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Rheumatoid Arthritis and Psoriatic Arthritis PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Rheumatoid Arthritis and Psoriatic Arthritis" by Daniel J. Wallace, MD, FACP, MACR.

This medical PowerPoint presentation is about rheumatoid arthritis (RA) and psoriatic arthritis (PsA), two types of autoimmune diseases that affect the joints and cause inflammation.

RA is a chronic inflammatory disorder that primarily affects the joints, causing pain, swelling, stiffness, and loss of function. It is caused by the bodys immune system mistakenly attacking the lining of the joints, which can lead to joint damage, disability, and deformity if left untreated. RA can also affect other parts of the body, such as the lungs, heart, and eyes.

PsA is a type of arthritis that occurs in people with psoriasis, a chronic skin condition characterized by red, scaly patches on the skin. PsA can cause joint pain, stiffness, and swelling, as well as skin and nail changes. It is caused by an overactive immune system that attacks healthy cells and tissues, leading to inflammation in the joints and skin.

Both RA and PsA are chronic diseases that can be managed with medication, physical therapy, and lifestyle changes, but there is no cure for either condition. It is important to see a healthcare provider if you experience joint pain, swelling, or stiffness, as early diagnosis and treatment can help prevent joint damage and disability.

Tags : Rheumatoid Arthritis, Psoriatic Arthritis, autoimmune diseases, Orthopaedic Surgery, Orthopaedic Surgery PowerPoint presentation

Published on : Jun 23, 2023 | Views : 2147 | Downloads : 8

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Daniel J. Wallace, MD, FACP, MACRAssociate Director, Rheumatology Fellowship ProgramBoard of Governors, Cedars-Sinai Medical CenterProfessor of Medicine, Cedars-Sinai Medical CenterDavid Geffen School of Medicine Center at UCLAIn affiliation with Attune HealthLos Angeles, California
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Disclosures Consultant: EMD, Exagen, Glenmark, Lilly, Serono Clinical area: Lupus
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Learning Objectives Describe the overall management, including diagnostic evaluation and initial treatment, in patients with PsA or RA. Collaborate with the patient using a shared decision-making approach to better understand patient concerns and inform treatment goals and plan. Perform a diagnostic evaluation, including differential diagnosis and assessment of comorbidities, for patients with possible PsA or RA. Individualize evidence-based treatment for treatment-naïve patients with PsA or RA consistent with current guideline recommendations. Consider a holistic management approach in patients with PsA or RA.
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RA and PsA Pathogenesis Coates LC, et al. Semin Arthritis Rheum. 2016;46:291-304. Macrophage Basophil Mast cell Eosinophil Neutrophil KeratinocyteSynoviocyte Osteoclast CD8+ T cell Osteoblast JAK signaling cascade Dendritic cell Naïve T cell MHC TCR IL-1 TNF IL-1 TNF IL-17 signaling cascade cAMP/PKA signaling cascade MAPK signaling cascade NFKB signaling cascade IL-1 TGF-β1 IL-17 IFN-γ IL-12/23 IL-6 IL-21 IL-23a IL-22 IFN-α
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Treatment of RA and PsA Core Principles Treatment should be based on shared decision-making between the patient and the health care provider Treatment choices should be individualized and based on factors such as disease activity, prognosis, comorbidities, safety, cost, and availability of medications Treat-to-target should be prioritized, whether that means low disease activity or remission Overall treatment goals and plan should: aim for lowest possible disease activity optimize functional status improve quality of life minimize structural damage avoid/minimize complications from either active disease or medications Aletaha D. Rheum Dis Clin North Am. 2019;45:xi-xii; Falzer PR. Int J Rheum Dis. 2019;22:1706-1713; Garrido-Cumbrera M, et al. Rheumatol Ther. 2017;4:219-231.
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Rheumatoid Arthritis
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Rheumatoid Arthritis Most Common Autoimmune Inflammatory Arthritis in Adults Onset is insidious, often beginning with fever, malaise, arthralgias, and weakness before progressing to joint inflammation and swelling Annual incidence is ~40 per 100,000 Prevalence is ~1% in Caucasians but varies between 0.1% (in rural Africans) and ~5% (in Pima, Blackfeet, and Chippewa Indians) Women are affected 2 to 3 times more often than men Can occur at any age Peak onset is between ages 50-75 Smolen JS, et al. Nat Rev Dis Primers. 2018;4:18001; Cross M, et al. Ann Rheum Dis. 2014;73:1316-1322; McDougall C, et al. Semin Arthritis Rheum. 2017;46:675-686.
