DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY...
Transcript of DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY...
![Page 1: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/1.jpg)
Rheumatology Red Flags
Emergencies the GP Should Not Miss
DR MICHAEL STARR
DIVISION OF RHEUMATOLOGY
MUHC
Family Medicine Review Course December 4 2016
Disclosures
Amgen
Janssen
Roche
BMS
Pfizer
UCB
Novartis
Advisory board speaker clinical trialshellip
Objectives
1 Recognize patterns of acute rheumatic scenarios that require timely management
2 Importance of early referral and treatment of patients with suspected inflammatory rheumatic syndromes
3 Update on current therapeutic options and side effects to be aware of
Topics to be reviewed
The hot joint
New onset Inflammatory Arthritis
GCA
The patient on biologics
The Hot Joint
Case
67 year old man
Type 2 diabetic suffers with ulcers on
legsrecent knee injection for OA
Presents with acute history (progressive over 48-
72 hours) of painful hot swollen red knee
Struggling to walk into clinic
Feels feverish past 36 hours
Acute Monoarthritis - Etiology
THE MOST CRITICAL DIAGNOSIS TO CONSIDER INFECTION
DDX
Crystal (Gout Pseudogout)
Hemarthrosis (heme disorders)
Monoarticular onset of systemic disease or other inflammatory arthritis ( ex RA Spondyloarthritis)
Trauma
Risk Factors for Septic Arthritis
Previous arthritis
Trauma
Diabetes Mellitus
Immunosupression
Bacteremia
Sickle cell anemia
Prosthetic joint Recent IA injection
Pathogens
90 non-gonococcal
staph aureus 50-80 streptococcus 15-20 haemophilus influenzae b 20 (infants 6mo-2yrs) anaerobes 5
Gonococcal
young sexually active
Pustular skin lesions (dermatitis-arthritis syndrome)
Tenosynovitis
Migratory arthralgias
Hand gt knee wrist ankle or elbow
INFECTIOUS (PYOGENIC)
ARTHRITIS Assume any monoarticular arthritis is infectious until
proven otherwise
Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days
If a nearby break in skin or bacteremia most definitely approach as infectious process
Septic joint carries high morbidity and mortality
Inflammatory arthritis can mimic septic joint
Empiric Therapy for Septic Arthritis
You must cover Staph and Strep
Oxacillin cephozolin
Vanco if PCN-allergic or if concern for MRSA
If infection is hospital acquired or prosthetic joint- cover gram negatives
3rd generation cephalosporin
Empiric coverage for GC is recommended if clinical suspicion
Frequent aspiration of joint
Treat 2-4 weeks iv then 2-4 weeks po
Learning points
1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations
1 Donrsquot miss septic arthritis Aspirate when possible
1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist
4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology
Case History 36 year old marathon runner notices
that the balls of her feet are sore when she awakenshellipshe attributes this to sports
2 months later 1 week swelling of kneehellipGP treats with an NSAID
3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running
Increasing am stiffness fatigue
Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most
common types - 1 of population
Psoriatic arthritis
Ankylosing spondylitis
Polyarticular goutpseudogout (calcium
pyrophosphate disease)
Reactive arthritis
Postviral arthritis
Enteropathic arthritis
1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003
Investigation of Suspected
Inflammatory Arthritis
Investigation of Inflammatory Arthritis Complete blood cell count (CBC)
Erythrocyte sedimentation rate (ESR) or
C-reactive protein (CRP) level
Urinalysis
Rheumatoid factor (RF)
Radiographs of hands and feet
New test now available
Anti-cyclic citrullinated peptide (anti-CCP)
1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346
IMPACT OF
RHEUMATOID ARTHRITIS
Disability
Limited activitieswork loss
Substantial morbidity
Increased mortality
Brief Delay of Therapy
Predicts Remission 2 Years
Fin-RA Co Study
Treatment Delay
Est
imate
d P
erc
en
t R
em
issi
on
Adjusted for age at BSL sex shared epitope RF and
ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002
11
35
p=0010
0
10
20
30
40
50
60
70
Single Treatment
gt 4 Months
lt 4 Months
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 2: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/2.jpg)
Disclosures
Amgen
Janssen
Roche
BMS
Pfizer
UCB
Novartis
Advisory board speaker clinical trialshellip
Objectives
1 Recognize patterns of acute rheumatic scenarios that require timely management
2 Importance of early referral and treatment of patients with suspected inflammatory rheumatic syndromes
3 Update on current therapeutic options and side effects to be aware of
Topics to be reviewed
The hot joint
New onset Inflammatory Arthritis
GCA
The patient on biologics
The Hot Joint
Case
67 year old man
Type 2 diabetic suffers with ulcers on
legsrecent knee injection for OA
Presents with acute history (progressive over 48-
72 hours) of painful hot swollen red knee
Struggling to walk into clinic
Feels feverish past 36 hours
Acute Monoarthritis - Etiology
THE MOST CRITICAL DIAGNOSIS TO CONSIDER INFECTION
DDX
Crystal (Gout Pseudogout)
Hemarthrosis (heme disorders)
Monoarticular onset of systemic disease or other inflammatory arthritis ( ex RA Spondyloarthritis)
Trauma
Risk Factors for Septic Arthritis
Previous arthritis
Trauma
Diabetes Mellitus
Immunosupression
Bacteremia
Sickle cell anemia
Prosthetic joint Recent IA injection
Pathogens
90 non-gonococcal
staph aureus 50-80 streptococcus 15-20 haemophilus influenzae b 20 (infants 6mo-2yrs) anaerobes 5
Gonococcal
young sexually active
Pustular skin lesions (dermatitis-arthritis syndrome)
Tenosynovitis
Migratory arthralgias
Hand gt knee wrist ankle or elbow
INFECTIOUS (PYOGENIC)
ARTHRITIS Assume any monoarticular arthritis is infectious until
proven otherwise
Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days
If a nearby break in skin or bacteremia most definitely approach as infectious process
