Rheumatology Red Flags

Emergencies the GP Should Not Miss

DR MICHAEL STARR

DIVISION OF RHEUMATOLOGY

MUHC

Family Medicine Review Course December 4 2016

Disclosures

Amgen

Janssen

Roche

BMS

Pfizer

UCB

Novartis

Advisory board speaker clinical trialshellip

Objectives

1 Recognize patterns of acute rheumatic scenarios that require timely management

2 Importance of early referral and treatment of patients with suspected inflammatory rheumatic syndromes

3 Update on current therapeutic options and side effects to be aware of

Topics to be reviewed

The hot joint

New onset Inflammatory Arthritis

GCA

The patient on biologics

The Hot Joint

Case

67 year old man

Type 2 diabetic suffers with ulcers on

legsrecent knee injection for OA

Presents with acute history (progressive over 48-

72 hours) of painful hot swollen red knee

Struggling to walk into clinic

Feels feverish past 36 hours

Acute Monoarthritis - Etiology

THE MOST CRITICAL DIAGNOSIS TO CONSIDER INFECTION

DDX

Crystal (Gout Pseudogout)

Hemarthrosis (heme disorders)

Monoarticular onset of systemic disease or other inflammatory arthritis ( ex RA Spondyloarthritis)

Trauma

Risk Factors for Septic Arthritis

Previous arthritis

Trauma

Diabetes Mellitus

Immunosupression

Bacteremia

Sickle cell anemia

Prosthetic joint Recent IA injection

Pathogens

90 non-gonococcal

staph aureus 50-80 streptococcus 15-20 haemophilus influenzae b 20 (infants 6mo-2yrs) anaerobes 5

Gonococcal

young sexually active

Pustular skin lesions (dermatitis-arthritis syndrome)

Tenosynovitis

Migratory arthralgias

Hand gt knee wrist ankle or elbow

INFECTIOUS (PYOGENIC)

ARTHRITIS Assume any monoarticular arthritis is infectious until

proven otherwise

Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days

If a nearby break in skin or bacteremia most definitely approach as infectious process

Septic joint carries high morbidity and mortality

Inflammatory arthritis can mimic septic joint

Empiric Therapy for Septic Arthritis

You must cover Staph and Strep

Oxacillin cephozolin

Vanco if PCN-allergic or if concern for MRSA

If infection is hospital acquired or prosthetic joint- cover gram negatives

3rd generation cephalosporin

Empiric coverage for GC is recommended if clinical suspicion

Frequent aspiration of joint

Treat 2-4 weeks iv then 2-4 weeks po

Learning points

1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations

1 Donrsquot miss septic arthritis Aspirate when possible

1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist

4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology

Case History 36 year old marathon runner notices

that the balls of her feet are sore when she awakenshellipshe attributes this to sports

2 months later 1 week swelling of kneehellipGP treats with an NSAID

3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running

Increasing am stiffness fatigue

Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most

common types - 1 of population

Psoriatic arthritis

Ankylosing spondylitis

Polyarticular goutpseudogout (calcium

pyrophosphate disease)

Reactive arthritis

Postviral arthritis

Enteropathic arthritis

1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003

Investigation of Suspected

Inflammatory Arthritis

Investigation of Inflammatory Arthritis Complete blood cell count (CBC)

Erythrocyte sedimentation rate (ESR) or

C-reactive protein (CRP) level

Urinalysis

Rheumatoid factor (RF)

Radiographs of hands and feet

New test now available

Anti-cyclic citrullinated peptide (anti-CCP)

1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346

IMPACT OF

RHEUMATOID ARTHRITIS

Disability

Limited activitieswork loss

Substantial morbidity

Increased mortality

Brief Delay of Therapy

Predicts Remission 2 Years

Fin-RA Co Study

Treatment Delay

Est

imate

d P

erc

en

t R

em

issi

on

Adjusted for age at BSL sex shared epitope RF and

ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002

11

35

p=0010

0

10

20

30

40

50

60

70

Single Treatment

gt 4 Months

lt 4 Months

REFERRAL To Local Rheumatologist

Patient Name

Address

City Postal Code

Telephone H) W)

Date of Birth Health Card Number

Reason for Referral Suspected Inflammatory Arthritis

When did symptoms start

How many swollen joints

Which joints

Other information

Laboratory and X-ray Results (Please attach pertinent results)