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Rheumatoid Arthritis Classification Criteria: ACR/EULAR 2010 Aletaha D, et al. Ann Rheum Dis. 2010;69:1580-1588. A. Joint involvement refers to any swollen or tender joint on examination, which may be confirmed by imaging evidence of synovitis. Distal interphalangeal joints, first carpometacarpal joints and first metatarsophalangeal joints are excluded from assessment. Categories of joint distribution are classified according to the location and number of involved joints, with placement into the highest category possible based on the pattern of joint involvement. B. ‘Large joints’ refers to shoulders, elbows, hips, knees and ankle. C. ‘Small joints’ refers to the metacarpophalangeal joints, proximal interphalangeal joints, second to fifth metatarsophalangeal joints, thumb interphalangeal joints and wrists. D. In this category, at least one of the involved joints must be a small joint; the other joints can include any combination of large and additional small joints, as well as other joints not specifically listed elsewhere (eg, temporomandibular, acromioclavicular, sternoclavicular, etc). D. Negative refers to international unit (IU) values that are less than or equal to the upper limit of normal (ULN) for the laboratory and assay; low-positive refers to IU values that are higher than the ULN but 3 or less times the ULN for the laboratory and assay; high-positive refers to IU values that are more than 3 times the ULN for the laboratory and assay. When rheumatoid factor (RF) information is only available as positive or negative, a positive result should be scored as low-positive for RF. A Score Of ≥6/10 Is Needed For Definite Classification of A Patient as Having RA
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Rheumatoid Arthritis Classification Criteria: ACR/EULAR 2010 (cont.) Aletaha D, et al. Ann Rheum Dis. 2010;69:1580-1588. F. Normal/abnormal is determined by local laboratory standards. G. Duration of symptoms refers to patient self-report of the duration of signs or symptoms of synovitis (eg, pain, swelling, tenderness) of joints that are clinically involved at the time of assessment, regardless of treatment status. ACPA, anti-citrullinated protein antibody; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate. A Score of ≥6/10 Is Needed for Definite Classification of a Patient as Having RA
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Established RA RA with duration of disease/symptoms of >=6 months or meeting 1987 ACR RA classification criteria Disease activity Low, moderate, or high as per validated scales RA remission A tender joint count, swollen joint count, C-reactive protein level (mg/dl), and patient global assessment of ≤1 each or a Simplified DAS of ≤3.3 Optimal dosing of RA treatments Dosing to achieve a therapeutic target derived from mutual patient-clinician consideration of patient priorities Given for at least 3 months before therapy escalation or switching Singh JA, et al. Arthritis Rheumatol. 2016;68:1-26. Rheumatoid Arthritis ACR 2015 Guidelines: Definitions to Know
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Rheumatoid Arthritis ACR 2015 Guidelines Instruments to Measure RA Disease Activity and to Define Remission Singh JA, et al. Arthritis Rheumatol. 2016;68:1-26.
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Rheumatoid Arthritis ACR 2015 Guidelines (cont.) Instruments to Measure RA Disease Activity and to Define Remission Singh JA, et al. Arthritis Rheumatol. 2016;68:1-26.
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Low-dose ≤10 mg/day of prednisone (or equivalent) High-dose >10 mg/day of prednisone (or equivalent) and up to 60 mg/day with a rapid taper Short-term <3 month treatment Singh JA, et al. Arthritis Rheumatol. 2016;68:1-26; Boers M, et al. Lancet. 1997;350:309-318. ACR 2015 Guidelines Drug Categories: Glucocorticoids (GCs)
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Methotrexate (MTX) Either oral or subcutaneous Hydroxychloroquine (HCQ) Leflunomide (LEF) Sulfasalazine (SSZ) Singh JA, et al. Arthritis Rheumatol. 2016;68:1-26. ACR 2015 Guidelines Drug Categories: DMARDs* *Excludes azathioprine, cyclosporine, minocycline, and gold. Can be given as mono, double, or triple therapy.
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Adalimumab Certolizumab pegol Etanercept Golimumab Infliximab Singh JA, et al. Arthritis Rheumatol. 2016;68:1-26. ACR 2015 Guidelines Drug Categories: TNFi Biologics* *Excludes anakirna.