Septic joint carries high morbidity and mortality
Inflammatory arthritis can mimic septic joint
Empiric Therapy for Septic Arthritis
You must cover Staph and Strep
Oxacillin cephozolin
Vanco if PCN-allergic or if concern for MRSA
If infection is hospital acquired or prosthetic joint- cover gram negatives
3rd generation cephalosporin
Empiric coverage for GC is recommended if clinical suspicion
Frequent aspiration of joint
Treat 2-4 weeks iv then 2-4 weeks po
Learning points
1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations
1 Donrsquot miss septic arthritis Aspirate when possible
1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist
4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology
Case History 36 year old marathon runner notices
that the balls of her feet are sore when she awakenshellipshe attributes this to sports
2 months later 1 week swelling of kneehellipGP treats with an NSAID
3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running
Increasing am stiffness fatigue
Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most
common types - 1 of population
Psoriatic arthritis
Ankylosing spondylitis
Polyarticular goutpseudogout (calcium
pyrophosphate disease)
Reactive arthritis
Postviral arthritis
Enteropathic arthritis
1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003
Investigation of Suspected
Inflammatory Arthritis
Investigation of Inflammatory Arthritis Complete blood cell count (CBC)
Erythrocyte sedimentation rate (ESR) or
C-reactive protein (CRP) level
Urinalysis
Rheumatoid factor (RF)
Radiographs of hands and feet
New test now available
Anti-cyclic citrullinated peptide (anti-CCP)
1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346
IMPACT OF
RHEUMATOID ARTHRITIS
Disability
Limited activitieswork loss
Substantial morbidity
Increased mortality
Brief Delay of Therapy
Predicts Remission 2 Years
Fin-RA Co Study
Treatment Delay
Est
imate
d P
erc
en
t R
em
issi
on
Adjusted for age at BSL sex shared epitope RF and
ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002
11
35
p=0010
0
10
20
30
40
50
60
70
Single Treatment
gt 4 Months
lt 4 Months
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 3: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/3.jpg)
Objectives
1 Recognize patterns of acute rheumatic scenarios that require timely management
2 Importance of early referral and treatment of patients with suspected inflammatory rheumatic syndromes
3 Update on current therapeutic options and side effects to be aware of
Topics to be reviewed
The hot joint
New onset Inflammatory Arthritis
GCA
The patient on biologics
The Hot Joint
Case
67 year old man
Type 2 diabetic suffers with ulcers on
legsrecent knee injection for OA
Presents with acute history (progressive over 48-
72 hours) of painful hot swollen red knee
Struggling to walk into clinic
Feels feverish past 36 hours
Acute Monoarthritis - Etiology
THE MOST CRITICAL DIAGNOSIS TO CONSIDER INFECTION
DDX
Crystal (Gout Pseudogout)
Hemarthrosis (heme disorders)
Monoarticular onset of systemic disease or other inflammatory arthritis ( ex RA Spondyloarthritis)
Trauma
Risk Factors for Septic Arthritis
Previous arthritis
Trauma
Diabetes Mellitus
Immunosupression
Bacteremia
Sickle cell anemia
Prosthetic joint Recent IA injection
Pathogens
90 non-gonococcal
staph aureus 50-80 streptococcus 15-20 haemophilus influenzae b 20 (infants 6mo-2yrs) anaerobes 5
Gonococcal
young sexually active
Pustular skin lesions (dermatitis-arthritis syndrome)
Tenosynovitis
Migratory arthralgias
Hand gt knee wrist ankle or elbow
INFECTIOUS (PYOGENIC)
ARTHRITIS Assume any monoarticular arthritis is infectious until
proven otherwise
Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days
If a nearby break in skin or bacteremia most definitely approach as infectious process
Septic joint carries high morbidity and mortality
Inflammatory arthritis can mimic septic joint
Empiric Therapy for Septic Arthritis
You must cover Staph and Strep
Oxacillin cephozolin
Vanco if PCN-allergic or if concern for MRSA
If infection is hospital acquired or prosthetic joint- cover gram negatives
3rd generation cephalosporin
Empiric coverage for GC is recommended if clinical suspicion
Frequent aspiration of joint
Treat 2-4 weeks iv then 2-4 weeks po
Learning points
1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations
1 Donrsquot miss septic arthritis Aspirate when possible
1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist
4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology
Case History 36 year old marathon runner notices
that the balls of her feet are sore when she awakenshellipshe attributes this to sports
2 months later 1 week swelling of kneehellipGP treats with an NSAID
3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running
Increasing am stiffness fatigue
Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most
common types - 1 of population
Psoriatic arthritis
Ankylosing spondylitis
Polyarticular goutpseudogout (calcium
pyrophosphate disease)
Reactive arthritis
Postviral arthritis
Enteropathic arthritis
1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003
Investigation of Suspected
Inflammatory Arthritis
Investigation of Inflammatory Arthritis Complete blood cell count (CBC)
Erythrocyte sedimentation rate (ESR) or
C-reactive protein (CRP) level
Urinalysis
Rheumatoid factor (RF)
Radiographs of hands and feet
New test now available
Anti-cyclic citrullinated peptide (anti-CCP)
1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346
IMPACT OF
RHEUMATOID ARTHRITIS
Disability
Limited activitieswork loss
Substantial morbidity
Increased mortality
Brief Delay of Therapy
Predicts Remission 2 Years
Fin-RA Co Study
Treatment Delay
Est
imate
d P
erc
en
t R
em
issi
on
Adjusted for age at BSL sex shared epitope RF and
ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002
11
35
p=0010
0
10
20
30
40
50
60
70
Single Treatment
gt 4 Months
lt 4 Months
