
Joints affected:Jaw
Elbow
Hip
Wrist,hand, fingers
Knee
Ankle, foot, toes
Shoulder
Spine
Other organs that may be affected if RA is not treated early:
Eyes: dryness and damage to delicate structures
Lungs: much greater risk of getting serious infections and other complications
Heart disease: may occurabout10years sooner than in people without RA
Stomach: high risk of bleeding
Double the risk of some types of cancer, so increased screening is advisable
Early diagnosis and treatment may prevent these complications.
Med
ical
Illu
stra
tion
Copy
right
© 2
010
Nucl
eus
Med
ical
Med
ia,
All r
ight
s re
serv
ed. w
ww
.nuc
leus
inc.
com
Are other parts of the body affected besides the joints?S
elf-R
ep
ort
Qu
estio
nn
air
e f
or
Rh
eu
ma
toid
Art
hri
tis
Plea
se c
heck
(3)t
heO
NEb
esta
nsw
erfo
ryou
rabi
litie
s.
If w
e as
ked
som
eone
who
spe
nds
a go
od d
eal o
f tim
e w
ith
you,
wou
ld th
ey s
ay th
at y
ou h
ave
diffi
culty
with
:
With
out
any
di
fficu
lty
With
so
me
diffi
culty
With
m
uch
diffi
culty
Unab
le
to d
o
1.D
ress
ing
your
self,
incl
udin
gty
ing
shoe
lace
san
ddo
ing
butto
ns?
2.G
ettin
gin
and
out
ofb
ed?
3.L
iftin
ga
full
cup
org
lass
toy
ourm
outh
?
4.W
alki
ngo
utdo
ors
onfl
atg
roun
d?
5.W
ashi
nga
ndd
ryin
gyo
ure
ntire
bod
y?
6.B
endi
ngd
own
top
ick
upc
loth
ing
from
the
floor
?
7.T
urni
ngre
gula
rfau
cets
(tap
s)o
nan
dof
f?
8.G
ettin
gin
and
out
ofa
car
?
Shar
eyo
ura
nsw
ers
with
you
rprim
ary
care
pro
vider
.
70
60
50
40
30
20
10
00 4321 5
Years of Disease
Dise
ase
Prog
ress
Without DMARDs, problems increase rapidly
With DMARDs, fewer problems
Treatment With Disease-Modifiying Antirheumatic Drugs(DMARDs) Improves Long-Term Outcomes
Immune cell
Target cell
ALSO AVAILABLE
An interactive version of this Rheumatoid Arthritis: Primary care Initiative for improved Diagnosis and outcomes (RAPID) clinician educator is now available as an iPhone app. The enhanced app version includes the following features:
• VideodemonstrationofthesqueezetestandprovisionalRAdiagnosis
• Videodiscussionofpatientpointofviewtowardsprimarycareproviders and the need for early diagnosis
• VideodiscussionofrecommendedvaccinationsforRApatientsand the presence of comorbid conditions
The free iPhone app is available in either of the following ways:
• Downloadtheappat http://www.curatiocme.com/RAPID/iphone
• UsingthecameraonyouriPhone,scantheQRcodebelow
Published in Rheumatology,3rded.GordonDA,HastingsDE.Clinicalfeaturesofrheumatoidarthritis,765-780.CopyrightElsevier2003.
Publ
ishe
d in
Rhe
umat
olog
y,3
rde
d.G
ordo
nDA
,Has
tings
DE.
Clin
ical
feat
ures
ofr
heum
atoi
dar
thrit
is,7
65-7
80.C
opyr
ight
Els
evie
r200
3.