Signature of Referring Physician

Physician Number

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Objectives

1 Recognize patterns of acute rheumatic scenarios that require timely management

2 Importance of early referral and treatment of patients with suspected inflammatory rheumatic syndromes

3 Update on current therapeutic options and side effects to be aware of

Topics to be reviewed

The hot joint

New onset Inflammatory Arthritis

GCA

The patient on biologics

The Hot Joint

Case

67 year old man

Type 2 diabetic suffers with ulcers on

legsrecent knee injection for OA

Presents with acute history (progressive over 48-

72 hours) of painful hot swollen red knee

Struggling to walk into clinic

Feels feverish past 36 hours

Acute Monoarthritis - Etiology

THE MOST CRITICAL DIAGNOSIS TO CONSIDER INFECTION

DDX

Crystal (Gout Pseudogout)

Hemarthrosis (heme disorders)

Monoarticular onset of systemic disease or other inflammatory arthritis ( ex RA Spondyloarthritis)

Trauma

Risk Factors for Septic Arthritis

Previous arthritis

Trauma

Diabetes Mellitus

Immunosupression

Bacteremia

Sickle cell anemia

Prosthetic joint Recent IA injection

Pathogens

90 non-gonococcal

staph aureus 50-80 streptococcus 15-20 haemophilus influenzae b 20 (infants 6mo-2yrs) anaerobes 5

Gonococcal

young sexually active

Pustular skin lesions (dermatitis-arthritis syndrome)

Tenosynovitis

Migratory arthralgias

Hand gt knee wrist ankle or elbow

INFECTIOUS (PYOGENIC)

ARTHRITIS Assume any monoarticular arthritis is infectious until

proven otherwise

Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days

If a nearby break in skin or bacteremia most definitely approach as infectious process

Septic joint carries high morbidity and mortality

Inflammatory arthritis can mimic septic joint

Empiric Therapy for Septic Arthritis

You must cover Staph and Strep

Oxacillin cephozolin

Vanco if PCN-allergic or if concern for MRSA

If infection is hospital acquired or prosthetic joint- cover gram negatives

3rd generation cephalosporin

Empiric coverage for GC is recommended if clinical suspicion

Frequent aspiration of joint

Treat 2-4 weeks iv then 2-4 weeks po

Learning points

1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations

1 Donrsquot miss septic arthritis Aspirate when possible

1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist

4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology

Case History 36 year old marathon runner notices

that the balls of her feet are sore when she awakenshellipshe attributes this to sports

2 months later 1 week swelling of kneehellipGP treats with an NSAID

3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running

Increasing am stiffness fatigue

Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most

common types - 1 of population

Psoriatic arthritis

Ankylosing spondylitis

Polyarticular goutpseudogout (calcium

pyrophosphate disease)

Reactive arthritis

Postviral arthritis

Enteropathic arthritis

1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003

Investigation of Suspected

Inflammatory Arthritis

Investigation of Inflammatory Arthritis Complete blood cell count (CBC)

Erythrocyte sedimentation rate (ESR) or

C-reactive protein (CRP) level

Urinalysis

Rheumatoid factor (RF)

Radiographs of hands and feet

New test now available

Anti-cyclic citrullinated peptide (anti-CCP)

1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346

IMPACT OF

RHEUMATOID ARTHRITIS

Disability

Limited activitieswork loss

Substantial morbidity

Increased mortality

Brief Delay of Therapy

Predicts Remission 2 Years

Fin-RA Co Study

Treatment Delay

Est

imate

d P

erc

en

t R

em

issi

on

Adjusted for age at BSL sex shared epitope RF and

ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002

11

35

p=0010

0

10

20

30

40

50

60

70

Single Treatment

gt 4 Months

lt 4 Months

REFERRAL To Local Rheumatologist

Patient Name

Address

City Postal Code

Telephone H) W)

Date of Birth Health Card Number

Reason for Referral Suspected Inflammatory Arthritis

When did symptoms start

How many swollen joints

Which joints

Other information

Laboratory and X-ray Results (Please attach pertinent results)

