Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical...
-
Upload
ralph-gray -
Category
Documents
-
view
236 -
download
1
Transcript of Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical...
![Page 1: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/1.jpg)
![Page 2: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/2.jpg)
Professor Syed Atiqul HaqChairman, Department of Rheumatology
Bangabandhu Sheikh Mujib Medical University
![Page 3: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/3.jpg)
Major HeadingBackground
Patient education
Disease activity assessment
Drugs
Follow up and monitoring
Pregnancy & lactation
Practice Points
Conclusions
![Page 4: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/4.jpg)
![Page 5: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/5.jpg)
Role of an Internist in RA
Diagnosis
Treatment
Referral
Follow up
![Page 6: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/6.jpg)
Predictors of Poor Prognosis
• Functional limitation
• Extra-articular disease e.g. nodules, vasculitis,
Felty’s syndrome
• RF or anti-CCP positive at high titer
• Bony erosion by radiograph (? deformities)
![Page 7: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/7.jpg)
Goals of Management
Relief of Pain
Suppression of active & progressive disease
Conservation & restoration of function in affected joints
![Page 8: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/8.jpg)
Tools of Management
Doctor-patient relation
Patient education
Vaccination
Drugs
Rest & physical measures
Referral
![Page 9: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/9.jpg)
![Page 10: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/10.jpg)
Information to be ProvidedNatural course and outcomes
Therapeutic options
Vaccination
Lifestyle modifications
Reassurance with facts
Need for long-term adherence & follow up
Disease activity measures
![Page 11: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/11.jpg)
Natural Course & Prognosis• Prolonged course
– Intermittent exacerbations & remissions
• Progressive joint damage
• Disability:
– 40% partially disabled in 3 years
– 80% moderate-severely disabled in 20 years
• 25% requires large joint replacements
• Spontaneous remissions: rarely lasting
![Page 12: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/12.jpg)
![Page 13: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/13.jpg)
![Page 14: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/14.jpg)
“When you cannot measure it,
when you cannot express it in numbers,
you have scarcely,
in your thoughts,
advanced to the stage of science,
whatever the matter may be”
-- Lord Kelvin (1824-1907)
![Page 15: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/15.jpg)
Visual Analog Scale
![Page 16: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/16.jpg)
DAS28(4) = 0.56*sqrt(t28) + 0.28*sqrt(sw28) + 0.70*Ln(ESR) + 0.014*GH
Disease Activity Assessment
![Page 17: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/17.jpg)
CDAI
• Tender joint count (0-28)+ swollen joint
count (0-28)+Patient global score (0-10)+
(Physician’s global score (0-10)= 0-76
![Page 18: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/18.jpg)
Classification of Severity
DAS 28 CDAI
Remission <2.6 <2.8
Low 2.6-3.2 2.8-10
Moderate 3.2-5.1 10-22
Severe >5.1 >22
![Page 19: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/19.jpg)
![Page 20: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/20.jpg)
Groups of Drugs• Pain-killers: NSAIDs, analgesics, steroids
• DMARDs
• Steroids
• Antidotes:
– Folic acid, anti-ulcer drugs, calcium, vitamin D
• Drugs for common co-morbidities:
– anti-depressants
![Page 21: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/21.jpg)
![Page 22: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/22.jpg)
NSAIDs• Development of full effect takes 2-4 weeks
• Optimum dose, interval and duration needed for response
• Continuous use during initial months offers greater relief &
safety compared to use on need basis
• Avoid multiple NSAIDs in combination
• If inadequate response in 2-4 wk, with a single NSAID:
– Switch over to another
– Add paracetamol/tramadol/prednisolone
![Page 23: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/23.jpg)
![Page 24: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/24.jpg)
NSAIDs: Vascular Events
• Most NSAIDs increase vascular events:
– Highest: diclofenac, indomethacin,
meloxicam
– Naproxen neither increases nor decreases
– Ibuprofen reduces efficacy of aspirin
![Page 25: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/25.jpg)
Choice of NSAIDs• Non-selective COX inhibitors
– Naproxen has greatest cardiovascular safety– Indomethacin is the most effective NSAID for at least some patients
– Other NSAIDs are also effective
– Diclofenac cheapest in BD
– PPI in patients at risk for g.i. bleeding
• Selective COX-2 inhibitors are as effective as conventional
– Commonly used: etoricoxib, meloxicam, aceclofenac
– cardiovascular effects limit use to those at risk for g.i. bleeding
![Page 26: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/26.jpg)
![Page 27: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/27.jpg)
Routes of Steroid Administration
Oral
Intra-articular
