1. Evidence-Informed Best Practices Rheumatoid Arthritis
Osteoarthritis
Dr. Diane Lacaille

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

3. Rationale for recommendations in guidelines
Rheumatoid Arthritis
Early diagnosis and early treatment with DMARDs
Prevention of joint damage
Management of co-morbidities
Monitoring of disease activity
Osteoarthritis
Reduction of pain
Improvement of function
Optimization of conservative care
Appropriate and timely referral for surgical intervention

5. 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.

6. RA is Not a Benign Disease
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.

7. Persistent Joint Swelling Leads to Joint Damage & Deformities
=>
If left untreated, swelling that persists over time leads to joint deformities

8. Early Diagnosis & Treatment of RA
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 MTPs, MCPs 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 (viral) < 6 weeks
Other inflammatory arthritis, also Rx with DMARDs E AR L Y

9. E AR L Y Early Diagnosis & Treatment of RA Early treatment of RA
Capture the window of opportunity
Early treatment with DMARDs 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
DMARDs 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.

10. Aggressive use of DMARDs Alters the course of RAY
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

11. Role of steroids in RA
Minimize steroids dose and duration, because of long term risks, esp. cardiovascular diseases
Oral steroids do have a role:
Small doses (< 10 mg daily), over short periods
Bridging therapy, while waiting for DMARDs
Early on at time of RA onset, but avoid prior to rheumatologist referral for diagnosis bcse masks signs.
To control flare-ups
Intramuscular (40 mg depomedrol) and intra- articular are good alternatives to oral.
If steroids are needed to control disease, then DMARDs need to be adjusted

12. E AR L Y Aggressive Use of DMARDs Alters the Course of RA
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

13. E AR L Y Remission is the new target of RA treatment
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.

14. E AR L Y Long-term use of DMARDs
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.

15. E AR L Y Yes DMARDs are safe when monitored regularly
Risks
Benefits
reduce mortality
reduce disability
prevent deformity
improve symptoms
cost
toxicity
Benefits of early DMARDs outweigh their risks

17. EARLY is the new standard of care
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.

18. Treatment of RA the standard of care has changed
DMARDs
NSAIDS

19. Management of Established RA
Objective:
Suppress inflammation, prevent joint damage
Task
Family Doctor
Rheumatologist
Monitor
Q 2-6 months
Q 6-12 months
Assess disease activity
(Joint Count + Blood Work)
Review Meds, S/E Adherence/ Dosage
Refer to PT/OT
Review/adjust meds
Rating of Disease Activity for decision-making
Assess Joint Damage
Pain Relief
Refer PT/OT, surgery
same
Review for Co-morbidities
Screen and Treat
Reinforce monitoring process
Use of Dosage charts
Patient may have combined active inflammation and joint damage

20. Consider chronic disease implications Comorbidities
Dealing with Chronic Pain
Psychosocial Issues
Increased infection risk
Immunizations
Osteoporosis
Cardiovascular Disease
Smoking Cessation
Weight Management

21. Osteoarthritis

22. Osteoarthritis (OA) 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, 1st CMC, 1st MTP.
Bony enlargement, crepitus, malalignement
If joint swelling, synovial fluid non-inflammatory, no crystals.

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

24. Other Diagnoses to Exclude
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

25. Investigations 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)

26. Management - Considerations
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)

27. Patient Education (OA and RA)
Guidelines
Patient Support
Family Support
Community Support
Patient Self Management (coping with pain and other arthritis symptoms, stress, lifestyle changes e.g. exercise).
Arthritis Self Management Program (ASMP) and CDSMP.

28. Management – Non pharmacological
Patient education
Self-management
Weight management – support, dietician
Exercise (ROM, strengthening, aerobic)
Physiotherapy: prescribe specific therapeutic exercise program
Walking aids
Occupational therapy: Orthotics, footwear, braces, splints, ADL aids, ergonomic modifications at work

29. Management - Pharmacological
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

31. Summary Differentiating inflammatory from non-inflammatory arthritis
Importance of early diagnosis and DMARD treatment in RA
Monitoring of disease activity to achieve treatment target
Goal of preventing joint damage, consequences of inflammation
Management of pain, improvement of function in OA
Weight management, exercise and rehab in OA
Multidisciplinary care of arthritis
Appropriate and timely referral for surgery
Management of co-morbidities, esp. cardiovascular diseases
Need for shared approach to care
Importance of patient education and self-management