Signature of Referring Physician

Physician Number

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Topics to be reviewed

The hot joint

New onset Inflammatory Arthritis

GCA

The patient on biologics

The Hot Joint

Case

67 year old man

Type 2 diabetic suffers with ulcers on

legsrecent knee injection for OA

Presents with acute history (progressive over 48-

72 hours) of painful hot swollen red knee

Struggling to walk into clinic

Feels feverish past 36 hours

Acute Monoarthritis - Etiology

THE MOST CRITICAL DIAGNOSIS TO CONSIDER INFECTION

DDX

Crystal (Gout Pseudogout)

Hemarthrosis (heme disorders)

Monoarticular onset of systemic disease or other inflammatory arthritis ( ex RA Spondyloarthritis)

Trauma

Risk Factors for Septic Arthritis

Previous arthritis

Trauma

Diabetes Mellitus

Immunosupression

Bacteremia

Sickle cell anemia

Prosthetic joint Recent IA injection

Pathogens

90 non-gonococcal

staph aureus 50-80 streptococcus 15-20 haemophilus influenzae b 20 (infants 6mo-2yrs) anaerobes 5

Gonococcal

young sexually active

Pustular skin lesions (dermatitis-arthritis syndrome)

Tenosynovitis

Migratory arthralgias

Hand gt knee wrist ankle or elbow

INFECTIOUS (PYOGENIC)

ARTHRITIS Assume any monoarticular arthritis is infectious until

proven otherwise

Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days

If a nearby break in skin or bacteremia most definitely approach as infectious process

Septic joint carries high morbidity and mortality

Inflammatory arthritis can mimic septic joint

Empiric Therapy for Septic Arthritis

You must cover Staph and Strep

Oxacillin cephozolin

Vanco if PCN-allergic or if concern for MRSA

If infection is hospital acquired or prosthetic joint- cover gram negatives

3rd generation cephalosporin

Empiric coverage for GC is recommended if clinical suspicion

Frequent aspiration of joint

Treat 2-4 weeks iv then 2-4 weeks po

Learning points

1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations

1 Donrsquot miss septic arthritis Aspirate when possible

1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist

4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology

Case History 36 year old marathon runner notices

that the balls of her feet are sore when she awakenshellipshe attributes this to sports

2 months later 1 week swelling of kneehellipGP treats with an NSAID

3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running

Increasing am stiffness fatigue

Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most

common types - 1 of population

Psoriatic arthritis

Ankylosing spondylitis

Polyarticular goutpseudogout (calcium

pyrophosphate disease)

Reactive arthritis

Postviral arthritis

Enteropathic arthritis

1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003

Investigation of Suspected

Inflammatory Arthritis

Investigation of Inflammatory Arthritis Complete blood cell count (CBC)

Erythrocyte sedimentation rate (ESR) or

C-reactive protein (CRP) level

Urinalysis

Rheumatoid factor (RF)

Radiographs of hands and feet

New test now available

Anti-cyclic citrullinated peptide (anti-CCP)

1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346

IMPACT OF

RHEUMATOID ARTHRITIS

Disability

Limited activitieswork loss

Substantial morbidity

Increased mortality

Brief Delay of Therapy

Predicts Remission 2 Years

Fin-RA Co Study

Treatment Delay

Est

imate

d P

erc

en

t R

em

issi

on

Adjusted for age at BSL sex shared epitope RF and

ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002

11

35

p=0010

0

10

20

30

40

50

60

70

Single Treatment

gt 4 Months

lt 4 Months

REFERRAL To Local Rheumatologist

Patient Name

Address

City Postal Code

Telephone H) W)

Date of Birth Health Card Number

Reason for Referral Suspected Inflammatory Arthritis

When did symptoms start

How many swollen joints

Which joints

Other information

Laboratory and X-ray Results (Please attach pertinent results)

Signature of Referring Physician

Physician Number

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

The Hot Joint

Case

67 year old man

Type 2 diabetic suffers with ulcers on

legsrecent knee injection for OA

Presents with acute history (progressive over 48-

72 hours) of painful hot swollen red knee

Struggling to walk into clinic

Feels feverish past 36 hours

Acute Monoarthritis - Etiology

THE MOST CRITICAL DIAGNOSIS TO CONSIDER INFECTION

DDX

Crystal (Gout Pseudogout)

Hemarthrosis (heme disorders)

Monoarticular onset of systemic disease or other inflammatory arthritis ( ex RA Spondyloarthritis)