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Abatacept Rituximab Tocilizumab Tofacitinib (oral synthetic small molecule) Singh JA, et al. Arthritis Rheumatol. 2016;68:1-26. ACR 2015 Guidelines Drug Categories: Non-TNF Biologics* and Oral JAKi *Excludes anakirna.
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Regardless of disease activity level: Use a treat-to-target approach (low disease activity or remission) use DMARD monotherapy (MTX preferred) If moderate/high disease activity despite DMARD: Use combo DMARDs or TNFi or non-TNF biologic +/- MTX If moderate/high disease activity despite biologic: Add low dose GCs (at lowest possible dose for shortest amount of time) Singh JA, et al. Arthritis Rheumatol. 2016;68:1-26. ACR 2015 Guidelines Treatment of Early RA
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Singh JA, et al. Arthritis Rheumatol. 2016;68:1-26. ACR 2015 Guidelines Early RA Treatment Algorithm
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Regardless of disease activity level: Use a treat-to-target approach (low disease activity or remission) Use DMARD monotherapy (MTX preferred) If moderate/high disease activity despite DMARD: Use combo DMARDs or TNFi or non-TNF biologic +/- MTX If moderate/high disease activity despite biologic: Add low dose GCs (at lowest possible dose for shortest amount of time) If in remission: Taper DMARDs, TNFi, non-TNF biologic, or tofacitinib Do not discontinue all therapy If low disease activity: Continue DMARDs, TNFi, non-TNF biologic, or tofacitinib rather than discontinuing Singh JA, et al. Arthritis Rheumatol. 2016;68:1-26. ACR 2015 Guidelines Treatment of Established RA
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Singh JA, et al. Arthritis Rheumatol. 2016;68:1-26. ACR 2015 Guidelines Established RA Treatment Algorithm
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Singh JA, et al. Arthritis Rheumatol. 2016;68:1-26. ACR 2015 Guidelines Established RA Treatment Algorithm
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Singh JA, et al. Arthritis Rheumatol. 2016;68:1-26. ACR 2015 Guidelines Established RA Treatment Algorithm
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Smolen JS, et al. Nat Rev Dis Primers. 2018;4:18001; Aletaha D, Smolen JS. JAMA. 2018;320:1360-1372. Smolen JS, et al. Lancet. 2016;388:2023-2203. Rheumatoid Arthritis Differential Diagnosis Viral polyarthritis —rubella, parvovirus B19, hepatitis B or C, Chikungunya, human T lymphotropic virus type 1 (HTLV-I) Other systemic rheumatic diseases — systemic lupus erythematosus (SLE), Sjögren's syndrome, dermatomyositis (DM), or overlap syndromes such as mixed connective tissue disease Hypermobility syndrome and fibromyalgia- no synovitis seen Reactive arthritis and inflammatory bowel disease (IBD)-associated arthropathy — HLA-B27 often present Psoriatic arthritis (PsA) Polymyalgia rheumatica Crystalline arthritis — gout and pseudo gout Infectious arthritis — septic arthritis, Lyme disease Osteoarthritis Paraneoplastic disease
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Cardiovascular Disease Myocardial infarction Stroke Atrial fibrillation Heart failure Hypertension Vasculitis Infectious Disease Lung Disease Chronic obstructive pulmonary disease (COPD) Interstitial lung disease (ILD) Dougados M, et al. Ann Rheum Dis. 2014;73:62-68. Rheumatoid Arthritis Comorbidities
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Osteoporosis Depression Malignancy Lung cancer Lymphoma GI ulcerations Eye Disease Uveitis Scleritis Rheumatoid Arthritis Comorbidities (cont.) Dougados M, et al. Ann Rheum Dis. 2014;73:62-68.
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Rheumatoid Arthritis Prevalence of Comorbidities Dougados M, et al. Ann Rheum Dis. 2014;73:62-68.
