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Rheumatoid Arthritis-RA-Management PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Rheumatoid Arthritis (RA) Management” by Dr MUKESH SINGLA.

This medical PowerPoint presentation is about rheumatoid arthritis (RA), a chronic autoimmune disorder that affects the joints, causing pain, stiffness, and inflammation. While there is no cure for RA, there are a variety of treatments available that can help manage the symptoms and slow the progression of the disease. This presentation lists some approaches to RA management.

Tags : Rheumatoid Arthritis, Rheumatoid Arthritis Management, chronic autoimmune disorder, Orthopaedic Surgery, Orthopaedic Surgery PowerPoint presentation

Published on : Jun 20, 2023 | Views : 861 | Downloads : 5

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Slide 1-

Rheumatoid Arthritis (RA) Management 1
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Objectives Define rheumatoid arthritis (RA) and discuss epidemiology and risk factors of RA Identify pathogenesis and clinical presentation of RA Review diagnostic criteria and RA disease activity Review the treatment algorithm for RA (pharmacologic & non-pharmacologic) 2
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NCQA Ratings and HEDIS Measures The National Committee for Quality Assurance (NCQA) is dedicated to improve the quality of health care by rating the established Healthcare Effectiveness Data and Information Set (HEDIS) measures The Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis is a HEDIS measure which is under the effectiveness of care domain The measure is the percentage of members 18 years of age and older diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for a disease-modifying anti-rheumatic drug (DMARD) 3
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What is Rheumatoid Arthritis? The most common systemic auto-immune inflammatory disease characterized by symmetric, relapsing, or chronic destructive synovitis Synovitis = inflammation of the synovial membrane which lines joints 4
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Epidemiology Annual incidence of RA: 40 per 100,000 per year About 1.3 million U.S. adults are affected Women are affected two to three times more often than men 5
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Risk Factors Smoking Genetic predisposition HLA-DRB1 gene family history Sex (female) Increasing age Obesity (overweight) 6
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Pathogenesis The initial triggering event is not clear T cells and B cells activated (in response to mutated citrullinated vimentin (MCV), structural protein in human) Antibodies to MCV complex with MCV to precipitate in joint Production of inflammatory cytokines (IL-6,TNF) Macrophages, lymphocytes, and plasma cells Metalloprotinases (MMP) from Macrophages to damage synovial tissue Rheumatoid factor from plasma cells 7
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Clinical Presentation Joint pain and stiffness (bilateral and symmetrical) Joint swelling and deformity (Hallux Valgus/Swan Neck Deformity) Tenderness Warmth Rheumatoid nodules
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Clinical Presentation 9 Low grade fever Loss of appetite Fatigue and weakness
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Complications of RA 10 Pulmonary – COPD, pulmonary fibrosis Cardiac – Pericarditis Eye – Inflammation of episclera Blood - Thrombocytosis
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Diagnostic Criteria The American College of Rheumatology and European League Against Rheumatism 2010 Guideline (ACR/EULAR 2010 guideline) There are categories A to D Category A: Joint Involvement Category B: Serology Category C: Acute Phase Reactants Category D: Duration of Symptoms Patients must have a score of equal or greater than 6 out of 10 11
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ACR/EULAR CriteriaCategory A: Joint Involvement Small Joint: wrists, metacarpophalangeal joints, proximal interphalangeal joints, 2nd – 5th metatarsophalangeal joints, and thumb joints Large joint: shoulders, elbows, hips, knees, and ankles 12
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ACR/EULAR CriteriaCategory B: Serology RF – rheumatoid factor ACPA – anti-citrullinated protein antibody Low-positive: defined as higher than the upper limit of normal (ULN) but not equal or less than three times of the ULN High-positive: defined as greater than three times of ULN 13
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ACR/EULAR CriteriaCategory C: Acute Phase Reactants CRP – C-reactive protein ESR – Erythrocyte sedimentation rate 14
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ACR/EULAR CriteriaCategory D: Duration of Symptoms Patient self-report on duration of signs/symptoms 15