Trauma

Risk Factors for Septic Arthritis

Previous arthritis

Trauma

Diabetes Mellitus

Immunosupression

Bacteremia

Sickle cell anemia

Prosthetic joint Recent IA injection

Pathogens

90 non-gonococcal

staph aureus 50-80 streptococcus 15-20 haemophilus influenzae b 20 (infants 6mo-2yrs) anaerobes 5

Gonococcal

young sexually active

Pustular skin lesions (dermatitis-arthritis syndrome)

Tenosynovitis

Migratory arthralgias

Hand gt knee wrist ankle or elbow

INFECTIOUS (PYOGENIC)

ARTHRITIS Assume any monoarticular arthritis is infectious until

proven otherwise

Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days

If a nearby break in skin or bacteremia most definitely approach as infectious process

Septic joint carries high morbidity and mortality

Inflammatory arthritis can mimic septic joint

Empiric Therapy for Septic Arthritis

You must cover Staph and Strep

Oxacillin cephozolin

Vanco if PCN-allergic or if concern for MRSA

If infection is hospital acquired or prosthetic joint- cover gram negatives

3rd generation cephalosporin

Empiric coverage for GC is recommended if clinical suspicion

Frequent aspiration of joint

Treat 2-4 weeks iv then 2-4 weeks po

Learning points

1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations

1 Donrsquot miss septic arthritis Aspirate when possible

1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist

4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology

Case History 36 year old marathon runner notices

that the balls of her feet are sore when she awakenshellipshe attributes this to sports

2 months later 1 week swelling of kneehellipGP treats with an NSAID

3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running

Increasing am stiffness fatigue

Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most

common types - 1 of population

Psoriatic arthritis

Ankylosing spondylitis

Polyarticular goutpseudogout (calcium

pyrophosphate disease)

Reactive arthritis

Postviral arthritis

Enteropathic arthritis

1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003

Investigation of Suspected

Inflammatory Arthritis

Investigation of Inflammatory Arthritis Complete blood cell count (CBC)

Erythrocyte sedimentation rate (ESR) or

C-reactive protein (CRP) level

Urinalysis

Rheumatoid factor (RF)

Radiographs of hands and feet

New test now available

Anti-cyclic citrullinated peptide (anti-CCP)

1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346

IMPACT OF

RHEUMATOID ARTHRITIS

Disability

Limited activitieswork loss

Substantial morbidity

Increased mortality

Brief Delay of Therapy

Predicts Remission 2 Years

Fin-RA Co Study

Treatment Delay

Est

imate

d P

erc

en

t R

em

issi

on

Adjusted for age at BSL sex shared epitope RF and

ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002

11

35

p=0010

0

10

20

30

40

50

60

70

Single Treatment

gt 4 Months

lt 4 Months

REFERRAL To Local Rheumatologist

Patient Name

Address

City Postal Code

Telephone H) W)

Date of Birth Health Card Number

Reason for Referral Suspected Inflammatory Arthritis

When did symptoms start

How many swollen joints

Which joints

Other information

Laboratory and X-ray Results (Please attach pertinent results)

Signature of Referring Physician

Physician Number

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Case

67 year old man

Type 2 diabetic suffers with ulcers on

legsrecent knee injection for OA

Presents with acute history (progressive over 48-

72 hours) of painful hot swollen red knee

Struggling to walk into clinic

Feels feverish past 36 hours

Acute Monoarthritis - Etiology

THE MOST CRITICAL DIAGNOSIS TO CONSIDER INFECTION

DDX

Crystal (Gout Pseudogout)

Hemarthrosis (heme disorders)

Monoarticular onset of systemic disease or other inflammatory arthritis ( ex RA Spondyloarthritis)

Trauma

Risk Factors for Septic Arthritis

Previous arthritis

Trauma

Diabetes Mellitus

Immunosupression

Bacteremia

Sickle cell anemia

Prosthetic joint Recent IA injection

Pathogens

90 non-gonococcal

staph aureus 50-80 streptococcus 15-20 haemophilus influenzae b 20 (infants 6mo-2yrs) anaerobes 5

Gonococcal

young sexually active

Pustular skin lesions (dermatitis-arthritis syndrome)

Tenosynovitis

Migratory arthralgias

Hand gt knee wrist ankle or elbow

INFECTIOUS (PYOGENIC)

