Rheumatoid Arthritis: Primary care Initiativefor improved Diagnosis and outcomes
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C L I N I C I A N E D U C A T O R V O L U M E 3
SIDE B is for patients
SIDE A is for clinicians
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Fusiform swelling of the hand
RHEUMATOID ARTHRITIS (RA) FACTSRA is a chronic, progressive, systemic inflammatory disease •Characterizedby: – Progressive destruction of synovial joints with loss of
cartilage and bony erosions – Symptoms that begin in the small joints of the fingers, wrists,
and feet – Warm, swollen, tender joints that are painful and difficult to
move – Loss of physical function and quality of life – Disability and underemployment with rapid loss of work
productivity and job loss •Affects1.3millionAmericans •Peakageofonset:40to60years •Twoto4timesmorecommoninwomenthanmen •Patientsare7timesaslikelytohavegreater-than-moderate
disabilitythanage-orsex-matchedindividuals •Lifeexpectancyreducedby5to15years –RAaccountsfor22%ofalldeathsfromarthritisandother
rheumatic conditions
It is never too late to stop further damage
RA IS A DISEASE OF THE ENTIRE BODYHeart: •Cardiovasculardisease(CVD)occursonaverage10yearsearlierin
RApatientsthaninthegeneralpopulationwithoutRA •PericarditisisnotuncommonLungs: Increased risk for multiple pulmonary comorbidities •Pleuritismayoccur,ortissuesmaybecomestifforovergrown •InterstitiallungdiseaseInfections: RApatientshavea6-to9-foldincreaseintherateofseriousinfections, including tuberculosis Malignancy: RAdoublestheriskformalignancy,particularlylymphomaGastrointestinal (GI): RApatientshaveaveryhighincidenceofGIbleeding,whichmaybeattributabletononsteroidalanti-inflammatorydrug(NSAID)andsteroiduseduringtherapyNervous system: ThedeformityofanddamagetojointsinRAmayleadtoentrapment of nerves, leading to serious consequences •MaypresentwithcarpaltunnelsyndromeOsteoporosis: Generalizedbonelossmayresultfromimmobility,theinflammatoryprocess,and/ortreatmentssuchassteroids •Periarticulardemineralizationmayresultfrommediatorsof
inflammation
PRIMARY CARE: EARLY DETECTION IS CRITICALTo prevent the progressive destruction of synovial joints and improve long-termoutcomes,RAmustbedetectedwithin3monthsofonset. •RAhasrapidonset;bonyerosionsaredetectablebyMRIwithin
6weeks •Rateofprogressionismorerapidinthefirstyearthaninthe
second and third •Within2years,mostindividualswilldevelopbonyerosions,and
mostofthose(~80%)willgoontodeveloplong-termdisability •Successfulmanagementrequiresapartnershipbetweenthe
primary care clinician and the rheumatologist
Benefitsofearlydetection: •DecreasedRAseverity,disability,andmortalitywitheffective
treatments,suchasdisease-modifyingantirheumaticdrugs(DMARDs)
•LowerratesofRAcomplications •Decliningratesoflower-extremityorthopedicsurgicalprocedures •Controlofinflammationmaydecreasecardiacandmalignancyrisks
DIAGNOSIS OF RAInitial referral to a rheumatologist is advised if the patient has any of the followingsymptoms: (See last panel for a diagnosis decision tree) •Atleast3swollenjoints •Positive“squeeze”testacrossmetacarpophalangeal/
metatarsophalangeal joints •Morningstiffness≥30minutes
Even if a patient has fewer than 3 swollen joints, a preliminary diagnosis of “possible RA” may be made, and the patient should be referred to a rheumatologist for a definitive diagnosis.