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 4: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/4.jpg)
Topics to be reviewed
The hot joint
New onset Inflammatory Arthritis
GCA
The patient on biologics
The Hot Joint
Case
67 year old man
Type 2 diabetic suffers with ulcers on
legsrecent knee injection for OA
Presents with acute history (progressive over 48-
72 hours) of painful hot swollen red knee
Struggling to walk into clinic
Feels feverish past 36 hours
Acute Monoarthritis - Etiology
THE MOST CRITICAL DIAGNOSIS TO CONSIDER INFECTION
DDX
Crystal (Gout Pseudogout)
Hemarthrosis (heme disorders)
Monoarticular onset of systemic disease or other inflammatory arthritis ( ex RA Spondyloarthritis)
Trauma
Risk Factors for Septic Arthritis
Previous arthritis
Trauma
Diabetes Mellitus
Immunosupression
Bacteremia
Sickle cell anemia
Prosthetic joint Recent IA injection
Pathogens
90 non-gonococcal
staph aureus 50-80 streptococcus 15-20 haemophilus influenzae b 20 (infants 6mo-2yrs) anaerobes 5
Gonococcal
young sexually active
Pustular skin lesions (dermatitis-arthritis syndrome)
Tenosynovitis
Migratory arthralgias
Hand gt knee wrist ankle or elbow
INFECTIOUS (PYOGENIC)
ARTHRITIS Assume any monoarticular arthritis is infectious until
proven otherwise
Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days
If a nearby break in skin or bacteremia most definitely approach as infectious process
Septic joint carries high morbidity and mortality
Inflammatory arthritis can mimic septic joint
Empiric Therapy for Septic Arthritis
You must cover Staph and Strep
Oxacillin cephozolin
Vanco if PCN-allergic or if concern for MRSA
If infection is hospital acquired or prosthetic joint- cover gram negatives
3rd generation cephalosporin
Empiric coverage for GC is recommended if clinical suspicion
Frequent aspiration of joint
Treat 2-4 weeks iv then 2-4 weeks po
Learning points
1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations
1 Donrsquot miss septic arthritis Aspirate when possible
1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist
4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology
Case History 36 year old marathon runner notices
that the balls of her feet are sore when she awakenshellipshe attributes this to sports
2 months later 1 week swelling of kneehellipGP treats with an NSAID
3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running
Increasing am stiffness fatigue
Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most
common types - 1 of population
Psoriatic arthritis
Ankylosing spondylitis
Polyarticular goutpseudogout (calcium
pyrophosphate disease)
Reactive arthritis
Postviral arthritis
Enteropathic arthritis
1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003
Investigation of Suspected
Inflammatory Arthritis
Investigation of Inflammatory Arthritis Complete blood cell count (CBC)
Erythrocyte sedimentation rate (ESR) or
C-reactive protein (CRP) level
Urinalysis
Rheumatoid factor (RF)
Radiographs of hands and feet
New test now available
Anti-cyclic citrullinated peptide (anti-CCP)
1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346
IMPACT OF
RHEUMATOID ARTHRITIS
Disability
Limited activitieswork loss
Substantial morbidity
Increased mortality
Brief Delay of Therapy
Predicts Remission 2 Years
Fin-RA Co Study
Treatment Delay
Est
imate
d P
erc
en
t R
em
issi
on
Adjusted for age at BSL sex shared epitope RF and
ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002
11
35
p=0010
0
10
20
30
40
50
60
70
Single Treatment
gt 4 Months
lt 4 Months
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 5: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/5.jpg)
The Hot Joint
Case
67 year old man
Type 2 diabetic suffers with ulcers on
legsrecent knee injection for OA
Presents with acute history (progressive over 48-
72 hours) of painful hot swollen red knee
Struggling to walk into clinic
Feels feverish past 36 hours
Acute Monoarthritis - Etiology
THE MOST CRITICAL DIAGNOSIS TO CONSIDER INFECTION
DDX
Crystal (Gout Pseudogout)
Hemarthrosis (heme disorders)
Monoarticular onset of systemic disease or other inflammatory arthritis ( ex RA Spondyloarthritis)
Trauma
Risk Factors for Septic Arthritis
Previous arthritis
Trauma
Diabetes Mellitus
Immunosupression
Bacteremia
Sickle cell anemia
Prosthetic joint Recent IA injection
Pathogens
90 non-gonococcal
staph aureus 50-80 streptococcus 15-20 haemophilus influenzae b 20 (infants 6mo-2yrs) anaerobes 5
Gonococcal
young sexually active
Pustular skin lesions (dermatitis-arthritis syndrome)
Tenosynovitis
Migratory arthralgias
Hand gt knee wrist ankle or elbow
INFECTIOUS (PYOGENIC)
ARTHRITIS Assume any monoarticular arthritis is infectious until
proven otherwise
Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days
If a nearby break in skin or bacteremia most definitely approach as infectious process
Septic joint carries high morbidity and mortality
Inflammatory arthritis can mimic septic joint
Empiric Therapy for Septic Arthritis
You must cover Staph and Strep
Oxacillin cephozolin
Vanco if PCN-allergic or if concern for MRSA
If infection is hospital acquired or prosthetic joint- cover gram negatives
3rd generation cephalosporin
Empiric coverage for GC is recommended if clinical suspicion
Frequent aspiration of joint
Treat 2-4 weeks iv then 2-4 weeks po
Learning points
1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations
1 Donrsquot miss septic arthritis Aspirate when possible
1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist
4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology
Case History 36 year old marathon runner notices
that the balls of her feet are sore when she awakenshellipshe attributes this to sports
2 months later 1 week swelling of kneehellipGP treats with an NSAID
3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running
Increasing am stiffness fatigue
Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most
common types - 1 of population
Psoriatic arthritis
Ankylosing spondylitis