ARTHRITIS Assume any monoarticular arthritis is infectious until

proven otherwise

Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days

If a nearby break in skin or bacteremia most definitely approach as infectious process

Septic joint carries high morbidity and mortality

Inflammatory arthritis can mimic septic joint

Empiric Therapy for Septic Arthritis

You must cover Staph and Strep

Oxacillin cephozolin

Vanco if PCN-allergic or if concern for MRSA

If infection is hospital acquired or prosthetic joint- cover gram negatives

3rd generation cephalosporin

Empiric coverage for GC is recommended if clinical suspicion

Frequent aspiration of joint

Treat 2-4 weeks iv then 2-4 weeks po

Learning points

1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations

1 Donrsquot miss septic arthritis Aspirate when possible

1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist

4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology

Case History 36 year old marathon runner notices

that the balls of her feet are sore when she awakenshellipshe attributes this to sports

2 months later 1 week swelling of kneehellipGP treats with an NSAID

3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running

Increasing am stiffness fatigue

Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most

common types - 1 of population

Psoriatic arthritis

Ankylosing spondylitis

Polyarticular goutpseudogout (calcium

pyrophosphate disease)

Reactive arthritis

Postviral arthritis

Enteropathic arthritis

1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003

Investigation of Suspected

Inflammatory Arthritis

Investigation of Inflammatory Arthritis Complete blood cell count (CBC)

Erythrocyte sedimentation rate (ESR) or

C-reactive protein (CRP) level

Urinalysis

Rheumatoid factor (RF)

Radiographs of hands and feet

New test now available

Anti-cyclic citrullinated peptide (anti-CCP)

1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346

IMPACT OF

RHEUMATOID ARTHRITIS

Disability

Limited activitieswork loss

Substantial morbidity

Increased mortality

Brief Delay of Therapy

Predicts Remission 2 Years

Fin-RA Co Study

Treatment Delay

Est

imate

d P

erc

en

t R

em

issi

on

Adjusted for age at BSL sex shared epitope RF and

ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002

11

35

p=0010

0

10

20

30

40

50

60

70

Single Treatment

gt 4 Months

lt 4 Months

REFERRAL To Local Rheumatologist

Patient Name

Address

City Postal Code

Telephone H) W)

Date of Birth Health Card Number

Reason for Referral Suspected Inflammatory Arthritis

When did symptoms start

How many swollen joints

Which joints

Other information

Laboratory and X-ray Results (Please attach pertinent results)

Signature of Referring Physician

Physician Number

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Acute Monoarthritis - Etiology

THE MOST CRITICAL DIAGNOSIS TO CONSIDER INFECTION

DDX

Crystal (Gout Pseudogout)

Hemarthrosis (heme disorders)

Monoarticular onset of systemic disease or other inflammatory arthritis ( ex RA Spondyloarthritis)

Trauma

Risk Factors for Septic Arthritis

Previous arthritis

Trauma

Diabetes Mellitus

Immunosupression

Bacteremia

Sickle cell anemia

Prosthetic joint Recent IA injection

Pathogens

90 non-gonococcal

staph aureus 50-80 streptococcus 15-20 haemophilus influenzae b 20 (infants 6mo-2yrs) anaerobes 5

Gonococcal

young sexually active

Pustular skin lesions (dermatitis-arthritis syndrome)

Tenosynovitis

Migratory arthralgias

Hand gt knee wrist ankle or elbow

INFECTIOUS (PYOGENIC)

ARTHRITIS Assume any monoarticular arthritis is infectious until

proven otherwise

Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days

If a nearby break in skin or bacteremia most definitely approach as infectious process

Septic joint carries high morbidity and mortality

Inflammatory arthritis can mimic septic joint

Empiric Therapy for Septic Arthritis

You must cover Staph and Strep

Oxacillin cephozolin

Vanco if PCN-allergic or if concern for MRSA

If infection is hospital acquired or prosthetic joint- cover gram negatives

3rd generation cephalosporin

Empiric coverage for GC is recommended if clinical suspicion

Frequent aspiration of joint

Treat 2-4 weeks iv then 2-4 weeks po

Learning points

1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations

1 Donrsquot miss septic arthritis Aspirate when possible

1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist

4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology

Case History 36 year old marathon runner notices

that the balls of her feet are sore when she awakenshellipshe attributes this to sports

