Understanding Rheumatoid Arthritis Randall J. Reed, MD Friday, November 13, :00 a.m. EST

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Understanding Rheumatoid Arthritis Randall J. Reed, MD Rheumatology Associates, PC Indianapolis, Indiana

Arthritis 66 million people with arthritis in America 2 nd only to heart disease in disability Costs US $86.2 billion More common in women than men Limits everyday activities for 7 million Americans

Types of Arthritis Over 100 different types of arthritis Osteoarthritis Rheumatoid Arthritis Gout Psoriatic Arthritis Systemic Lupus Erythematosus Septic Arthritis Lyme Disease Ankylosing Spondylitis CPPD Deposition Disease Temporal Arteritis/Polymyalgia Rheumatica

Rheumatoid Arthritis (RA) Around 2 million people in the US More common in women than men Can occur at any age, onset usually in 3 rd to 5 th decades of life Chronic, inflammatory disease that primarily involves joints Rheumatoid arthritis can also affect the skin, saliva glands, eyes, lungs, and heart

Inflammatory versus degenerative arthritis

What’s happening in RA? Immune system attacks proteins in joints Thickening of synovium Influx of immune cells into joint

Why do people get RA? Genetic predisposition – Family History – Certain Ethnic populations – Genetic marker HLA-DR4 Environmental exposures? – Viruses – Bacteria – Food allergies? Role of Hormones Immune System

Symptoms of RA Pain and swelling of joints, usually symmetrical pattern Morning stiffness lasting longer than 1 hour Nodules underneath the skin Joint deformity Non-joint symptoms

Joint Swelling

Joint Deformity

Nodules of RA

How is RA diagnosed? Clinical History and Exam Blood tests – Rheumatoid Factor – Anti-CCP antibody X-rays MRI

X-ray image

MRI Image of RA From Bocaradiology.com

What should I expect with RA? A chronic illness, only 5-10% remission rate Untreated, 90-95% of patients will have bone damage, usually within first 2 years 5-10% of RA patients become disabled every year (old data) Associated with increased risk of infections, heart disease, and lymphoma

What’s the good news?! Advancements in diagnosis – CCP antibody – MRI and Ultrasound Better treatments! Advancing Research – Stem cell – Genetic based therapies – Individualized therapies

Goals of therapy for RA Reduce joint pain and swelling Improve Function Prevent erosions and joint deformity Minimize risk of adverse events from medications

How is RA treated Most patients will require a “disease modifying anti-rheumatic drug”, or DMARD Corticosteroids, i.e. prednisone Non-steroidal anti-inflammatory drugs (NSAIDS) / COX-2 inhibitors Joint injections Biological Response Modifiers

Disease Modifying Anti- Rheumatic Drugs (DMARDS) Methotrexate (Trexall) Sulfasalazine (Azulfidine) Hydroxychloroquine (Plaquenil) Leuflonomide (Arava) Azathioprine (Imuran) Cyclosporine (Neoral) Minocycline (Minocin) Gold (Auranofin) First Line Therapy Second Line Therapy

Biological therapy Biologics - drugs derived from living organisms that are designed to either inhibit or supplement a specific component of the immune system

Biologic Response Modifiers Tumor necrosis factor Inhibitors- “Anti-TNF therapy” – Humira (Adalimumab) – Enbrel (Etanercept) – Remicade (Infliximab) – Cimzia (certolizumab pegol) – Simponi (golimumab) Kineret (Anikinra) Orencia (Abatacept) Rituxan (Rituximab) Actemra (tocilizumab)

Abbvie Study Figure 1: ACR 20 Responses over 52 Weeks

Anti-TNF medicines have revolutionized treatment for RA "The PREMIER data are encouraging because they suggest that early and aggressive treatment may slow or inhibit patients' joint damage," said Ferdinand Breedveld, M.D., professor, Department of Rheumatology, University of Leiden, Leiden, Netherlands –from Arthritis News June 9 th 2005.

Risks of therapy All treatments will carry some risk! Not treating RA also carries a risk Ask doctor about increased risk of infection, potential liver toxicity, stomach upset, interactions with other medicines; recent press about increased cancer risk Many of the medications require chronic laboratory monitoring

Diet and Arthritis Weight loss Anti-oxidants? Vitamin C Supplements

Exercise and arthritis Water Aerobics Walking Physical Therapy Yoga

Surgery for RA

Summary Rheumatoid arthritis is a chronic inflammatory disease that affects joints in a symmetrical pattern; usually hands, wrists and feet become involved Left untreated, RA typically leads to joint damage and disability Medical treatment for RA can halt disease progression and has improved quality of life for patients