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Psoriatic Arthritis
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Psoriatic Arthritis CASPAR: ClASsification Criteria for Psoriatic ARthritis Taylor W, et al. Arthritis Rheum. 2006;54:2665-2673. Inflammatory musculoskeletal disease (arthritis, spondylitis, enthesitis) with 3 or more points from the following:
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PsA Manifestations and Comorbidities Extra-Articular and Extra-Cutaneous 1. Shah K, et al. RMD Open. 2017;3:e000588. 2. Kaine J, et al. J Manag Care Spec Pharm. 2019;25:122-132. Uveitis (1.55%)1 Ulcerative colitis (1.28%)1 Cerebrovascular disease (7.32%)1 Metabolic syndrome Obesity (16.45%), hypertension (47.28%), hyperlipidemia (47.47%)1 Fatty liver/NASH (5.77%)1 Depression (21.2%)1, suicidal ideation (0.48%)1 Fatigue (15.8%)2 Fibromyalgia (16.58%)1 Osteoporosis (9.33%)1 Need for teamwork with PCP, Ophthalmology, GI, Psych
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Delayed Diagnosis of PsA Worse Long-Term Outcomes Haroon M, et al. Ann Rheum Dis. 2015;74:1045-1050. †Clinical features recorded as percent, unless otherwise stated; DMARD, disease-modifying antirheumatic drug; HAQ, health assessment questionnaire; OR, odds ratio Odds ratio (95% CI) 4.6 (2.5–8.2) 1.1 (1.0–1.1) 2.3 (1.2–4.4) 10.6 (1.4–80.6) 2.2 (1.3–3.6) 0.4 (0.2–0.9) *** ** ** *p<0.05; **p<0.01; ***p<0.001 * * * Association of clinical features† with >6-month delay in diagnosis (univariate analysis model)
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Psoriatic Arthritis Outcomes Measures Mease P. Arthritis Care Res. 2011;63:64-85; Mease P, et al. Ann Rheum Dis. 2005;64:ii49-ii54; Mease P, van der Heijde D. Int J Adv Rheum. 2006;4:38-48.
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Psoriatic Disease Severity Impact
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PsA GRAPPA Recommendations: 2015 Overarching Principles Achieve lowest possible level of disease activity in all domains of disease Optimize functional status, improve QoL, and prevent structural damage Assessment requires consideration of all major disease domains, including peripheral arthritis, axial disease, enthesitis, dactylitis, psoriasis, and nail disease The impact of disease on pain, function, QoL, and structural damage should be examined In addition, activity in other potential related conditions and comorbidities should be considered including CVD, uveitis, IBD, obesity, metabolic syndrome, gout, diabetes, liver disease, depression, and anxiety Patient-reported measures with a comprehensive history and physical examination, often supplemented by laboratory tests and imaging techniques, should also be included Therapeutic decisions need to be individualized Ideally, patients should be reviewed promptly Early diagnosis and treatment are likely to be of benefit Coates L, et al. Arthritis Rheumatol. 2016;68:1060-1071.
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PsA EULAR Recommendations: 2015 Update Overarching Principles Treatment should maximize HRQoL through control of symptoms, prevention of structural damage, and normalization of function and social participation Abrogation of inflammation is an important component necessary to achieve these goals Aim should be best care based on a shared decision between patient and rheumatologist, considering efficacy, safety, and costs Because of its heterogeneity and potential severity, multidisciplinary treatment may be required Rheumatologists should primarily care for musculoskeletal manifestations; in the presence of clinically significant skin involvement a rheumatologist and a dermatologist should collaborate in diagnosis and management Extra-articular manifestations, metabolic syndrome, CVD and other comorbidities should also be taken into account Gossec L, et al. Ann Rheum Dis. 2016;75:499-510.
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Psoriatic Arthritis Types of Therapy Singh A, et al. Arth Rheum. 2019;71;5-32.
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Psoriatic Arthritis Non-Pharmacologic Strategies Education Patient Family Allied health professionals Counselling Diet/weight loss Physical/occupational therapy Exercise May consider no exercise in patients with existing muscle/tendon injury or multiple inflamed symptomatic joints with worsening pain with exercise May consider low-impact exercise (eg, tai chi, yoga, swimming) over high-impact exercise (eg, running) Massage therapy Acupuncture Smoking cessation
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Psoriatic Arthritis GRAPPA Treatment Recommendations 2015 Coates LC, et al. Arthritis Rheumatol. 2016;68:1060-1071. Standard therapeutic route Expedited therapeutic route Assess activity, impact and prognostic factors DMARDs (MTX, SSZ, LFN), TNFi or PDE4i Biologics (TNFi, IL12/23i IL17i) or PDE4i Peripheral arthritis Switch biologic (TNFi, IL12/23i or IL17i) NSAIDs and IAI corticosteroids as indicated NSAIDs only TNFi, IL17i or *IL12/23i Axial disease Switch biologic (TNFi, IL17i or *IL12/23i) Physiotherapy and NSAIDs No direct evidence for therapies in axial PsA recommendations based on axial SpA literature NSAIDs Biologics (TNFi IL12/23i, IL17i) or PDE4i Enthesitis Switch biologic (TNFi, IL12/23i, IL17i) or PDE4i Physiotherapy CS injections: consider on an individual basis due to potential for serious side effects; no clear evidence for efficacy NSAIDs DMARDs (MTX, LEF, SSZ) or PDE4i Dactylitis Biologics (TNFi, IL12/23i) Corticosteroid injections as indicated Switch biologic (TNFi, IL12/23i, IL17i) or PDE4i Topicals (keratolytics, steroids, vit. D analogues, emollients, calcineurin i) Phototherapy or DMARDs (MTX, CSA, acitretin, fumaric acid esters) or PDE4i Skin Biologics (TNFi, IL12/23i, IL17i) or PDE4i Topicals as indicated Switch biologics (TNFi, IL12/23i, IL17i) or PDE4i Biologics (TNFi, IL12/23i, IL17i) or PDE4i Topical or procedural or DMARDs (CSA, LEF, MTX, acitretin) Nails Switch biologic (TNFi, IL12/23i, IL17i) or PDE4i Which domains are involved?
