1. Understanding Rheumatoid Arthritis Randall J. Reed, MD Friday, November 13, 2015 11:00 a.m. EST

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6. AgrAbility: USDA-sponsored program that assists farmers, ranchers, and other agricultural workers with disabilities. – Partners land grant universities with disability services organizations. Currently 20 state projects – National AgrAbility Project: Led by Purdue’s Breaking New Ground Resource Center. Partners include: Goodwill of the Finger Lakes The Arthritis Foundation, Heartland Region University of Illinois at Urbana-Champaign Colorado State University – More information available at www.agrability.org

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

8. 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

9. 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

10. 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

11. Inflammatory versus degenerative arthritis www.vics.com

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

13. 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

14. 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

15. Joint Swelling

16. Joint Deformity

17. Nodules of RA

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

19. X-ray image

20. MRI Image of RA From Bocaradiology.com

21. 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

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

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

24. 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

25. 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

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

27. 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)

28. Abbvie Study Figure 1: ACR 20 Responses over 52 Weeks

29. 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.

30. 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

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

32. Exercise and arthritis Water Aerobics Walking Physical Therapy Yoga

33. Surgery for RA

34. 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