2 months later 1 week swelling of kneehellipGP treats with an NSAID

3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running

Increasing am stiffness fatigue

Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most

common types - 1 of population

Psoriatic arthritis

Ankylosing spondylitis

Polyarticular goutpseudogout (calcium

pyrophosphate disease)

Reactive arthritis

Postviral arthritis

Enteropathic arthritis

1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003

Investigation of Suspected

Inflammatory Arthritis

Investigation of Inflammatory Arthritis Complete blood cell count (CBC)

Erythrocyte sedimentation rate (ESR) or

C-reactive protein (CRP) level

Urinalysis

Rheumatoid factor (RF)

Radiographs of hands and feet

New test now available

Anti-cyclic citrullinated peptide (anti-CCP)

1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346

IMPACT OF

RHEUMATOID ARTHRITIS

Disability

Limited activitieswork loss

Substantial morbidity

Increased mortality

Brief Delay of Therapy

Predicts Remission 2 Years

Fin-RA Co Study

Treatment Delay

Est

imate

d P

erc

en

t R

em

issi

on

Adjusted for age at BSL sex shared epitope RF and

ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002

11

35

p=0010

0

10

20

30

40

50

60

70

Single Treatment

gt 4 Months

lt 4 Months

REFERRAL To Local Rheumatologist

Patient Name

Address

City Postal Code

Telephone H) W)

Date of Birth Health Card Number

Reason for Referral Suspected Inflammatory Arthritis

When did symptoms start

How many swollen joints

Which joints

Other information

Laboratory and X-ray Results (Please attach pertinent results)

Signature of Referring Physician

Physician Number

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Risk Factors for Septic Arthritis

Previous arthritis

Trauma

Diabetes Mellitus

Immunosupression

Bacteremia

Sickle cell anemia

Prosthetic joint Recent IA injection

Pathogens

90 non-gonococcal

staph aureus 50-80 streptococcus 15-20 haemophilus influenzae b 20 (infants 6mo-2yrs) anaerobes 5

Gonococcal

young sexually active

Pustular skin lesions (dermatitis-arthritis syndrome)

Tenosynovitis

Migratory arthralgias

Hand gt knee wrist ankle or elbow

INFECTIOUS (PYOGENIC)

ARTHRITIS Assume any monoarticular arthritis is infectious until

proven otherwise

Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days

If a nearby break in skin or bacteremia most definitely approach as infectious process

Septic joint carries high morbidity and mortality

Inflammatory arthritis can mimic septic joint

Empiric Therapy for Septic Arthritis

You must cover Staph and Strep

Oxacillin cephozolin

Vanco if PCN-allergic or if concern for MRSA

If infection is hospital acquired or prosthetic joint- cover gram negatives

3rd generation cephalosporin

Empiric coverage for GC is recommended if clinical suspicion

Frequent aspiration of joint

Treat 2-4 weeks iv then 2-4 weeks po

Learning points

1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations

1 Donrsquot miss septic arthritis Aspirate when possible

1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist

4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology

Case History 36 year old marathon runner notices

that the balls of her feet are sore when she awakenshellipshe attributes this to sports

2 months later 1 week swelling of kneehellipGP treats with an NSAID

3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running

Increasing am stiffness fatigue

Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most

common types - 1 of population

Psoriatic arthritis

Ankylosing spondylitis

Polyarticular goutpseudogout (calcium

pyrophosphate disease)

Reactive arthritis

Postviral arthritis

Enteropathic arthritis

1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003

Investigation of Suspected

Inflammatory Arthritis

Investigation of Inflammatory Arthritis Complete blood cell count (CBC)

Erythrocyte sedimentation rate (ESR) or

C-reactive protein (CRP) level

Urinalysis

Rheumatoid factor (RF)

Radiographs of hands and feet

New test now available

Anti-cyclic citrullinated peptide (anti-CCP)

1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346

IMPACT OF

RHEUMATOID ARTHRITIS

Disability

Limited activitieswork loss

Substantial morbidity

Increased mortality

Brief Delay of Therapy

Predicts Remission 2 Years

Fin-RA Co Study

Treatment Delay

Est

imate

d P

erc

en

t R

em

issi

on

Adjusted for age at BSL sex shared epitope RF and

ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002

11

35

p=0010

0

10

20

30

40

50

60

70

Single Treatment

gt 4 Months

lt 4 Months

REFERRAL To Local Rheumatologist

Patient Name

Address

City Postal Code

Telephone H) W)

