Evidence-Informed Best Practice RA and OA Dr. Diane Lacaille

2 Describe the rationale for key recommendations for best practice care for Rheumatoid Arthritis and Osteoarthritis according to the BC Guidelines. Objectives

NECESSARY SAFE EFFECTIVE Early Treatment of RA with DMARDs

4 EARLY Treatment of RA with DMARDs EARLY DIAGNOSIS AND TREATMENT OF RA AGGRESSIVE USE OF DMARDS ALTERS THE COURSE OF RA REMISSION IS THE NEW TARGET OF RA TREATMENT LONG TERM USE OF DMARDS YES, DMARDS ARE SAFE WHEN MONITORED REGULARLY This is the new standard of care. EARLYEARLY

5 If not controlled, RA inflammation leads to:  joint damage and joint deformities  progressive loss of physical function  work disability (32-50% after 10 years of RA)  premature mortality, mainly from cardiovascular disease (50% increase in risk of death from CVD) All these outcomes are preventable. RA is Not a Benign Disease

6 Persistent Joint Swelling Leads to Joint Damage & Deformities =>

7 Early Diagnosis & Treatment of RA Early diagnosis Recognizing signs of inflammation – clues pointing to RA  Early morning stiffness > 30 minutes  Worse pain in the morning and post immobility  Swelling of small joints  Pain or tenderness on squeezing the MTP s, MCP s or wrists  Symmetrical involvement  Systemic symptoms, such as fatigue Ruling out other diagnosis  Septic arthritis, especially if monoarthritis  Crystal arthritis, such as gout or pseudogout  Joint aspiration for acute monoarthritis to R/O infection or when crystal arthritis is suspected  Transient inflammatory arthritis, i.e. viral lasts 6 weeks or less EARLYEARLY

8 Early treatment of RA Capture the window of opportunity  Early treatment with DMARD s alters the disease course.  Joint damage occurs early (within months) and is irreversible.  RA is more responsive to treatment early on.  Early treatment increases the chances of remission. New onset RA requires urgent care  DMARD s should be started within 2 months of symptoms.  Referral to a rheumatologist for new onset RA should be seen within 4 weeks. State ‘new onset of RA ’ on referral.  Rheumatologists prefer early referrals. EARLYEARLY Early Diagnosis & Treatment of RA

9 Aggressive use of DMARD s Alters the course of RA What are DMARDs?  Disease Modifying Anti-Rheumatic Drugs  They improve symptoms and prevent joint damage.  Methotrexate, Sulfasalazine, Hydroxychloroquine, Gold, Cyclosporine, Leflunomide and biologic agents. Think RA, think DMARDs  All RA patients with active inflammation should be on a DMARD. NSAIDs and prednisone are not enough  NSAIDs improve symptoms but fail to prevent joint damage.  Prednisone should not be used alone because of long term toxicities EARLYEARLY

10  DMARDs alter the course of RA by: Preventing joint damage and deformities Reducing physical and work disability Preventing premature mortality  Aggressive use of DMARDs means: Starting DMARDs early Using DMARDs continuously, often in combination Evaluating response every 1 to 3 months Modifying DMARD therapy until the target is reached Aiming to eradicate inflammation Aggressive Use of DMARD s Alters the Course of RA EARLYEARLY

11 The goal of RA treatment is no longer to simply control symptoms, but to eradicate inflammation. The target of DMARD therapy is no signs of active inflammation i.e., No swollen joints Normal ESR or CRP Little to no radiographic progression Although remission is the target, minimal disease activity may be an acceptable alternative, when remission is not possible, especially in established long-standing disease, or when co-morbidities or other patient factors limit DMARD options. EARLYEARLY Remission is the new target of RA treatment

12  DMARDs should be used continuously, throughout the disease.  When sustained remission is achieved, DMARDs may be slowly decreased to find a lower dose that maintains remission.  DMARD discontinuation is not recommended because of high risk of flare off DMARDs.  All RA requires DMARD, the earlier the better, but even late RA requires DMARDs to reduce further damage. Long-term use of DMARD s EARLYEARLY

13 RisksBenefits reduce mortality reduce disability prevent deformity improve symptoms cost toxicity Benefits of early DMARD s outweigh their risks Yes DMARDs are safe when monitored regularly EARLYEARLY

14  Family physicians play a critical role in early diagnosis and treatment of RA.  DMARDs should be prescribed in all RA patients and should be started early. EARLY is the new standard of care

15 NSAIDS DMARDs Treatment of RA the standard of care has changed

16 Guidelines and Protocols Advisory Committee. Rheumatoid Arthritis: Diagnosis and Management. British Columbia Medical Association American College of Rheumatology Ad Hoc Committees on Clinical Guidelines. Guidelines for the management of rheumatoid arthritis. Arthritis Rheum.1996,39: American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 Update. Arthritis Rheum 2002;46: Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum 2008;59: Bykerk V, replace with 2010 CRA RA guidelines Smolen JS, Aletaha D, Bijlsma JW, et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis 2010;69:631–637 Recommendations are based on the following references:

Osteoarthritis

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

19 Joint Distribution Black= joints most commonly affected Grey= joints often affected White= joints usually not affected

20  Septic arthritis (acute monoarthritis requires joint aspiration)  Crystal arthritis: gout, pseudogout (CPPD) (joint aspiration)  Inflammatory arthritis: esp. psoriatic arthritis  Non-articular : e.g. bursitis (trochanteric, pes anserine), tendonitis (shoulder, elbow)  Bone pain (multiple myeloma, metastasis)  Soft tissue pain syndromes  Referred pain Other Diagnoses to Exclude

21  X Rays › Provide clinical information › Can be normal in early OA › Often don’t correlate with degree of pain › Knee Xrays must be ordered weight bearing (PA, lat, skyline) › Hip (OA hip series: incl. lateral view and upper 1/3 femur)  Absence of inflammatory markers (CBC, CRP normal)  Labs can be useful to rule out other conditions (e.g. thyroid disease) or to assess for comorbidities prior to Rx (e.g. Cr, LFT) Investigations

22  Severity of pain (with activity, at rest, interferes with sleep)  Impact on function (ADLs, IADLs)  Impact on participation (work, family obligations, social activities, leisure)  Impact on independence  Psychosocial issues (pain amplification, coping strategies, depression, adherence to treatment, social support) Management - Considerations

23  Patient education  Self-management (pain, limited physical function, stress, exercise, coping, pacing)  Weight management – support, dietician  Exercise  Physiotherapy: prescribe specific therapeutic exercise program  Walking aids  Occupational therapy: Orthotics, footwear, braces, ADL aids, ergonomic modifications at work Management – Non pharmacological

24  Acetaminophen: › regular schedule vs. prn › up to 4 gm/day, less if liver disease  NSAIDs: › Gastroprotection if high GI risk › Consider cardiovascular risk factors › Topical NSAIDs  Glucosamine and chondroitin sulfate: › Not recommended, insufficient evidence of efficacy  Intra-articular steroids  Hyaluronic acid – limited benefit, can cause inflammatory reaction Management - Pharmacological

25  Failure of conservative management (trial acetaminophen, NSAIDs, intraarticular injection steroids, physiotherapy, regular exercise program)  Inadequate pain control (pain at rest, significant pain with walking, pain interfering with sleep, incr. need for narcotics)  Impact on function (limited ADLs, limitations in meaningful activities – work, family, leisure)  Threat to independence  Significant deformities (e.g. FD, valgus knees, loss IR hip, LLD)  Xray flags: acetabular protrusion, femoral head collapse, progressive bone loss, Management – Indications for Surgery

26 Summary