living with rheumatoid arthritis
TRANSCRIPT
Living with Rheumatoid Arthritis
Presented by:
Lauren Kennish, MD
Rheumatologist
May 6, 2015
Lecture Outline
• What is Rheumatoid Arthritis (RA)?• How is it diagnosed?• What are the symptoms of RA? • What are the treatment options?• How do we live well with RA?• What is new on the horizon?
What is Rheumatoid Arthritis?• RA is an autoimmune disease• Autoimmune disease:
Immune system incorrectly targets your own tissues and organs
Antibodies form and attack cells
Inflammation/Swelling
Damage/Disease
What is Rheumatoid Arthritis?• Type of inflammatory arthritis = pain,
swelling and stiffness in the joints• Systemic – can affect whole body• Chronic condition• Can damage cartilage,
bone
• Mild Severe
Arthritis.org, 12/2013
flare relapse
remission
What is RA?
• Prevalence: 0.5-1% population, about 1.5 million
• Diagnosis age: Average
30-60 years old
• Females (3x) > Males Helmick et al. A&R, 2008.
What Causes RA?
• Largely unknown• Theories:
Genetics +
Environment• Possible Triggers
Infection• Gut/Gum bacteria
Smoking Obesity Stress Female hormones
How is RA Diagnosed?
• History, Symptoms, Exam
• Blood tests Rheumatoid factor, anti-CCP, anti-MCV Inflammatory markers – ESR, CRP
Medscape.com
How is RA Diagnosed?
• Imaging Xray MRI Ultrasound
Copyright ACR, 2013
What are the Symptoms of RA?
• Joint pain and swelling Small joints, symmetric
• Morning stiffness > 1 hour
• Difficulty with activities
Copyright ACR, 12/2013
Arthritis.org, 12/2013
What are the Symptoms of RA?
• Joint Damage
Copyright ACR, 12/2013
What are the Symptoms of RA?
• Fatigue
• Anemia
• Skin nodules
• Inflammation – Eyes Blood vessels Lungs Heart
Copyright ACR, 12/2013
Associated Autoimmune Diseases
• Sjogren’s Syndrome
• Hashimoto’s Thyroiditis (Hypothyroidism)
Webmd.com
Associated Conditions• Osteoarthritis
• FibromyalgiaWebmd.com, 2013Copyright ACR, 2013
Associated Conditions• Osteoporosis
• Heart Disease Atherosclerosis -> high cholesterol, heart attack
• Increased risk of: Infections Cancer
Related Types of Arthritis
• Spondyloarthritis Psoriatic Arthritis Ankylosing Spondylitis Reactive Arthritis
Copyright ACR, 2013
How is RA Treated?
• There is no cure yet
• BUT…
• Many treatment options to decrease symptoms and associated conditions
• Can lead active, healthy lives
How is RA Treated?• Goal:
Reduce symptoms Maintain remission Prevent flares, complications Prevent joint damage, disability Maintain quality of life
• Treatment is tailored to individual Based on symptoms, concurrent conditions, lifestyle Treatment is usually continuous Combination of medication and non-medical therapy
• EARLY treatment is KEY
How is RA Treated?
• Use: Temporary relief of pain and stiffness
• Mechanism: Anti-inflammatory
• Side effects: Stomach ulcers, kidney/liver problems, high blood
pressure, heart disease
NSAIDs: Non-Steroidal Anti-Inflammatory Drugs
How is RA Treated?
• Suppresses immune system cells from forming and making antibodies to tissues
• Modifies disease• Oral, Injection• Requires close
monitoring
Immunosuppressive Therapy
How is RA Treated?
• Use: Joint pain and swelling
• Mechanism: Anti-inflammatory, Immune suppressing
• Potential side effects: Weight gain, mood change, infections, diabetes, high
blood pressure, osteoporosis, cataracts
Steroids / Prednisone
How is RA Treated?
• Widely used, first-line medications
• Methotrexate• Leflunomide (Arava)• Sulfasalazine• Hydroxychloroquine (Plaquenil)
Disease Modifying Anti-Rheumatic Drugs
How is RA Treated?
• Use: Joint pain Swelling, Stiffness Reduce risk of progression and joint damage Prevent flares
• Mechanism: Immune suppressing, Disease modifying
• Potential side effects: Stomach upset, infection, hair loss, oral ulcers, rash, low
blood counts, inflammation of liver or lungs, vision problems
DMARDs
How is RA Treated?