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GRAPPA 2015 Recommendations Therapy Considerations vis-à-vis Comorbidities Coates LC, et al. Arthritis Rheumatol. 2016;68:1060-1071. *Corticosteroids used as preferred therapy for uveitis are most commonly given as topical and/or intraocular injections in preference to oral steroids. †When treating patients with chronic infections that can affect the liver, consider consultation with providers having expertise in the area.
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Predominant Peripheral PsA EULAR 2015 vs GRAPPA 2015 Recommendations Gossec L, et al. Nat Rev Rheumatol. 2016;12:743-750. *Conditional recommendation in the guidelines for drugs without current regulatory approval or where recommendations are based on abstract data only.
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PsA EULAR Recommendations Update Gossec L, et al. EULAR 2019, Madrid. Switch to alternative biologic (TNFi, IL17, IL12/23, abatacept) or JAKi Polyarthritis Rapid use of csDMARD (MTX if psoriasis) Biologics if 1 csDMARD failure (TNFi, IL17, IL12/23) Prefer IL17, IL12/23 if severe psoriasis Enthesitis No evidence for csDMARDs First-line biologics Oligoarthritis Consider DMARD if poor prognostic factors (erosions,  CRP, steroid, nails) Biologics if 1 csDMARD failure (TNFi, IL17, IL12/23) Axial No evidence for csDMARDs First-line biologics (TNFi or IL17) IL17 if severe psoriasis Apremilast for mild arthritis/skin where other options are not appropriate Consider cautious tapering for patients with sustained remission
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Treatment-Naive Active PsA ACR/NPF Treatment Recommendations Singh A, et al. Arth Rheum. 2019;71;5-32. Begin with TNFi over OSMs, IL17, or IL12/23 Continued active disease? Switch to IL17i* Continued active disease? Switch to different TNFi* Switch to IL12/23i* Continued active disease? Methotrexate or other OSMs can be employed if indicated by cost or other reasons, depending on local situation, as monotherapy or in combination with biologics or tsDMARDs to bolster effect or combat immunogenicity *Biologic therapy is recommended over biologic-with-MTX combination therapy
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Active PsA Post-OSM ACR/NPF Treatment Recommendations Singh A, et al. Arth Rheum. 2019;71;5-32. Begin with TNFi over OSMs, IL17, or IL12/23 Continued active disease? Switch to IL17i* Continued active disease? Switch to different TNFi* Switch to IL12/23i* Tofacitinib may be considered if the patient prefers an oral therapy Continued active disease? *Biologic therapy is recommended over biologic-with-MTX combination therapy
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PsA With Predominant Enthesitis ACR/NPF Treatment Recommendations Singh A, et al. Arth Rheum. 2019;71;5-32. Start oral NSAIDs, TNFi biologic, or tofacitinib over an OSM (specifically apremilast) Continued active disease? Switch to IL17i over IL12/23i or another OSM Continued active disease? Switch to TNFi over IL17i, IL12/23i or another OSM Switch to IL12/23i over another OSM Continued active disease? *Biologic therapy is recommended over biologic-with-MTX combination therapy
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Psoriatic Arthritis Risks of Therapy Serious infections TB/opportunistic infections Neoplasia/lymphoma Autoimmune disease Lupus MS CHF-exacerbation Liver toxicity Hematologic toxicity IBD Shah K, et al. RMD Open. 2017;3:e000588; Kaine J, et al. J Manag Care Spec Pharm. 2019;25:122-132.