Arheumatologistwillmakeadefinitivediagnosisbasedonthefollowingcriteria: 1. Morningstiffness 2. Arthritisin3ormorejointareas 3. Arthritisofhandjointsorballsofthesmallertoejoints 4. Symmetricarthritis
THE RA TEAMSuccessfulmanagementofRAwillrequirelong-termteaminvolvement.The primary care clinician will be responsible for identifying possible casesofRAandreferral. •Earlyreferraltoarheumatologistiscritical
•Earlytreatmentbytheprimarycareclinicianisintendedtorelievepain and enhance mobility
–NSAIDs – Short courses of prednisone – On occasion, opioids
•Tofacilitatetheevaluationofthepatient,itisadvisabletoobtain: –Rheumatoidfactor(RF) o30%-70%ofpatientsarepositive –Anti-CCPantibody o40%-60%ofpatientsarepositive oPatientwhoisRFandanti-CCPnegativemaystillhaveRA –C-reactiveprotein –Erythrocytesedimentationrate –CBC –LFT –X-raysofthehands,wrists,andfeet
•Monitorforalarmsigns(infection,dyspnea,neckpain,rheumatoideyedisease,painfulredeye)
HochbergMC,SilmanAJ,SmolenJS,WeinblattME,WeismanMH,eds.Rheumatology.3rded.NewYork,NY:Mosby;2003:757-763.AmericanCollegeofRheumatologyFactSheet.http://www.rheumatology.org/public/factsheets/diseases_and_conditions/ra.asp?aud=pat.AccessedSeptember10,2009.MacLeanCH,LouieR,LeakeB,etal.Qualityofcareforpatientswithrheumatoidarthritis.JAMA.2000;284(8):984-992.
DeaneK.ManagingcomorbiditiesinRA.J Musculoskel Med.2006;23(suppl):S24-S31.BöttcherJ,PfeilA.DiagnosisofperiarticularosteoporosisinrheumatoidarthritisusingdigitalX-rayradiogrammetry.Arthritis Res Ther.2008;10(1):103.
McQueenFM,StewartN,CrabbeJ,etal.Magneticresonanceimagingofthewrist in early rheumatoid arthritis reveals a high prevalence of erosions at four monthsaftersymptomonset.Ann Rheum Dis.1998;57(6):350-356.BykerkVP,KeystoneEC.RAinprimarycare:20clinicalpearls.J Musculoskelet Med.2004;21:133-146.
EmeryP,BreedveldFC,DougadosM,KaldenJR,SchiffMH,SmolenJS.Earlyreferralrecommendationfornewlydiagnosedrheumatoidarthritis:evidencebaseddevelopmentofaclinicalguide.Ann Rheum Dis.2002;61(4):290-297.Adaptedfrom:HochbergMC,SilmanAJ,SmolenJS,WeinblattME,WeismanMH,eds.Rheumatology.3rded.NewYork,NY:Mosby;2003.ArnettFC,EdworthySM,BlochDA,etal.TheAmericanRheumatismAssociation1987revisedcriteriafortheclassificationofrheumatoidarthritis.Arthritis Rheum.1988;31(3):315-324.
BridgesSL.SpottingaggressiveRAearly:thephysicalexamination,testing,andimaging.J Musculoskelet Med.2006;23(supplNov):S10-S14.
CVD10 Years Earlier
6-9 x ↑ SeriousInfection Rate
2 x ↑ Rate of Malignancy
↑ PulmonaryDisease
↑ GI Bleeding
↑ Osteoporosis
4Months
2Years
10-20Years
RA Sx Onset
Bony Erosions 70%-80%
Long-term Disability80%
Rheumatology:DMARD/
BiologicsRx
PCP:EarlyIdentification & Rheumatology
Referral at ≤3Months
PCP:Long-termComorbidityManagement
The “squeeze test” is a simple, but reliable diagnostic test for early RA
O
O
PRIMARY CARE
Initial diagnosisReferral to
rheumatologistImmunizationsPPD/ChestX-ray
Monitorfortoxicitiesand disease progression
Monitorforalarmsigns
RHEUMATOLOGY
ConfirmdiagnosisInitiate early,
aggressiveDMARDtherapy
COLLABORATION
OVERVIEWThis Clinician Educator is designed to aid primary care clinicians in recognizing theearly signsof rheumatoidarthritis (RA)anddeterminingwhen to referapatient toarheumatologist. Side A discusses the role of the primary care clinician in the earlydiagnosisofRA,anddescribeshowtheprimarycarecliniciancanworkintandemwiththepatient’srheumatologist toeffectivelymanagethisdisease.SideB isdesignedtohelppatientsunderstandRA.
