Evidence-Informed Best Practice RA and OA Dr. Diane Lacaille.
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Transcript of Evidence-Informed Best Practice RA and OA Dr. Diane Lacaille.
Evidence-Informed Best PracticeRA and OA
Dr. Diane Lacaille
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Describe the rationale for key recommendations for
best practice care for Rheumatoid Arthritis and
Osteoarthritis according to the BC Guidelines.
www.bcguidelines.ca
Objectives
NECESSARY
SAFE
EFFECTIVE
Early Treatment of RA with DMARDs
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EARLY Treatment of RA with DMARDs
EARLY DIAGNOSIS AND TREATMENT OF RA
AGGRESSIVE USE OF DMARDS ALTERS THE COURSE OF RA
REMISSION IS THE NEW TARGET OF RA TREATMENT
LONG TERM USE OF DMARDS
YES, DMARDS ARE SAFE WHEN MONITORED REGULARLY
This is the new standard of care.
EARLY
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If not controlled, RA inflammation leads to:
joint damage and joint deformitiesprogressive loss of physical functionwork disability (32-50% after 10 years of RA)premature mortality, mainly from cardiovascular disease (50% increase in risk of death from CVD)
All these outcomes are preventable.
RA is Not a Benign Disease
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Persistent Joint Swelling Leads to Joint Damage & Deformities
=>
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Early Diagnosis & Treatment of RA
Early diagnosis
Recognizing signs of inflammation – clues pointing to RAEarly morning stiffness > 30 minutesWorse pain in the morning and post immobilitySwelling of small jointsPain or tenderness on squeezing the MTPs, MCPs or wristsSymmetrical involvementSystemic symptoms, such as fatigue
Ruling out other diagnosis Septic arthritis, especially if monoarthritisCrystal arthritis, such as gout or pseudogout Joint aspiration for acute monoarthritis to R/O infection
or when crystal arthritis is suspectedTransient inflammatory arthritis, i.e. viral
lasts 6 weeks or less
EARLY
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Early treatment of RA
Capture the window of opportunityEarly treatment with DMARDs alters the disease course.Joint damage occurs early (within months) and is
irreversible.RA is more responsive to treatment early on.Early treatment increases the chances of remission.
New onset RA requires urgent careDMARDs should be started within 2 months of symptoms.Referral to a rheumatologist for new onset RA should be
seen within 4 weeks. State ‘new onset of RA’ on referral.Rheumatologists prefer early referrals.
EARLY
Early Diagnosis & Treatment of RA
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Aggressive use of DMARDs Alters the course of RA
What are DMARDs?
Disease Modifying Anti-Rheumatic Drugs
They improve symptoms and prevent joint damage.
Methotrexate, Sulfasalazine, Hydroxychloroquine, Gold, Cyclosporine, Leflunomide and biologic agents.
Think RA, think DMARDs
All RA patients with active inflammation should be on a DMARD.
NSAIDs and prednisone are not enough NSAIDs improve symptoms but fail to prevent joint damage. Prednisone should not be used alone because
of long term toxicities
EARLY
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DMARDs alter the course of RA by:
• Preventing joint damage and deformities
• Reducing physical and work disability
• Preventing premature mortality
Aggressive use of DMARDs means:
• Starting DMARDs early
• Using DMARDs continuously, often in combination
• Evaluating response every 1 to 3 months
• Modifying DMARD therapy until the target is reached
• Aiming to eradicate inflammation
Aggressive Use of DMARDs Alters the Course of RA
EARLY
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The goal of RA treatment is no longer to simply control symptoms, but to eradicate inflammation.
The target of DMARD therapy is no signs of active
inflammation i.e.,
• No swollen joints
• Normal ESR or CRP
• Little to no radiographic progression
Although remission is the target, minimal disease activity may be an acceptable alternative, when remission is not possible, especially in established long-standing disease, or when co-morbidities or other patient factors limit DMARD options.
EARLY
Remission is the new target of RA treatment
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DMARDs should be used continuously, throughout the disease.
When sustained remission is achieved, DMARDs may be slowly decreased to find a lower dose that maintains remission.
DMARD discontinuation is not recommended because of high risk of flare off DMARDs.
All RA requires DMARD, the earlier the better, but even late RA requires DMARDs to reduce further damage.