Polyarticular goutpseudogout (calcium
pyrophosphate disease)
Reactive arthritis
Postviral arthritis
Enteropathic arthritis
1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003
Investigation of Suspected
Inflammatory Arthritis
Investigation of Inflammatory Arthritis Complete blood cell count (CBC)
Erythrocyte sedimentation rate (ESR) or
C-reactive protein (CRP) level
Urinalysis
Rheumatoid factor (RF)
Radiographs of hands and feet
New test now available
Anti-cyclic citrullinated peptide (anti-CCP)
1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346
IMPACT OF
RHEUMATOID ARTHRITIS
Disability
Limited activitieswork loss
Substantial morbidity
Increased mortality
Brief Delay of Therapy
Predicts Remission 2 Years
Fin-RA Co Study
Treatment Delay
Est
imate
d P
erc
en
t R
em
issi
on
Adjusted for age at BSL sex shared epitope RF and
ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002
11
35
p=0010
0
10
20
30
40
50
60
70
Single Treatment
gt 4 Months
lt 4 Months
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 6: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/6.jpg)
Case
67 year old man
Type 2 diabetic suffers with ulcers on
legsrecent knee injection for OA
Presents with acute history (progressive over 48-
72 hours) of painful hot swollen red knee
Struggling to walk into clinic
Feels feverish past 36 hours
Acute Monoarthritis - Etiology
THE MOST CRITICAL DIAGNOSIS TO CONSIDER INFECTION
DDX
Crystal (Gout Pseudogout)
Hemarthrosis (heme disorders)
Monoarticular onset of systemic disease or other inflammatory arthritis ( ex RA Spondyloarthritis)
Trauma
Risk Factors for Septic Arthritis
Previous arthritis
Trauma
Diabetes Mellitus
Immunosupression
Bacteremia
Sickle cell anemia
Prosthetic joint Recent IA injection
Pathogens
90 non-gonococcal
staph aureus 50-80 streptococcus 15-20 haemophilus influenzae b 20 (infants 6mo-2yrs) anaerobes 5
Gonococcal
young sexually active
Pustular skin lesions (dermatitis-arthritis syndrome)
Tenosynovitis
Migratory arthralgias
Hand gt knee wrist ankle or elbow
INFECTIOUS (PYOGENIC)
ARTHRITIS Assume any monoarticular arthritis is infectious until
proven otherwise
Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days
If a nearby break in skin or bacteremia most definitely approach as infectious process
Septic joint carries high morbidity and mortality
Inflammatory arthritis can mimic septic joint
Empiric Therapy for Septic Arthritis
You must cover Staph and Strep
Oxacillin cephozolin
Vanco if PCN-allergic or if concern for MRSA
If infection is hospital acquired or prosthetic joint- cover gram negatives
3rd generation cephalosporin
Empiric coverage for GC is recommended if clinical suspicion
Frequent aspiration of joint
Treat 2-4 weeks iv then 2-4 weeks po
Learning points
1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations
1 Donrsquot miss septic arthritis Aspirate when possible
1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist
4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology
Case History 36 year old marathon runner notices
that the balls of her feet are sore when she awakenshellipshe attributes this to sports
2 months later 1 week swelling of kneehellipGP treats with an NSAID
3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running
Increasing am stiffness fatigue
Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most
common types - 1 of population
Psoriatic arthritis
Ankylosing spondylitis
Polyarticular goutpseudogout (calcium
pyrophosphate disease)
Reactive arthritis
Postviral arthritis
Enteropathic arthritis
1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003
Investigation of Suspected
Inflammatory Arthritis
Investigation of Inflammatory Arthritis Complete blood cell count (CBC)
Erythrocyte sedimentation rate (ESR) or
C-reactive protein (CRP) level
Urinalysis
Rheumatoid factor (RF)
Radiographs of hands and feet
New test now available
Anti-cyclic citrullinated peptide (anti-CCP)
1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346
IMPACT OF
RHEUMATOID ARTHRITIS
Disability
Limited activitieswork loss
Substantial morbidity
Increased mortality
Brief Delay of Therapy
Predicts Remission 2 Years
Fin-RA Co Study
Treatment Delay
Est
imate
d P
erc
en
t R
em
issi
on
Adjusted for age at BSL sex shared epitope RF and
ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002
11
35
p=0010
0
10
20
30
40
50
60
70
Single Treatment
gt 4 Months
lt 4 Months
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 7: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/7.jpg)
Acute Monoarthritis - Etiology
THE MOST CRITICAL DIAGNOSIS TO CONSIDER INFECTION
DDX
Crystal (Gout Pseudogout)
Hemarthrosis (heme disorders)
Monoarticular onset of systemic disease or other inflammatory arthritis ( ex RA Spondyloarthritis)
Trauma
Risk Factors for Septic Arthritis
Previous arthritis
Trauma
Diabetes Mellitus
Immunosupression
Bacteremia
Sickle cell anemia
Prosthetic joint Recent IA injection
Pathogens
90 non-gonococcal
staph aureus 50-80 streptococcus 15-20 haemophilus influenzae b 20 (infants 6mo-2yrs) anaerobes 5
Gonococcal
young sexually active
Pustular skin lesions (dermatitis-arthritis syndrome)
Tenosynovitis
Migratory arthralgias
Hand gt knee wrist ankle or elbow
INFECTIOUS (PYOGENIC)
ARTHRITIS Assume any monoarticular arthritis is infectious until
proven otherwise
Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days
If a nearby break in skin or bacteremia most definitely approach as infectious process
Septic joint carries high morbidity and mortality
Inflammatory arthritis can mimic septic joint
Empiric Therapy for Septic Arthritis
You must cover Staph and Strep
Oxacillin cephozolin
Vanco if PCN-allergic or if concern for MRSA
If infection is hospital acquired or prosthetic joint- cover gram negatives
3rd generation cephalosporin
Empiric coverage for GC is recommended if clinical suspicion
Frequent aspiration of joint
Treat 2-4 weeks iv then 2-4 weeks po
Learning points
