1. Rheumatology Update 2008 R.W.Jackson,D.O.,F.A.C.O.I. Kirksville, MO. rheumdr@hotmail.com

2. Rheumatology Three Major Risks >Heart Heart< >Head Head< >Bugs Bugs< These represent the major Causes of death & lawsuits

3. ‘HEART’ Rheumatology patients have a major increase risk in CAD due more to ‘inflammation’ then atherosclerosis Rheumatology patients have a major increase risk in CAD due more to ‘inflammation’ then atherosclerosis Dr. Sherine Gabriel ACR Winter Conf. Rheum pts. Have 2 X greater risk for CHF Rheum pts. Have 2 X greater risk for CHF Anti-TNF therapy contra-indicated in patients who have advanced CHF Anti-TNF therapy contra-indicated in patients who have advanced CHF Rheum pts. Have 10yrs reduced life-span Rheum pts. Have 10yrs reduced life-span

4. ‘HEART’ Aggressively evaluate patients with CP, SOB, atypical CP & Pre-op. presentations Aggressively evaluate patients with CP, SOB, atypical CP & Pre-op. presentations Stress to Cardiology consultants the need for added attention to Rheum pts. Stress to Cardiology consultants the need for added attention to Rheum pts. Control the ‘inflammation’ with goals to normalize the ESR (sed rate) and CRP Control the ‘inflammation’ with goals to normalize the ESR (sed rate) and CRP (C-reactive protein) (C-reactive protein)

5. ‘HEAD’ SLE, Temporary arteritis, Sjogrens, and Vasculopathies all associated with CNS ds. SLE, Temporary arteritis, Sjogrens, and Vasculopathies all associated with CNS ds. CNS vasculopathies very difficult to dx. CNS vasculopathies very difficult to dx. Rheum diseases can result in CVA sx, MS, seizures, dementia and neuropathies. Rheum diseases can result in CVA sx, MS, seizures, dementia and neuropathies. Rheum diseases are potentially preventable and quiet treatable causes of these conditions. Rheum diseases are potentially preventable and quiet treatable causes of these conditions.

6. ‘BUGS’ Rheumatology patients are inherently prone to ‘infections’. (Pneumonia is the number cause of death in RA patients) Rheumatology patients are inherently prone to ‘infections’. (Pneumonia is the number cause of death in RA patients) Therapy with prednisone and immunosuppressive agents obviously increase this risk. By as much as 2X! Therapy with prednisone and immunosuppressive agents obviously increase this risk. By as much as 2X! Treat all patients with autoimmune diseases as ‘high risk’ Treat all patients with autoimmune diseases as ‘high risk’

7. ‘BUDS’ Any fever in Rheum patients is significant and treat a temp of 100F = 104F Any fever in Rheum patients is significant and treat a temp of 100F = 104F Start antimicrobial therapy earlier and more aggressively Start antimicrobial therapy earlier and more aggressively Withhold DMARDs (ie. MTX and Biologics) during the treatment if infections Withhold DMARDs (ie. MTX and Biologics) during the treatment if infections IMMUNIZE!!!! (avoid attenuated live virus vaccinations in patients on Biologics!) IMMUNIZE!!!! (avoid attenuated live virus vaccinations in patients on Biologics!)

8. Osteoarthritis Update ‘SINGLE” injection viscosupplementation ‘SINGLE” injection viscosupplementation Oral hyaluronates (Membrell NEM) Oral hyaluronates (Membrell NEM) Glucosamine/chondroitin sulfate helpful Glucosamine/chondroitin sulfate helpful Traditional NSAIDs causing ‘havoc’ the only UGI protection is from PPIs & misoprotol Traditional NSAIDs causing ‘havoc’ the only UGI protection is from PPIs & misoprotol Topical ketoprofen now available Topical ketoprofen now available