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Psoriatic Arthritis Treatment Strategies Treat-to-target What target? MDA/VLDA DAPSA remission/LDA PASDAS remission/LDA CPDAI remission/LDA Etc. TICOPA Controlled taper Controlled withdrawal Aletaha D. Reumatologia. 2016;54:1-2.
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Minimal Disease Activity (MDA) GRAPPA Criteria A patient is classified as having MDA when they meet 5 out of 7 of the following criteria: Tender joint count ≤1 Swollen joint count ≤1 PASI ≤1 or BSA ≤3 Patient pain VAS ≤15 Patient global activity VAS ≤20 HAQ ≤0.5 Tender entheseal points ≤1 Coates LC, et al. Ann Rheum Dis. 2010;69;48-53.
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TICOPA: Tight Control/T2T in PsA Study Design Coates LC, et al. BMC Musculoskelet Disord. 2013 Mar 21;14:101. Safety visit Wk -4 12 32 0 4 8 16 20 24 28 36 40 44 48 52 DMARD naive early PsA (n=206) StdC(n=105) TC (n=101) Blinded assessment of clinical and PROs MDA MDA MDA MDA MDA MDA MDA MDA Assessments Q12 wks in both groups; additional review Q4 wks in tight control only Radiograph hands/feet Radiograph hands/feet R: 1:1 Treatment at rheumatologist’s discretion; no set protocol  To anti-TNF if ≥3 tender/swollen joints or alternative DMARD + MTX if no MDA but with <3 active joints  To combination DMARDs if MDA not reached  MTX to 25 mg atWk 6 if tolerated TC: Start on MTX (n=101) StdC (n=105) 6 12 24 0 T2T: Treatment escalation if MDA not reached 48
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TICOPA: Tight Control/T2T in PsA ACR Responses Coates LC, et al. BMC Musculoskelet Disord. 2013 Mar 21;14:101. Tight control Standard care Primary outcome: complete case analysis Tight control was associated with significantly greater improvements in signs and symptoms of disease at week 48. ITT with multiple imputations
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TICOPA PASI Responses Coates LC, et al. BMC Musculoskelet Disord. 2013 Mar 21;14:101. Reduction in psoriasis severity was achieved in a higher proportion of patients in the tight control arm.
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TICOPA AEs and SAEs Incidence: Up to Week 48 Coates LC, et al. BMC Musculoskelet Disord. 2013 Mar 21;14:101.
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Addressing the Burden of RA and PsA The Key Take-Home Point: A Multidisciplinary Approach Rheumatic diseases are complex systemic illnesses that can affect many aspects of the patient’s life. A collaborative effort between a diverse group of professionals is needed to streamline an effective management strategy. Rheumatologists, psychologists, physician assistants and nurse specialists should collaborate to adopt an individualized, multidisciplinary approach to the care of RA and PsA patients (the latter should include dermatologists as well). The role of the multidisciplinary team is to assess and manage the patient’s symptoms and their effects on physical, psychological, and social functioning. Patients should be encouraged and empowered to take an active role in setting individualized, achievable therapeutic goals and working with their providers to choose an appropriate management plan.
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Psoriatic Arthritis Patient Resources National Psoriasis Foundation https://www.psoriasis.org/connect-kit https://www.psoriasis.org/publications/patient-education/booklets https://www.psoriasis.org/publications/patient-education/fact-sheets Arthritis Foundation https://www.arthritis.org/toolkits/better-living/about/psoriatic-arthritis/ https://www.arthritis.org/about-arthritis/types/psoriatic-arthritis/ https://www.arthritis.org/about-arthritis/types/psoriatic-arthritis/articles/ http://blog.arthritis.org/psoriatic-arthritis/?_ga=2.265133391.1150616224.1575976313-781067379.1575976313
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Rheumatoid Arthritis Patient Resources American College of Rheumatology https://www.rheumatology.org/I-Am-A/Patient-Caregiver https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Patient-FAQs https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Patient-Education-Videos https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Patient-and-Caregiver-Resources http://simpletasks.org/share-your-story/ https://www.rheumatology.org/Advocacy/Legislative-Action-Center https://www.rheumatology.org/Portals/0/Files/Assistance%20Programs.pdf Arthritis Foundation https://www.arthritis.org/about-arthritis/types/rheumatoid-arthritis/ https://www.arthritis.org/about-arthritis/types/rheumatoid-arthritis/articles/