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RA Disease Activity Instruments 16
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Treatment Algorithm for RA
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Treatment Algorithm for Early RA: < 6 months 18 Early RA
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Treatment Algorithm forEstablished RA: ≥ 6 months 19
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Treatment Algorithm forEstablished RA: ≥ 6 months (Continues) 20
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Medications (DMARDs) 21
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Traditional DMARDs 22
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Biologic DMARDs (TNF-I) Etanercept (Enbrel) – 50 mg SC once weekly Adalimumab (Humira) – 40 mg SC every 2 weeks Infliximab (Remicade) – 3 mg/kg IV over ≥2 hrs at 0,2, and 6 weeks. Certolizumab pegol (Cimzia) – 400 mg SC at 0,2, and 4 weeks initially and 200 mg SC every other week or 400 mg every 4 weeks for maintenance. Golimumab (Simponi Aria) – 50 mg SC once a month or 2 mg/kg IV over 30 min at 0 and 4, then every 8 weeks. 23
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Biologic DMARDs (non-TNF) Rituximab (Rituxan) – 1000 mg IV on days 1 and 15 Anakinra (Kineret) – 100 mg SC once a day Abatacept (Orencia) – 500 – 1000 mg IV at 0,2, and 4 weeks, then every 4 weeks or 125 mg SC weekly Tocilizumab (Actemra) – 4 mg/kg IV over 60 min every 4 weeks or 162 mg SC every week (for ≥100kg) and every other week (for <100 kg) Sarilumab (Kevzara) – 200 mg SC every 2 weeks 24
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Biologic DMARDs (TNFI & non-TNF) Must screen patient for TB prior to initiate therapy Treat latent or active TB for 1 month prior to starting or resuming biologics Avoid live vaccines while on therapy Give appropriate vaccinations (inactivated) Pneumococcal Influenza (IM) Hepatitis B (if risk factors exist: healthcare personnel, drug abuse, multiple sex partners) 25
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Synthetic small molecule Tofacitinib (Xeljanz, Xeljanz XR) – 5 mg by mouth twice a day for immediate release and 11 mg by mouth once a day for extended release. Adverse reactions – Serious infections including TB, fungal, viral, or other opportunistic infections, Lipid abnormalities, Bradycardia, Malignancy Patient education – avoid live vaccines during therapy and check TB prior to therapy 26
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Other Treatments Nonsteroidal anti-inflammatory drugs (NSAIDs) Corticosteroids Thermotherapy Electromagnetic and ultrasound therapies Patient education programs like nurse-led patient education program, mindfulness-based stress reduction, and coaching program for healthy physical activity. 27
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Interesting/Useful App MyRA Track joint pain daily Track medications Track activity limits Summary report 28
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References Helmick CG, Felson DT, Lawrence RC, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States- Part I. Arthritis & Rheum. 2008: 58(1):15-25. Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States- Part II. Arthritis & Rheum. 2008: 58(1):26-35. Sugiyama D, Nishimura K, et al. “Impact of smoking as a risk factor for developing rheumatoid arthritis: a meta-analysis of observational studies” Ann Rheum Dis. 2010 Jan;69(1):70-81. doi: 10.1136/ard.2008.096487. Turesson C, Matteson EL. „Genetics of rheumatoid arthritis“ Mayo Clin Proc. 2006 Jan;81(1):94-101 Robinson V, Brosseau L, et al. “Thermotherapy for treating rheumatoid arthritis” Cochrane Database Syst Rev. 2002;(2):CD002826. Brosseau L. Robinson V, et al. “ Low level laser therapy (Classes I, II, and III) for treating rheumatoid arthritis” Cochrane Database Syst Rev. 2005 Oct 19;(4):CD002049 Gronning K, Rannestad T, et al. “Long-term effects of a nurse-led group and individual patient education programme for patients with chronic inflammatory polyarthritis” J Clin Nurs. 2014 Apr;23(7-8):1005-17. doi: 10.1111/jocn.12353. Epub 2013 Jul 22. Pradhan EK, Baumgarten M, et al. “Effect of Mindfulness-based stress reduction in rheumatoid arthritis patients” Arthritis Rheum. 2007 Oct 15;57(7):1134-42. Brodin N, Eurenius E, et al. “Coaching patients with early rheumatoid arthritis to healthy physical activity:a multicenter , randomized, controlled study” Arthritis Rheum. 2008 Mar 15;59(3):325-31. doi: 10.1002/art.23327. The Centers for Disease Control and Prevention March 2017 Vital signs The American College of Rheumatology and European League Against Rheumatism 2010 Guideline The American College of Rheumatology 2012 and 2015 Guidelines 29