Date of Birth Health Card Number

Reason for Referral Suspected Inflammatory Arthritis

When did symptoms start

How many swollen joints

Which joints

Other information

Laboratory and X-ray Results (Please attach pertinent results)

Signature of Referring Physician

Physician Number

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Pathogens

90 non-gonococcal

staph aureus 50-80 streptococcus 15-20 haemophilus influenzae b 20 (infants 6mo-2yrs) anaerobes 5

Gonococcal

young sexually active

Pustular skin lesions (dermatitis-arthritis syndrome)

Tenosynovitis

Migratory arthralgias

Hand gt knee wrist ankle or elbow

INFECTIOUS (PYOGENIC)

ARTHRITIS Assume any monoarticular arthritis is infectious until

proven otherwise

Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days

If a nearby break in skin or bacteremia most definitely approach as infectious process

Septic joint carries high morbidity and mortality

Inflammatory arthritis can mimic septic joint

Empiric Therapy for Septic Arthritis

You must cover Staph and Strep

Oxacillin cephozolin

Vanco if PCN-allergic or if concern for MRSA

If infection is hospital acquired or prosthetic joint- cover gram negatives

3rd generation cephalosporin

Empiric coverage for GC is recommended if clinical suspicion

Frequent aspiration of joint

Treat 2-4 weeks iv then 2-4 weeks po

Learning points

1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations

1 Donrsquot miss septic arthritis Aspirate when possible

1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist

4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology

Case History 36 year old marathon runner notices

that the balls of her feet are sore when she awakenshellipshe attributes this to sports

2 months later 1 week swelling of kneehellipGP treats with an NSAID

3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running

Increasing am stiffness fatigue

Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most

common types - 1 of population

Psoriatic arthritis

Ankylosing spondylitis

Polyarticular goutpseudogout (calcium

pyrophosphate disease)

Reactive arthritis

Postviral arthritis

Enteropathic arthritis

1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003

Investigation of Suspected

Inflammatory Arthritis

Investigation of Inflammatory Arthritis Complete blood cell count (CBC)

Erythrocyte sedimentation rate (ESR) or

C-reactive protein (CRP) level

Urinalysis

Rheumatoid factor (RF)

Radiographs of hands and feet

New test now available

Anti-cyclic citrullinated peptide (anti-CCP)

1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346

IMPACT OF

RHEUMATOID ARTHRITIS

Disability

Limited activitieswork loss

Substantial morbidity

Increased mortality

Brief Delay of Therapy

Predicts Remission 2 Years

Fin-RA Co Study

Treatment Delay

Est

imate

d P

erc

en

t R

em

issi

on

Adjusted for age at BSL sex shared epitope RF and

ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002

11

35

p=0010

0

10

20

30

40

50

60

70

Single Treatment

gt 4 Months

lt 4 Months

REFERRAL To Local Rheumatologist

Patient Name

Address

City Postal Code

Telephone H) W)

Date of Birth Health Card Number

Reason for Referral Suspected Inflammatory Arthritis

When did symptoms start

How many swollen joints

Which joints

Other information

Laboratory and X-ray Results (Please attach pertinent results)

Signature of Referring Physician

Physician Number

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

INFECTIOUS (PYOGENIC)

ARTHRITIS Assume any monoarticular arthritis is infectious until

proven otherwise

Sudden onset and very painful is more suggestive of crystalline disease ndash bacterial infection peaks over a few days

If a nearby break in skin or bacteremia most definitely approach as infectious process

Septic joint carries high morbidity and mortality

Inflammatory arthritis can mimic septic joint

Empiric Therapy for Septic Arthritis

You must cover Staph and Strep

Oxacillin cephozolin

Vanco if PCN-allergic or if concern for MRSA

If infection is hospital acquired or prosthetic joint- cover gram negatives

3rd generation cephalosporin

Empiric coverage for GC is recommended if clinical suspicion

Frequent aspiration of joint

Treat 2-4 weeks iv then 2-4 weeks po

Learning points

1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations

1 Donrsquot miss septic arthritis Aspirate when possible

1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist

4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology

Case History 36 year old marathon runner notices

that the balls of her feet are sore when she awakenshellipshe attributes this to sports