INTENDED AUDIENCEThistoolisintendedforprimarycareclinicians.
FACULTYVivian Bykerk, MD AssistantProfessorandDirector,EarlyArthritisProgram,UniversityofToronto;AssistantDirector,DivisionofAdvancedTherapeutics,MountSinaiHospital, Toronto,Canada
Joyce P. Carlone, MN, RN, CFNP, CCRC NursePractitioner,DivisionofRheumatology,EmoryUniversity,Atlanta,GA
Martin M. Miner, MD Co-Director,Men’sHealthCenter,TheMiriamHospital,Providence,RI
DISCLOSUREIt isthepolicyofTheChathamInstitutetoensurebalance,independence,objectivity,andscientificrigorinallofitseducationalprograms.Allfaculty,planners,andmanagerswho affect the content of medical education activities sponsored by The ChathamInstitute are required to disclose to the audience any real or apparent conflict ofinterestrelatedtotheactivity.Faculty,planners,andmanagersnotcomplyingwiththedisclosurepolicywillnotbepermittedtoparticipateinthisactivity.Disclosureinformationisprovidedbelow.
Vivian Bykerk, MDSpeaker Bureaus:AbbottLaboratories,Roche,WyethPharmaceuticalsAdvisory Boards:AbbottLaboratories,Bristol-MyersSquibbCompany,Roche, sanofi-aventisU.S.LLC,Schering-PloughCorporation,WyethPharmaceuticalsConsultant:AbbottLaboratories,Bristol-MyersSquibbCompany,Roche, Schering-PloughCorporation,WyethPharmaceuticalsResearch Grants:AbbottLaboratories,Centocor,Inc.,PfizerInc,Roche, Wyeth Pharmaceuticals
Joyce P. Carlone, MN, RN, CFNP, CCRCSpeaker Bureaus: Wyeth PharmaceuticalsAdvisory Boards and Consultant:UCBPharma,Inc.
Martin M. Miner, MDNorealorapparentconflictstoreport
Daniel Duch, PhD, MedicalDirector Cynthia Fontán, MPA, EducationManagerTheChathamInstituteNorealorapparentconflictstoreport
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Rheumatology:Long-termRAManagement
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What is rheumatoid arthritis (RA)?•RAisachronicdiseasethatdamagesthejointsofthebody.Chronicdiseasesarelonglasting(greaterthan3months)anddonot easily or quickly go away
•RAaffectswomenmorethantwiceasmuchasmen.Althoughitmay occur at any age, it usually starts in patients when they are between40and60yearsold
•RAcausescontinuingdamageformostpatients,andmustbeoptimally managed throughout life
What are the symptoms?EarlysignsofRAinclude:•Swellingorstiffnessinthejointsofthehands•Painorachinginthehandsandwrists•Morningstiffnessthatlastsforatleastahalfhour,andmayoften
last for several hours•Youmaynotbeabletogripthingsasstronglyasyouusedto•Later,RAmayaffectmanyjointsinthebody,includingthefeet,
ankles, knees, hips, elbows, and shoulders
O
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Are other parts of the body affected besides the joints?
Other organs that may be affected if RA is not treated early:
Eyes: dryness and damage to delicate structures
Lungs: much greater risk of getting serious infections and other complications
Heart disease: may occur about 10yearssoonerthaninpeoplewithoutRA
Stomach: high risk of bleeding
Double the risk of some types of cancer, so increased screening is advisable
JointsAffected:
Jaw
Spine
Shoulder
Elbow
Hip
Knee
Ankle,foot, toes
Wrist,hand,fingers Early diagnosis and
treatment may prevent these complications.
ImmuneCell
Target Cell
What causes RA?•ItisnotknownwhatcausesRA,butitisan autoimmune disease.
This means that the body attacks itself
•Thebody’simmunesystemisusedbythebodytofightoffinfections caused by invading bacteria and viruses
•InautoimmunediseaseslikeRA,thebodyrespondsasifitsnormal tissues are invading target cells, and attacks them
•GeneticsmayplayapartinthedevelopmentofRA,butmanypeoplewhogetRAdonothaveanyrelativeswiththedisease
What happens when RA causes an autoimmune response? When an immune response is triggered, inflammation occurs in the areasthatareattackedbytheimmunesystem.