9. Rheumatoid Arthritis Update Anti-TNF + MTX ‘best hope’ of DMARDs Anti-TNF + MTX ‘best hope’ of DMARDs Certolizumab (Cimzia) fully human monoclonal antibody; Golimumab (SQ monthly);Ocrelizumab & Atumumab deplete B-cells Certolizumab (Cimzia) fully human monoclonal antibody; Golimumab (SQ monthly);Ocrelizumab & Atumumab deplete B-cells Orencia (abataxcept) – AG presenting process Orencia (abataxcept) – AG presenting process Rituxan (rituximab: anti CD-20 B-cells) Rituxan (rituximab: anti CD-20 B-cells) IL-6 inhibitor tocilizumab (Actemra) IL-6 inhibitor tocilizumab (Actemra) Kenerit (IL-1 ihibitor) remains disappointing Kenerit (IL-1 ihibitor) remains disappointing

10. Fibromyalgia Update Lyrica (pregabalin) first FDA approved medication for fibromyalgia (FM) Lyrica (pregabalin) first FDA approved medication for fibromyalgia (FM) Cymbalta (duloxetine) soon to be approved for FM Cymbalta (duloxetine) soon to be approved for FM Mirapex (pramipexole) has showen new promise in the treatment of FM Mirapex (pramipexole) has showen new promise in the treatment of FM

11. Systemic Lupus Erythematosus Update Biologics now show promise in the treatment of Lupus nephritis with both rituxan and atacicept Biologics now show promise in the treatment of Lupus nephritis with both rituxan and atacicept Lower dose cyclosporine (European minipulse) 500mg/2 weeks x 12weeks; instead of USA 1g/m2 per month for 6 to 12 months.(*) Lower dose cyclosporine (European minipulse) 500mg/2 weeks x 12weeks; instead of USA 1g/m2 per month for 6 to 12 months.(*) CellCept (mycophenolate) now less exciting for SLE nephritis in Caucasians (*) CellCept (mycophenolate) now less exciting for SLE nephritis in Caucasians (*) Dr. David Wofsy reports at ACR Winter Conf.

12. GOUT Update Febuxostat (Adenuric/Puricase) first new medication in 40 years (1964) for gout! Febuxostat (Adenuric/Puricase) first new medication in 40 years (1964) for gout! -more twice as effective than allopurinol -less adverse side-effects than allopurinol -useful in patients with advance renal ds. New goal : reduce the uric acid <4.5mg% New goal : reduce the uric acid <4.5mg%

13. Scleroderma with Pulmonary Artery Hypertension (PAH) Update PAH now treatable! (Past Mortalities <2yr) PAH now treatable! (Past Mortalities <2yr)-epoprostenol-bosentan -inhaled treprostinil -tadafil Very expensive & requires Sub-specialists

14. Juvenile Ideopathic Arthritis Update JIR ‘New title’ for Juvenile Rheumatoid Arthritis JIR ‘New title’ for Juvenile Rheumatoid Arthritis JIR probably represents 5 different conditions JIR probably represents 5 different conditions More common overlap of RA/SLE/Spondylitis features More common overlap of RA/SLE/Spondylitis features Arthralgias during the daytime not “growing pains” Arthralgias during the daytime not “growing pains” Don’t forget about Rheumatic Fever Don’t forget about Rheumatic Fever

15. Osteoporosis Update “Best Calcium” > Membrell Eggshell Calcium for Bone Health – 3 caps/day “Best Calcium” > Membrell Eggshell Calcium for Bone Health – 3 caps/day “Best Vitamin D” 25-hydroxyvitamin (D3) Maxium D3 10000 iu / week “Best Vitamin D” 25-hydroxyvitamin (D3) Maxium D3 10000 iu / week Vit D3 treatment goal >40ng/ml Vit D3 treatment goal >40ng/ml New FDA guidelines will increase Vit D suggested supplementation to 1000iu/d New FDA guidelines will increase Vit D suggested supplementation to 1000iu/d

16. Questions? Comments. Thank you! R.W.Jackson,D.O.,F.A.C.O.I. Kirksville, MO rheumdr@hotmail.com