31316 /
334/
31316 / 313
16 / 31316 / 313
16 / 31316 / 313
16 /
332 /
31116 /
614/
3418/
what is rheumatoid arthritis (RA)?•RAisachronicconditionthatdamagesthejointsofthe
body.Chronicconditionsarelonglasting(greaterthan3months)anddonotgoawayeasilyorquickly.RAaffectswomenmorethantwiceasmuchasmen.Althoughitmayoccur at any age, it usually starts in patients when they arebetween30and60yearsold.RAcausescontinuingjointdamageandassociatedconditionsformanypatients.To reduce complications, RA should be diagnosed and treatedearlyandoptimallymanagedthroughoutlife.
what are the symptoms?EarlysignsofRAinclude:•Swelling,stiffness,aching,orpaininoneormorejoints•Morningstiffnessthatlastsforatleast30minutesand
often for several hours•Difficultygraspingobjectsasstronglyasyouusedto
RA commonly affects the small joints of the fingers, wrists, and feet, but it may also affect other joints as the disease progresses, includingtheankles,knees,hips,elbows,andshoulders.
1B 2B 3B 4B 5B 6B 7B 8B
what causes RA?•ItisnotknownwhatcausesRA,butitisanautoimmune
disease.Thismeansthatthebodyattacksitself
•Thebody’simmunesystemfightsoffinfectionscausedbyinvading bacteria and viruses
•InautoimmunediseaseslikeRA,thebodyrespondsasifitsnormal cells are foreign cells and attacks them
•GeneticsmayplayapartinthedevelopmentofRA,butmany people who get RA do not have any relatives with the condition
what happens when RA causes an autoimmune response? Whenanimmuneresponseistriggered,inflammationoccursintheareasthatareattackedbytheimmunesystem.
•Inflammationcausesrednessandwarmth,swelling,stiffness, and pain in the affected joints
•Iftheautoimmuneresponseisnotslowedorstopped,itcan permanently damage the affected joints and other tissues over time
Can RA be prevented?Because we do not know why RA happens, there is no known waytopreventthedisease.However, early diagnosis and early treatment are the best ways to fight RA.
•Treatmentisfirstfocusedonreducinginflammationandrelieving pain
•WhenadiagnosisofRAisconfirmed,treatmentalsoaimsatstopping or slowing joint damage and damage to other parts of the body
How can RA be controlled?TherehasbeengreatimprovementinthedrugsusedtotreatRA.
•Aclassofdrugsreferredtoas“DMARDs” acts to slow or stop the progression of RA to more advanced stages of the disease
•Ifyoulookatthegraphabove,youwillseethatwhenaDMARD is not used (the red line), the problems caused by RAincreaserapidly,especiallyinthefirst2years
•However,whentreatedwithDMARDs(theblueline),thedisease progresses much more slowly, and fewer problems occur
•DMARDssuchasmethotrexate,hydroxychloroquine,sulfasalazine,orbiologicDMARDsaremostoftenusedtocontrol RA
I have some pain in my joints. How can I tell if I have RA?•IfyouthinkyoumayhaveRA,youneedtotellyourhealthcare
provider.Heorshewillexamineyouandaskthefollowingquestions:
–Whathurtsasyougetoutofbedinthemorning? – How long does it take to feel as limber as you’re going to
feelfortheday? –Whenisyourpaintheworst(AMorPM)? –DoanymembersofyourfamilyhaveRA? –Isitdifficultforyouto: n Turnfaucethandles? n Holdahairbrush/toothbrush? n Dress/batheindependently? n Fixyourownbreakfast? n Walkoutdoorsonflatground? –Howisyourenergylevel? –Doyousmoke? –Signsthatmaysuggestotherreasonsforyourpain: n Fever n Nightsweats n Unexpected weight loss n Rash, tick exposure n Recent contact with sick children
Youmayalsofilloutthequestionnaireonpanel8B,whichwillhelpidentifythecauseofyourdiscomfort.
what happens next?•IfyourhealthcareproviderthinksyoumayhaveRA,he
or she will prescribe medication to reduce the pain and inflammationinthejoints.Heorshewillalsoreferyoutoarheumatologist,whichisadoctorwhospecializesinRAandrelateddiseases.
•The rheumatologist will confirm the diagnosis of RA and prescribe appropriate medication to slow or stop the autoimmuneprocessandjointdamage.