Long-term use of DMARDs
EARLY
13Benefits of early DMARDs outweigh their risks
Yes DMARDs are safe when monitored regularly
EARLY
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Family physicians play a critical role in early diagnosis and treatment of RA.
DMARDs should be prescribed in all RA patients and should be started early.
EARLY is the new standard of care
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NSAIDS
DMARDs
Treatment of RAthe standard of care has changed
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Guidelines and Protocols Advisory Committee. Rheumatoid Arthritis: Diagnosis and Management. British Columbia Medical Association. 2006. www.bcguidelines.ca
American College of Rheumatology Ad Hoc Committees on Clinical Guidelines. Guidelines for the management of rheumatoid arthritis. Arthritis Rheum.1996,39:713-22.
American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 Update. Arthritis Rheum 2002;46:328-346.
Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifyingantirheumatic drugs in rheumatoid arthritis. Arthritis Rheum 2008;59:762-84.
Bykerk V, replace with 2010 CRA RA guidelines
Smolen JS, Aletaha D, Bijlsma JW, et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis 2010;69:631–637
Recommendations are based on the following references:
Osteoarthritis
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Features suggestive of OA:Absence of inflammatory features: morning stiffness < 30 min; gelling < 5 min; minimal swelling & heat; no redness.Pain worse with activity, better with restAdvanced OA => constant pain including at restAbsence of systemic symptomsGradual onsetHistory of prior injury (e.g. knee), prior deformity / malalignement Joint distribution: hips, knees, C & L spine, hands: DIP, PIP, 1st CMC, 1st MTP. Bony enlargement, crepitus, malalignementIf joint swelling, synovial fluid non-inflammatory, no crystals.
Osteoarthritis (OA)
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Joint Distribution
Black= joints most commonly affectedGrey= joints often affectedWhite= joints usually not affected
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Septic arthritis (acute monoarthritis requires joint aspiration)
Crystal arthritis: gout, pseudogout (CPPD) (joint aspiration)
Inflammatory arthritis: esp. psoriatic arthritis Non-articular : e.g. bursitis (trochanteric, pes anserine),
tendonitis (shoulder, elbow) Bone pain (multiple myeloma, metastasis) Soft tissue pain syndromes Referred pain
Other Diagnoses to Exclude
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X Rays
› Provide clinical information
› Can be normal in early OA
› Often don’t correlate with degree of pain
› Knee Xrays must be ordered weight bearing (PA, lat, skyline)
› Hip (OA hip series: incl. lateral view and upper 1/3 femur)
Absence of inflammatory markers (CBC, CRP normal)
Labs can be useful to rule out other conditions (e.g. thyroid disease) or to assess for comorbidities prior to Rx (e.g. Cr, LFT)
Investigations
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Severity of pain (with activity, at rest, interferes with sleep)
Impact on function (ADLs, IADLs) Impact on participation (work, family obligations, social
activities, leisure) Impact on independence Psychosocial issues (pain amplification, coping
strategies, depression, adherence to treatment, social support)
Management - Considerations
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Patient education Self-management (pain, limited physical function, stress,
exercise, coping, pacing) Weight management – support, dietician Exercise Physiotherapy: prescribe specific therapeutic exercise
program Walking aids Occupational therapy: Orthotics, footwear, braces, ADL
aids, ergonomic modifications at work
Management – Non pharmacological
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Acetaminophen:
› regular schedule vs. prn
› up to 4 gm/day, less if liver disease NSAIDs:
› Gastroprotection if high GI risk
› Consider cardiovascular risk factors
› Topical NSAIDs Glucosamine and chondroitin sulfate:
› Not recommended, insufficient evidence of efficacy Intra-articular steroids Hyaluronic acid – limited benefit, can cause inflammatory
reaction
Management - Pharmacological
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Failure of conservative management (trial acetaminophen, NSAIDs, intraarticular injection steroids, physiotherapy, regular exercise program)
Inadequate pain control (pain at rest, significant pain with walking, pain interfering with sleep, incr. need for narcotics)
Impact on function (limited ADLs, limitations in meaningful activities – work, family, leisure)
Threat to independence Significant deformities (e.g. FD, valgus knees, loss IR hip,
LLD) Xray flags: acetabular protrusion, femoral head collapse,
progressive bone loss,
Management – Indications for Surgery
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Summary