1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations
1 Donrsquot miss septic arthritis Aspirate when possible
1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist
4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology
Case History 36 year old marathon runner notices
that the balls of her feet are sore when she awakenshellipshe attributes this to sports
2 months later 1 week swelling of kneehellipGP treats with an NSAID
3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running
Increasing am stiffness fatigue
Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most
common types - 1 of population
Psoriatic arthritis
Ankylosing spondylitis
Polyarticular goutpseudogout (calcium
pyrophosphate disease)
Reactive arthritis
Postviral arthritis
Enteropathic arthritis
1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003
Investigation of Suspected
Inflammatory Arthritis
Investigation of Inflammatory Arthritis Complete blood cell count (CBC)
Erythrocyte sedimentation rate (ESR) or
C-reactive protein (CRP) level
Urinalysis
Rheumatoid factor (RF)
Radiographs of hands and feet
New test now available
Anti-cyclic citrullinated peptide (anti-CCP)
1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346
IMPACT OF
RHEUMATOID ARTHRITIS
Disability
Limited activitieswork loss
Substantial morbidity
Increased mortality
Brief Delay of Therapy
Predicts Remission 2 Years
Fin-RA Co Study
Treatment Delay
Est
imate
d P
erc
en
t R
em
issi
on
Adjusted for age at BSL sex shared epitope RF and
ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002
11
35
p=0010
0
10
20
30
40
50
60
70
Single Treatment
gt 4 Months
lt 4 Months
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 8: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/8.jpg)
Risk Factors for Septic Arthritis
Previous arthritis
Trauma
Diabetes Mellitus
Immunosupression
Bacteremia
Sickle cell anemia
Prosthetic joint Recent IA injection
Pathogens
90 non-gonococcal
staph aureus 50-80 streptococcus 15-20 haemophilus influenzae b 20 (infants 6mo-2yrs) anaerobes 5
Gonococcal
young sexually active
Pustular skin lesions (dermatitis-arthritis syndrome)
Tenosynovitis
Migratory arthralgias
Hand gt knee wrist ankle or elbow
INFECTIOUS (PYOGENIC)
ARTHRITIS Assume any monoarticular arthritis is infectious until
proven otherwise
Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days
If a nearby break in skin or bacteremia most definitely approach as infectious process
Septic joint carries high morbidity and mortality
Inflammatory arthritis can mimic septic joint
Empiric Therapy for Septic Arthritis
You must cover Staph and Strep
Oxacillin cephozolin
Vanco if PCN-allergic or if concern for MRSA
If infection is hospital acquired or prosthetic joint- cover gram negatives
3rd generation cephalosporin
Empiric coverage for GC is recommended if clinical suspicion
Frequent aspiration of joint
Treat 2-4 weeks iv then 2-4 weeks po
Learning points
1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations
1 Donrsquot miss septic arthritis Aspirate when possible
1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist
4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology
Case History 36 year old marathon runner notices
that the balls of her feet are sore when she awakenshellipshe attributes this to sports
2 months later 1 week swelling of kneehellipGP treats with an NSAID
3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running
Increasing am stiffness fatigue
Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most
common types - 1 of population
Psoriatic arthritis
Ankylosing spondylitis
Polyarticular goutpseudogout (calcium
pyrophosphate disease)
Reactive arthritis
Postviral arthritis
Enteropathic arthritis
1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003
Investigation of Suspected
Inflammatory Arthritis
Investigation of Inflammatory Arthritis Complete blood cell count (CBC)
Erythrocyte sedimentation rate (ESR) or
C-reactive protein (CRP) level
Urinalysis
Rheumatoid factor (RF)
Radiographs of hands and feet
New test now available
Anti-cyclic citrullinated peptide (anti-CCP)
1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346
IMPACT OF
RHEUMATOID ARTHRITIS
Disability
Limited activitieswork loss
Substantial morbidity
Increased mortality
Brief Delay of Therapy
Predicts Remission 2 Years
Fin-RA Co Study
Treatment Delay
Est
imate
d P
erc
en
t R
em
issi
on
Adjusted for age at BSL sex shared epitope RF and
ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002
11
35
p=0010
0
10
20
30
40
50
60
70
Single Treatment
gt 4 Months
lt 4 Months
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 9: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/9.jpg)
Pathogens
90 non-gonococcal
staph aureus 50-80 streptococcus 15-20 haemophilus influenzae b 20 (infants 6mo-2yrs) anaerobes 5
Gonococcal
young sexually active
Pustular skin lesions (dermatitis-arthritis syndrome)
Tenosynovitis
Migratory arthralgias
Hand gt knee wrist ankle or elbow
INFECTIOUS (PYOGENIC)
ARTHRITIS Assume any monoarticular arthritis is infectious until
proven otherwise
Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days
If a nearby break in skin or bacteremia most definitely approach as infectious process
Septic joint carries high morbidity and mortality
Inflammatory arthritis can mimic septic joint
Empiric Therapy for Septic Arthritis
You must cover Staph and Strep
Oxacillin cephozolin
Vanco if PCN-allergic or if concern for MRSA
If infection is hospital acquired or prosthetic joint- cover gram negatives
3rd generation cephalosporin
Empiric coverage for GC is recommended if clinical suspicion
Frequent aspiration of joint
Treat 2-4 weeks iv then 2-4 weeks po
Learning points
1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations
1 Donrsquot miss septic arthritis Aspirate when possible
1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist
4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology
Case History 36 year old marathon runner notices
that the balls of her feet are sore when she awakenshellipshe attributes this to sports
2 months later 1 week swelling of kneehellipGP treats with an NSAID
3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running
Increasing am stiffness fatigue
Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most
common types - 1 of population
Psoriatic arthritis
Ankylosing spondylitis
Polyarticular goutpseudogout (calcium
pyrophosphate disease)
Reactive arthritis
Postviral arthritis
Enteropathic arthritis
1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003
Investigation of Suspected
Inflammatory Arthritis
Investigation of Inflammatory Arthritis Complete blood cell count (CBC)
Erythrocyte sedimentation rate (ESR) or
C-reactive protein (CRP) level
Urinalysis
Rheumatoid factor (RF)
Radiographs of hands and feet
New test now available
Anti-cyclic citrullinated peptide (anti-CCP)
1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346
IMPACT OF
RHEUMATOID ARTHRITIS
Disability
Limited activitieswork loss
Substantial morbidity
Increased mortality
Brief Delay of Therapy
Predicts Remission 2 Years
Fin-RA Co Study
Treatment Delay
Est
imate
d P
erc
en
t R
em
issi
on
Adjusted for age at BSL sex shared epitope RF and
ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002
11
35
p=0010
0
10
20
30
40
50
60
70
Single Treatment
gt 4 Months
lt 4 Months
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 10: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/10.jpg)
INFECTIOUS (PYOGENIC)
ARTHRITIS Assume any monoarticular arthritis is infectious until
proven otherwise
Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days
If a nearby break in skin or bacteremia most definitely approach as infectious process
Septic joint carries high morbidity and mortality
Inflammatory arthritis can mimic septic joint
Empiric Therapy for Septic Arthritis
You must cover Staph and Strep
Oxacillin cephozolin
Vanco if PCN-allergic or if concern for MRSA
If infection is hospital acquired or prosthetic joint- cover gram negatives
3rd generation cephalosporin
Empiric coverage for GC is recommended if clinical suspicion
Frequent aspiration of joint
Treat 2-4 weeks iv then 2-4 weeks po
Learning points
1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations
1 Donrsquot miss septic arthritis Aspirate when possible
1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist
4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology
Case History 36 year old marathon runner notices
that the balls of her feet are sore when she awakenshellipshe attributes this to sports
2 months later 1 week swelling of kneehellipGP treats with an NSAID
3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running
Increasing am stiffness fatigue
Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most
common types - 1 of population
Psoriatic arthritis
Ankylosing spondylitis
Polyarticular goutpseudogout (calcium
pyrophosphate disease)
Reactive arthritis
Postviral arthritis
Enteropathic arthritis
1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003
Investigation of Suspected
Inflammatory Arthritis
Investigation of Inflammatory Arthritis Complete blood cell count (CBC)
Erythrocyte sedimentation rate (ESR) or
C-reactive protein (CRP) level
Urinalysis
Rheumatoid factor (RF)
Radiographs of hands and feet
New test now available
Anti-cyclic citrullinated peptide (anti-CCP)
1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346
IMPACT OF
RHEUMATOID ARTHRITIS
Disability
Limited activitieswork loss
Substantial morbidity
Increased mortality
Brief Delay of Therapy
Predicts Remission 2 Years
Fin-RA Co Study
Treatment Delay
Est
imate
d P
erc
en
t R
em
issi
on
Adjusted for age at BSL sex shared epitope RF and
ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002
11
35
p=0010
0
10
20
30
40
50
60
70
Single Treatment
gt 4 Months
lt 4 Months
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 11: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/11.jpg)
Empiric Therapy for Septic Arthritis
You must cover Staph and Strep
Oxacillin cephozolin
Vanco if PCN-allergic or if concern for MRSA
If infection is hospital acquired or prosthetic joint- cover gram negatives
3rd generation cephalosporin
Empiric coverage for GC is recommended if clinical suspicion
Frequent aspiration of joint
Treat 2-4 weeks iv then 2-4 weeks po
Learning points
1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations
1 Donrsquot miss septic arthritis Aspirate when possible
1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist
4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology
Case History 36 year old marathon runner notices
that the balls of her feet are sore when she awakenshellipshe attributes this to sports
2 months later 1 week swelling of kneehellipGP treats with an NSAID
3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running
Increasing am stiffness fatigue
Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most
common types - 1 of population
Psoriatic arthritis
Ankylosing spondylitis
Polyarticular goutpseudogout (calcium
pyrophosphate disease)
Reactive arthritis
Postviral arthritis
Enteropathic arthritis
1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003
Investigation of Suspected
Inflammatory Arthritis
Investigation of Inflammatory Arthritis Complete blood cell count (CBC)
Erythrocyte sedimentation rate (ESR) or
C-reactive protein (CRP) level
Urinalysis
Rheumatoid factor (RF)
Radiographs of hands and feet
New test now available
Anti-cyclic citrullinated peptide (anti-CCP)
1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346
IMPACT OF
RHEUMATOID ARTHRITIS
Disability
Limited activitieswork loss
Substantial morbidity
Increased mortality
Brief Delay of Therapy
Predicts Remission 2 Years
Fin-RA Co Study
Treatment Delay
Est
imate
d P
erc
en
t R
em
issi
on
Adjusted for age at BSL sex shared epitope RF and
ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002