•Depending on the extent of injury caused by RA, you may be referred to a physical or occupational therapist, a podiatrist, orotherspecialists,suchasanorthopedicsurgeon.
Rheumatoid Arthritis Resources and InformationThe American College of Rheumatology http://www.rheumatology.org/The Arthritis Foundation http://www.arthritis.org/The National Library of Medicine/Medline Plus http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
Healthy joint Damaged joint
Destruction of cartilage
Cutaway view
Joints affected:Jaw
Elbow
Hip
Wrist,hand, fingers
Knee
Ankle, foot, toes
Shoulder
Spine
Other organs that may be affected if RA is not treated early:
Eyes: dryness and damage to delicate structures
Lungs: much greater risk of getting serious infections and other complications
Heart disease: may occurabout10years sooner than in people without RA
Stomach: high risk of bleeding
Double the risk of some types of cancer, so increased screening is advisable
Early diagnosis and treatment may prevent these complications.
Med
ical
Illu
stra
tion
Copy
right
© 2
010
Nucl
eus
Med
ical
Med
ia,
All r
ight
s re
serv
ed. w
ww
.nuc
leus
inc.
com
Are other parts of the body affected besides the joints?
Se
lf-R
ep
ort
Qu
estio
nn
air
e f
or
Rh
eu
ma
toid
Art
hri
tis
Plea
se c
heck
(3)t
heO
NEb
esta
nsw
erfo
ryou
rabi
litie
s.
If w
e as
ked
som
eone
who
spe
nds
a go
od d
eal o
f tim
e w
ith
you,
wou
ld th
ey s
ay th
at y
ou h
ave
diffi
culty
with
:
With
out
any
di
fficu
lty
With
so
me
diffi
culty
With
m
uch
diffi
culty
Unab
le
to d
o
1.D
ress
ing
your
self,
incl
udin
gty
ing
shoe
lace
san
ddo
ing
butto
ns?
2.G
ettin
gin
and
out
ofb
ed?
3.L
iftin
ga
full
cup
org
lass
toy
ourm
outh
?
4.W
alki
ngo
utdo
ors
onfl
atg
roun
d?
5.W
ashi
nga
ndd
ryin
gyo
ure
ntire
bod
y?
6.B
endi
ngd
own
top
ick
upc
loth
ing
from
the
floor
?
7.T
urni
ngre
gula
rfau
cets
(tap
s)o
nan
dof
f?
8.G
ettin
gin
and
out
ofa
car
?
Shar
eyo
ura
nsw
ers
with
you
rprim
ary
care
pro
vider
.
70
60
50
40
30
20
10
00 4321 5
Years of Disease
Dise
ase
Prog
ress
Without DMARDs, problems increase rapidly
With DMARDs, fewer problems
Treatment With Disease-Modifiying Antirheumatic Drugs(DMARDs) Improves Long-Term Outcomes
Immune cell
Target cell
ALSO AVAILABLE
An interactive version of this Rheumatoid Arthritis: Primary care Initiative for improved Diagnosis and outcomes (RAPID) clinician educator is now available as an iPhone app. The enhanced app version includes the following features:
• VideodemonstrationofthesqueezetestandprovisionalRAdiagnosis
• Videodiscussionofpatientpointofviewtowardsprimarycareproviders and the need for early diagnosis
• VideodiscussionofrecommendedvaccinationsforRApatientsand the presence of comorbid conditions
The free iPhone app is available in either of the following ways:
• Downloadtheappat http://www.curatiocme.com/RAPID/iphone
• UsingthecameraonyouriPhone,scantheQRcodebelow
Published in Rheumatology,3rded.GordonDA,HastingsDE.Clinicalfeaturesofrheumatoidarthritis,765-780.CopyrightElsevier2003.
Publ
ishe
d in
Rhe
umat
olog
y,3
rde
d.G
ordo
nDA
,Has
tings
DE.
Clin
ical
feat
ures
ofr
heum
atoi
dar
thrit
is,7
65-7
80.C
opyr
ight
Els
evie
r200
3.