•Inflammationcausesrednessandwarmth,swelling,stiffness,and pain in the affected joints
•Iftheautoimmuneresponseisnotslowedorstopped,itcanpermanently damage the affected joints and other tissues
Can RA be prevented?BecausewedonotknowwhyRAhappens,thereisnowaytopreventthedisease.
•Early diagnosis and aggressive treatment are the best ways to fight RA
•Treatmentisfirstfocusedonreducinginflammationandrelieving pain
•WhenadiagnosisofRAisconfirmed,treatmentalsoaimsatstopping or slowing joint damage and damage to other parts of the body
Treatment With Disease-modifiying Antirheumatic Drugs (DMARDs) Improves Long-term Outcomes
Healthy Joint Damaged Joint
DestructionofCartilage
Cut-away View
Dis
ease
Pro
gres
s
Years of Disease
Without DMARDs, problems increase rapidly
With DMARDs, fewer problems
How can RA be stopped?TherehasbeenalargeimprovementinthedrugsusedtotreatRA.
•Aclassofdrugsreferredtoasdisease-modifiying antirheumatic drugs (DMARDs)actstosloworstoptheprogressionofRAtomore advanced stages of the disease
•Ifyoulookatthegraphabove,youwillseethatwhenaDMARDisnotused(theredline),theproblemscausedbyRAincreaserapidly,especiallyinthefirst2years
•However,whentreatedwithDMARDs(theblueline),thediseaseprogresses much more slowly, and fewer problems occur
•DMARDssuchasmethotrexate,hydroxychloroquine,sulfasalazine,orbiologicDMARDsaremostoftenusedto controlRA
Q: I have some pain in my hands. How can I tell if I have RA?
A: IfyouthinkyoumayhaveRA,youneedtotellyourhealthcareprovider.He/Shewillexamineyouandaskthefollowingquestions:
•Whathurtsasyougetoutofbedinthemorning? •Howlongdoesittaketofeelaslimberasyou’regoingto
feelfortheday? •Whenisyourpaintheworst(AMorPM)? •Doyousmoke? •DoanymembersofyourfamilyhaveRA? •Canyou –Turnfaucethandles? –Holdahairbrush/toothbrush? –Dress/batheindependently? –Fixyourownbreakfast? –Walkoutdoorsonflatground? •Howisyourenergylevel? •Importantcluestodiagnoseotherdiseases –Fever? –Nightsweats? –Unexpectedweightloss? –Rash,tickexposure? –Recentcontactwithsickchildren?Youmayalsofilloutthequestionnaireonpanel8B,whichwillhelpindiagnosingthecauseofyourdiscomfort.
Q: What happens next?
A: IfyourhealthcareproviderthinksyoumayhaveRA,he/shewillprescribemedicationtoreducethepainandinflammationinthejoints.He/Shewillalsoreferyoutoarheumatologist, which isadoctorwhospecializesinRAandrelateddiseases.
TherheumatologistwillconfirmthediagnosisofRAandprescribe appropriate medication to slow or stop the autoimmuneprocess.
DependingontheextentofinjurycausedbyRA,youmaybereferredtoaphysicaloroccupationaltherapist,orapodiatrist.
Rheumatoid Arthritis Resources and InformationThe American College of Rheumatology http://www.rheumatology.org/
The Arthritis Foundation http://www.arthritis.org/
The National Library of Medicine/Medline Plus http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
The Mayo Clinic http://www.mayoclinic.com/health/rheumatoid-arthritis/DS00020
GordonDA,HastingsDE.Clinicalfeaturesofrheumatoidarthritis.In:HochbergMC,SilmanAJ,SmolenJS,WeinblattME,WeismanMH,eds.
Rheu
mat
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y.3rded.NewYork,NY:Mosby;2003:765-780.Withpermission.
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Copyright © 1972-2004 American College of Rheumatology Slide Collection. All rights reserved.
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