11
35
p=0010
0
10
20
30
40
50
60
70
Single Treatment
gt 4 Months
lt 4 Months
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 12: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/12.jpg)
Learning points
1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations
1 Donrsquot miss septic arthritis Aspirate when possible
1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist
4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology
Case History 36 year old marathon runner notices
that the balls of her feet are sore when she awakenshellipshe attributes this to sports
2 months later 1 week swelling of kneehellipGP treats with an NSAID
3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running
Increasing am stiffness fatigue
Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most
common types - 1 of population
Psoriatic arthritis
Ankylosing spondylitis
Polyarticular goutpseudogout (calcium
pyrophosphate disease)
Reactive arthritis
Postviral arthritis
Enteropathic arthritis
1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003
Investigation of Suspected
Inflammatory Arthritis
Investigation of Inflammatory Arthritis Complete blood cell count (CBC)
Erythrocyte sedimentation rate (ESR) or
C-reactive protein (CRP) level
Urinalysis
Rheumatoid factor (RF)
Radiographs of hands and feet
New test now available
Anti-cyclic citrullinated peptide (anti-CCP)
1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346
IMPACT OF
RHEUMATOID ARTHRITIS
Disability
Limited activitieswork loss
Substantial morbidity
Increased mortality
Brief Delay of Therapy
Predicts Remission 2 Years
Fin-RA Co Study
Treatment Delay
Est
imate
d P
erc
en
t R
em
issi
on
Adjusted for age at BSL sex shared epitope RF and
ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002
11
35
p=0010
0
10
20
30
40
50
60
70
Single Treatment
gt 4 Months
lt 4 Months
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 13: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/13.jpg)
Case History 36 year old marathon runner notices
that the balls of her feet are sore when she awakenshellipshe attributes this to sports
2 months later 1 week swelling of kneehellipGP treats with an NSAID
3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running
Increasing am stiffness fatigue
Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most
common types - 1 of population
Psoriatic arthritis
Ankylosing spondylitis
Polyarticular goutpseudogout (calcium
pyrophosphate disease)
Reactive arthritis
Postviral arthritis
Enteropathic arthritis
1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003
Investigation of Suspected
Inflammatory Arthritis
Investigation of Inflammatory Arthritis Complete blood cell count (CBC)
Erythrocyte sedimentation rate (ESR) or
C-reactive protein (CRP) level
Urinalysis
Rheumatoid factor (RF)
Radiographs of hands and feet
New test now available
Anti-cyclic citrullinated peptide (anti-CCP)
1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346
IMPACT OF
RHEUMATOID ARTHRITIS
Disability
Limited activitieswork loss
Substantial morbidity
Increased mortality
Brief Delay of Therapy
Predicts Remission 2 Years
Fin-RA Co Study
Treatment Delay
Est
imate
d P
erc
en
t R
em
issi
on
Adjusted for age at BSL sex shared epitope RF and
ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002
11
35
p=0010
0
10
20
30
40
50
60
70
Single Treatment
gt 4 Months
lt 4 Months
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 14: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/14.jpg)
Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most
common types - 1 of population
Psoriatic arthritis
Ankylosing spondylitis
Polyarticular goutpseudogout (calcium
pyrophosphate disease)
Reactive arthritis
Postviral arthritis
Enteropathic arthritis
1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003
Investigation of Suspected
Inflammatory Arthritis
Investigation of Inflammatory Arthritis Complete blood cell count (CBC)
Erythrocyte sedimentation rate (ESR) or
C-reactive protein (CRP) level
Urinalysis
Rheumatoid factor (RF)
Radiographs of hands and feet
New test now available
Anti-cyclic citrullinated peptide (anti-CCP)
1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346
IMPACT OF
RHEUMATOID ARTHRITIS
Disability
Limited activitieswork loss
Substantial morbidity
Increased mortality
Brief Delay of Therapy
Predicts Remission 2 Years
Fin-RA Co Study
Treatment Delay
Est
imate
d P
erc
en
t R
em
issi
on
Adjusted for age at BSL sex shared epitope RF and
ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002
11
35
p=0010
0
10
20
30
40
50
60
70
Single Treatment
gt 4 Months
lt 4 Months
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 15: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/15.jpg)
Investigation of Suspected
Inflammatory Arthritis
Investigation of Inflammatory Arthritis Complete blood cell count (CBC)
Erythrocyte sedimentation rate (ESR) or
C-reactive protein (CRP) level
Urinalysis
Rheumatoid factor (RF)
Radiographs of hands and feet
New test now available
Anti-cyclic citrullinated peptide (anti-CCP)
1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346
IMPACT OF
RHEUMATOID ARTHRITIS
Disability
Limited activitieswork loss
Substantial morbidity
Increased mortality
Brief Delay of Therapy
Predicts Remission 2 Years
Fin-RA Co Study
Treatment Delay
Est
imate
d P
erc
en
t R
em
issi
on
Adjusted for age at BSL sex shared epitope RF and
ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002
11
35
p=0010
0
10
20
30
40
50
60
70
Single Treatment
gt 4 Months
lt 4 Months
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 16: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/16.jpg)
IMPACT OF
RHEUMATOID ARTHRITIS
Disability
Limited activitieswork loss
Substantial morbidity
Increased mortality
Brief Delay of Therapy
Predicts Remission 2 Years
Fin-RA Co Study
Treatment Delay
Est
imate
d P
erc
en
t R
em
issi
on
Adjusted for age at BSL sex shared epitope RF and
ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002
11
35
p=0010
0
10
20
30
40
50
60
70
Single Treatment
gt 4 Months
lt 4 Months
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 17: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/17.jpg)
Brief Delay of Therapy
Predicts Remission 2 Years
Fin-RA Co Study
Treatment Delay
Est
imate
d P
erc
en
t R
em
issi
on
Adjusted for age at BSL sex shared epitope RF and
ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002
11
35
p=0010
0
10
20
30
40
50
60
70
Single Treatment
gt 4 Months
lt 4 Months
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 18: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/18.jpg)
REFERRAL To Local Rheumatologist
Patient Name
Address
City Postal Code
Telephone H) W)
Date of Birth Health Card Number
Reason for Referral Suspected Inflammatory Arthritis
When did symptoms start
How many swollen joints
Which joints
Other information
Laboratory and X-ray Results (Please attach pertinent results)
Signature of Referring Physician
Physician Number
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 19: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/19.jpg)
Key Messages
Disability and joint damage occur early in RA
Short delay in therapy may have a long term effect on increasing joint damage
Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 20: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/20.jpg)
Case Study
67 yo woman
TIA resolved put on ASA
Malaise myalgias weight loss low grade fever
few months
Left arm feels weak achy with use
Left subclavian bruit on exam
ESR 86 CRP 58
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 21: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/21.jpg)
GCA- (Giant Cell Arteritis)
Clinical Features amp Epidemiology
Mean age is 70
75 females
Onset often abrupt
Wide spectrum of symptoms
PMR in 40 - 60
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 22: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/22.jpg)
GIANT CELL ARTERITIS Clues
gt 50 yo
NEW headache
Jaw claudication or arm claudication
Sudden visual loss diplopia
Systemically ill with many markers of systemic
inflammation increased CRP Ferritin ESR
Approach
TREAT and then biopsy
You have 2 weeks to get the biopsy
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 23: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/23.jpg)
Treatment of GCA
Prednisone 40-60 mgday
iv pulse methylprednisolone for patients with
visual symptoms
Treat full dose 4-6 weeks then reduce by 10
every 2 weeks more slowly once 20 mgday has
been reached
Alternate day therapy NOT recommended
Add ASA 80 mg
Steroid sparing drugs- MTX Tocilizumab
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 24: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/24.jpg)
Side Effects Corticosteroids
Osteoporosis
Osteoporosis Society of Canada (OSC)
recommends Bisphosphonate therapy for
all patients who take gt75 mgday of
Prednisone for gt3 months
Calcium 1200-1500 mgday and Vitamin D
1000 uday
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 25: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/25.jpg)
The Patient on Biologics
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 26: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/26.jpg)
MCQ-1
Which of the following is false
Biologic agents have been associated with which
all of the following
1 increased risk of infection
2 increased risk of demyelinating disease
3 increased risk of MI and CVA
4 increased risk of skin cancers
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 27: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/27.jpg)
Mini Case 1
61 year old male with RA Tx with Adalimumab
MTX Diclofenac Presents to ER with cellulitus
left leg WBC 122 Temp 38 He is due for
Adalimumab SC injection in 2 days
What should you do
1 Start Abrsquos and tell him to take his Adalimumab as usual
2 Start Abrsquos and tell him to hold Adalimumab until infection
is clear
3 Advise to stop Adalimumab permanently since it has
increased his infection risk
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 28: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/28.jpg)
Infections Anti-TNF Agents
All TNF antagonists have warnings about
serious infections in package insert
Administration of any of the anti-TNF
therapies should be discontinued if the
patient develops serious infection or sepsis
and should not be initiated in patients with
active infection
Education of Pts And GPrsquos is key
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 29: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/29.jpg)
Recommended management of
anti-TNF biologics in infection
Simple upper respiratory tract viral infections No modification of treatment
More severe viral infection (influenza herpes
zosterhellip) or severe bacterial infection (fever
bacteremia systemic infection recurrent
infectionhellip) Anti-TNF therapy should be temporarily discontinued
Appropriate antibiotic or antiviral therapy
Resumption of anti-TNF after resolution of the infection
Taylor PC Presented at ACR Clinical Symposium
November 2007
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key
![Page 30: DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHCcourse-mcgill.ca/web/images/2016/material/PL-5-2_Starr.pdf · DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC ... GP treats with an](https://reader030.fdocuments.in/reader030/viewer/2022021610/5b36d30b7f8b9a4a728b5618/html5/thumbnails/30.jpg)
Take away Points
Biologics Safety Treatment of IA patients with Biologic therapy is generally safe
and well tolerated
Rare important events have been seen with all TNF antagonists
Serious infections
TB and other opportunistic infections (more common with mAbrsquos)
Lymphomas
Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities
Screening for TB recommended in all patients
Vigilance required re infectious and malignant complications
Patient and physician education key