![Page 28: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/28.jpg)
Indications for Oral Prednisolone• Severe extra-articular manifestations, e.g., vasculitis,
neuropathy, DPLD
• Bridge therapy: early 3-6 months of DMARDs
– Severe pain and gross functional decline
– Bread-winners of family
– Elderly bed-bound patients
– Risk factors for toxicity or contra-indications to NSAIDs
– Early (<6 months), severe disease with predictors of poor prognosis
![Page 29: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/29.jpg)
Intra-articular Steroids
• Indications:
– Severe inflammation in residual 1-3 joints after resolution
in all others
– Severely affected 1-3 joints interfering with ADL, e.g.,
knees
• 72 hrs rest recommended after administration
• Drugs: triamcinolone hexacetonide or acetonide
![Page 30: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/30.jpg)
![Page 31: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/31.jpg)
Effects
• Slowly suppresses inflammation
– Reduces pain and need for NSAIDs
• Prevents progression of joint damage
– eventually prevents deformities
![Page 32: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/32.jpg)
DMARDs
• cDMARDs
– csDMARDs
– ctDMARDs
• bDMARDS
– boDMARDs
– bsDMARDs
![Page 33: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/33.jpg)
cDMARDs
csDMARDs• Methotrexate
• Sulphasalazine
• Leflunomide
• Hydroxychloroquine
• Gold salts
• Tacrolimus
• Ciclosporin
• Bucillamine
ctDMARDs
• Tofacitinib
![Page 34: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/34.jpg)
bDMARDs
• Anti-TNF: infliximab, etanercept,
adalumimab
• Anti-IL6: Tocilizumab
• Anti-B cell (CD20): Rituximab
![Page 35: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/35.jpg)
MTX: Dosing Protocols
1. Start 7.5 to 10 mg/wk
– ↑ at 4 wk intervals by 2.5-5 mg/wk. Maximum 25 mg
– eGFR 30 to 59 ml/min: start with 5 mg, increase at 6 to 8 wk intervals. Max. 20 mg/wk
– Weight >90 kg: start with 10 mg/wk
– Suitable for pts with established RA, staying far from facilities
![Page 36: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/36.jpg)
Contraindications• Age >70 years
• Significant renal disease (eGFR <30)
• Hepatic disorders
• Cytopenias
• Pregnancy, desired pregnancy, lactation
• Active infections, including tuberculosis
• Malignancies
• DPLD
• Uncontrolled cardio-respiratory failure
• Major psychiatric disorders, dementia
![Page 37: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/37.jpg)
Sulfasalazine
• Dose : 500mg/d in 1st wk then↑500mg/d wkly until 2-3 gm/d
• Safe in pregnancy and lactation
• Avoided in patients with HO allergy to Sulfa drugs
![Page 38: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/38.jpg)
Leflunomide (LEF)
• Mono & combination therapy
• Pts who cannot tolerate or do not respond
adequately to MTX
• Dose - 20 mg/d
• Contra-indications similar to MTX
![Page 39: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/39.jpg)
• Least toxic & least effective as monotherapy
• Combined particularly with MTX
• Dose 4-6.5 mg/kg/day (200–400 mg/d)
• Baseline eye exam before/within a yr
• Monitoring (1 yr) for retinopathy by Amsler
grid→abnormality→Ophthalmologist
Hydroxychloroquine (HCQ)
![Page 40: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/40.jpg)
![Page 41: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/41.jpg)
Common AEs of DMARDS
MTX – anorexia, nausea, stomatitis, dizziness, hair loss,
hepatotoxicity, cytopenias, pneumonitis
SSZ - skin reaction, LFT abnormality, headache, GI
upset, reversible oligospermia & infertility
LEF -GI upset, HTN, weight loss, LFT abnormalities
HCQ- corneal deposits, retinopathy, GI upset, skin
changes
![Page 42: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/42.jpg)
![Page 43: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/43.jpg)
Monitoring Intervals
• Till substantial improvement and consequent
reinforcement of DMARDs: 4-6 weeks
• After substantial improvement: 8-12 weeks
– May be progressively increased to 6 months when
the disease condition and drugs are stable
![Page 44: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/44.jpg)
Monitoring Tools -- Clinical
• Response to treatment: DAS28,
CDAI, VAS
• Adverse effects
![Page 45: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/45.jpg)
Monitoring Tools -- Laboratory
• Parameters of efficacy
– ESR, CRP
• Parameters of toxicity
– CBC
– ALT, serum albumin
– Serum creatinine
– Selective: depending on clinically apparent AEs
![Page 46: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/46.jpg)
Guidelines For Dose TitrationParameter Don’t increase Reduce Stop
Remission/LDA Achieved Sustained 1 yr
Clinical AEs Mild Moderate Severe
ALT >1.5-2 ULN >2-3 ULN >3 ULN
S. Creatinine (MTX)
>1.4-1.6 >1.6-2 >2
Hb% <8 g/dl <7 g/dl <6 g/dl
WBC count <4,500 <4,000 <3,000
Platelet count <1,50,000 <1,00,000 <80,000
![Page 47: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/47.jpg)
“Some fell by laudanum and some by steel,
And death in ambush lay in every pill”
-- Sir Samuel Garth (1661 -- 1719)
![Page 48: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/48.jpg)
![Page 49: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/49.jpg)
Pregnancy Concerns…• Some patients enjoy partial remission