• Use: Joint pain, swelling, stiffness Reduces risk of progression and joint damage Prevents flares
• Mechanism: Specifically targets molecules of the immune system, Immunesuppressing
• Potential side effects: Infection, rash, allergy, low blood counts, heart failure,
neurologic condition, skin cancer
Biologics
How is RA Treated?
• TNF inhibitors: Etanercept (Enbrel) Adalimumab (Humira) Infliximab (Remicade) Certolizumab (Cimzia) Golimumab (Simponi)
• Abatacept (Orencia)• Tocilizumab (Actemra)• Rituximab (Rituxan)• Anakinra (Kineret)
Biologics
Nature.com, 2013
How is RA Treated?
• Arthrocentesis = joint injections Steroids Hyaluronic Acid
• Surgery: Joint replacement Joint fusion Tendon repair
Interventional Treatment
How is RA Treated?
• Exercise Low-moderate activities Stretching, strengthening Yoga, Pilates, Tai Chi
• Physical Therapy
• Bracing
• Acupuncture
Additional Treatment
How to Live Well with RA?
• How to: Maintain control of disease to prevent flares Avoid complications and associated risks Cope with the disease Feel healthy
• To lead an active, high-quality life
How to Live Well with RA?
Follow-up with Rheumatologist Regularly: • 2-6 months for monitoring• Even if feeling well• Recognize symptoms of flares• Get treated early• Take medications consistently
Follow-up with Your Doctors:• Follow regularly for preventative care
Internist/Primary care• Follow with Specialists
Ophthalmologist, Orthopedist, Cardiologist• Planned surgery
Best when low activity
How to Live Well with RA?
How to Live Well with RA?
Reduce Risk of Infections:• Increased risk of infection• Up to date with vaccines
Influenza, Pneumonia, Shingles• Wash hands frequently• Stay away from people who are sick• Get evaluated sooner rather than later
How to Live Well with RA?
Healthy Lifestyle and Selfcare:• Exercise • Don’t smoke
• Heat/Cold therapy• Topical therapies• Modify activities
How to Live Well with RA?Healthy Lifestyle:• Manage fatigue
Get enough sleep Rest during the day Plan your time effectively Medications Exercise
• Treat depression Reduce stress Social support Positive attitude Arthritis.org.
How to Live Well with RA?
Healthy Lifestyle:• Healthy well balanced diet• Mediterranean diet• Weight loss • Calcium, Vitamin D• Omega-3 fatty acids• ? Avoid certain foods• Alternative treatments/supplements –
not well studied
How to Live Well with RA?
Planned Pregnancy:• Ideally when in remission• Many medications have to be stopped
before pregnancy• Higher risk of preterm birth • Usually symptoms improve during
pregnancy
What’s New with RA?• Tofacitinib (Xeljanz) – JAK inhibitor
Use: Similar to biologics in effectiveness and side effects
Mechanism:• Oral disease modifying medication• Targets inflammation signaling
pathway
• Biosimilars• Blood tests
14-3-3 ETA test for early diagnosis Vectra-DA test for RA activity
Nature.com
cell
What’s New with RA?
• 65+ new medications in development for RA!
http://www.ahdbonline.com/issues/2014
• Barcitinib – JAK1/2 inhibitor – Phase IIb trial
• Decernotinib – JAK 3 inhibitor – Phase II trial
• Mavrilimumab – anti-GM-CSF receptor – Phase II trial
• Sarilumab – Il-6 inhibitor – Phase III
• Secukinumab – Il-17 inhibitor – Phase III
What’s New with RA?
• Ongoing research: Why RA develops Biomarkers to better diagnose and predict
response to medication Curative treatments
What’s New at SMG?
• Best Practices in Managing Patients with Rheumatoid Arthritis Learning Collaborative
American Medical Group Foundation Advance the care of those with rheumatoid
arthritis for better diagnosis, treatment and monitoring
For More Information
• Arthritis Foundation www.arthritis.org
• National Institute of Arthritis and Musculoskeletal and Skin Diseases
www.niams.nih.gov
• American College of Rheumatology www.rheumatology.org
• Patient Perspectives
• Questions?
Thank you!
Lauren Kennish, MD
Summit Medical Group
Rheumatology
908-277-8640
www.summitmedicalgroup.com
Facebook/SummitMedicalNJ
Twitter: @SummitMedicalNJ