• MTX & leflu teratogenic. Stopped before conception
– MTX: 3 months
– Leflunomide: 18 months
• Sulphasalazine safe: continued up to term
• HCQ borderline
• Common pain-killers are safe up to 6 months
– Premature closure of ductus during last 3 months
• LDGC safer than others
![Page 50: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/50.jpg)
Tr. Before & During Pregnancy
• Sulphasalazine (full dose) + some NSAID (up to 6
months)
• In dire cases: SSZ+ HCQ+ LDGC+ some NSAID (up
to 6 months)
• LDGC may replace NSAIDs during last trimester
![Page 51: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/51.jpg)
Safe Drugs During Lactation
SSZ
HCQ
NSAIDs
LDGC
![Page 52: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/52.jpg)
![Page 53: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/53.jpg)
• Be sure of Dx
• Mild-moderate-severe
• Predictors of poor prognosis
• Contra-indications to MTX
• Predictors of NSAID GI toxicity
• Rask factors for osteoporosis
• Vaccination status
![Page 54: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/54.jpg)
Vaccination
• Pneumococcal 23-valent
• Influenza
• Hepatitis B
![Page 55: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/55.jpg)
Baseline Lab Evaluation
CBC
Serum creatinine
Hepatic transaminases
Serum albumin
CXR
HBsAg
![Page 56: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/56.jpg)
Extended Baselines
Anti-HCV
Fasting blood glucose
Lipid profile
Pregnancy test
HIV
Abdominal USG
![Page 57: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/57.jpg)
Minimal Baseline: Resource Constraint
CBC
S. ALT
S. Creatinine
![Page 58: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/58.jpg)
Pain Relief: Titration of Therapy
Titrate against Efficacy & Toxicity
Introduce NSAID
wait 2 to 4 wks
No response-switch to one with higher efficacy, or add
analgesic
wait 2 to 4 wks
If no response add 5 to 10 mg Pred
![Page 59: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/59.jpg)
• Mild disease:
– HCQ/SSZ/CQ+ NSAIDs
– SSZ in women with childbearing potential
• Moderate disease:
– MTX/SSZ+NSAID low dose prednisolne
• Severe disease, particularly early:
– MTX+SSZ+HCQ+ 2.5 to 7.5 mg Pred+NSAID
![Page 60: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/60.jpg)
• Introduce first DMARD (MTX or SSZ)
• Build up the dose
– till toxicity supervenes
– highest recommended dose reached
– Target achieved
![Page 61: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/61.jpg)
Treatment Targets
• Remission (DAS28 <2.6, CDAI <2.8)
• LDA (DAS28 <2.6-3.2, CDAI <2.8-10)
![Page 62: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/62.jpg)
Quantitation of Response
• Partial response: decrease of DAS28 by >1.2
• Achievement of target: remission or LDA
![Page 63: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/63.jpg)
3 Timelines
• 3 months: partially responded (DAS28 decreased
by > 1.2) or failed
• 6 months: Target (LDA or remission) achieved or
not
• Any time: unacceptable (intolerable or serious)
adverse events
![Page 64: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/64.jpg)
Strategies After Failure of Initial Therapy
• Triple therapy: MTX+SSZ+HCQ
• MTX+Leflu
• MTX+biologics
• MTX+calcineurin inhibitors
• Leflu+cyclosporin
![Page 65: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/65.jpg)
Titration of Therapy -- for Disease ControlTitrate against Efficacy & Toxicity
• If no response in 3 months, substitute with another
DMARD, or combination therapy
• If target not achieved in 6 mo, combination therapy
• If no further response after 9 months or target not achieved
after a 2nd block of 6 months:
– HDA/PPP: MTX+biologics
– MDA or resource constraint: a different combination
![Page 66: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/66.jpg)
![Page 67: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/67.jpg)
![Page 68: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/68.jpg)
Taper off the NSAID (switch to ad lib)
If no relapse, slowly taper off prednisolone, if given
If no relapse, very slowly reduce the dose of DMARD
to the lowest recommended dose
Maintain for years
![Page 69: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/69.jpg)
When To Refer to Rheumatologist?• When the disease is not controlled with effective DMARD
combinations
• When conventional DMARDs are not tolerated
• Severe extra-articular manifestations, e.g., vasculitis, SSS
• Pain is not controlled with maximum tolerated combinations of pain-killers
• When you don’t feel satisfied with improvement in functional capacity & QoL
• Early aggressive disease
![Page 70: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/70.jpg)
![Page 71: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/71.jpg)
RA could not dampen her spirit
• "I think when you are involved with RA, you are
involved with loss and maybe sometimes despair,
but art is a good balance for that. It’s life-giving,
it gives you an opportunity to play, and it can be
meditative.“
• May be true to every profession if you work with
passion
![Page 72: Professor Syed Atiqul Haq Chairman, Department of Rheumatology Bangabandhu Sheikh Mujib Medical University.](https://reader036.fdocuments.in/reader036/viewer/2022081508/56649e4f5503460f94b4624d/html5/thumbnails/72.jpg)