2 months later 1 week swelling of kneehellipGP treats with an NSAID

3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running

Increasing am stiffness fatigue

Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most

common types - 1 of population

Psoriatic arthritis

Ankylosing spondylitis

Polyarticular goutpseudogout (calcium

pyrophosphate disease)

Reactive arthritis

Postviral arthritis

Enteropathic arthritis

1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003

Investigation of Suspected

Inflammatory Arthritis

Investigation of Inflammatory Arthritis Complete blood cell count (CBC)

Erythrocyte sedimentation rate (ESR) or

C-reactive protein (CRP) level

Urinalysis

Rheumatoid factor (RF)

Radiographs of hands and feet

New test now available

Anti-cyclic citrullinated peptide (anti-CCP)

1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346

IMPACT OF

RHEUMATOID ARTHRITIS

Disability

Limited activitieswork loss

Substantial morbidity

Increased mortality

Brief Delay of Therapy

Predicts Remission 2 Years

Fin-RA Co Study

Treatment Delay

Est

imate

d P

erc

en

t R

em

issi

on

Adjusted for age at BSL sex shared epitope RF and

ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002

11

35

p=0010

0

10

20

30

40

50

60

70

Single Treatment

gt 4 Months

lt 4 Months

REFERRAL To Local Rheumatologist

Patient Name

Address

City Postal Code

Telephone H) W)

Date of Birth Health Card Number

Reason for Referral Suspected Inflammatory Arthritis

When did symptoms start

How many swollen joints

Which joints

Other information

Laboratory and X-ray Results (Please attach pertinent results)

Signature of Referring Physician

Physician Number

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Empiric Therapy for Septic Arthritis

You must cover Staph and Strep

Oxacillin cephozolin

Vanco if PCN-allergic or if concern for MRSA

If infection is hospital acquired or prosthetic joint- cover gram negatives

3rd generation cephalosporin

Empiric coverage for GC is recommended if clinical suspicion

Frequent aspiration of joint

Treat 2-4 weeks iv then 2-4 weeks po

Learning points

1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations

1 Donrsquot miss septic arthritis Aspirate when possible

1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist

4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology

Case History 36 year old marathon runner notices

that the balls of her feet are sore when she awakenshellipshe attributes this to sports

2 months later 1 week swelling of kneehellipGP treats with an NSAID

3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running

Increasing am stiffness fatigue

Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most

common types - 1 of population

Psoriatic arthritis

Ankylosing spondylitis

Polyarticular goutpseudogout (calcium

pyrophosphate disease)

Reactive arthritis

Postviral arthritis

Enteropathic arthritis

1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003

Investigation of Suspected

Inflammatory Arthritis

Investigation of Inflammatory Arthritis Complete blood cell count (CBC)

Erythrocyte sedimentation rate (ESR) or

C-reactive protein (CRP) level

Urinalysis

Rheumatoid factor (RF)

Radiographs of hands and feet

New test now available

Anti-cyclic citrullinated peptide (anti-CCP)

1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346

IMPACT OF

RHEUMATOID ARTHRITIS

Disability

Limited activitieswork loss

Substantial morbidity

Increased mortality

Brief Delay of Therapy

Predicts Remission 2 Years

Fin-RA Co Study

Treatment Delay

Est

imate

d P

erc

en

t R

em

issi

on

Adjusted for age at BSL sex shared epitope RF and

ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002

11

35

p=0010

0

10

20

30

40

50

60

70

Single Treatment

gt 4 Months

lt 4 Months

REFERRAL To Local Rheumatologist

Patient Name

Address

City Postal Code

Telephone H) W)

Date of Birth Health Card Number

Reason for Referral Suspected Inflammatory Arthritis

When did symptoms start

How many swollen joints

Which joints

Other information

Laboratory and X-ray Results (Please attach pertinent results)

Signature of Referring Physician

Physician Number

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Learning points

1 In acute inflammatory mono or polyarthritis an appropriate history and physical will narrow the Ddx and help guide the investigations

1 Donrsquot miss septic arthritis Aspirate when possible

1 In acute inflammatory monoarthritis symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy Beware that gout and sepsis can co-exist

4 Acute monoarthritis (but no history of trauma) or polyarthritis with systemic features refer to Rheumatology

Case History 36 year old marathon runner notices

that the balls of her feet are sore when she awakenshellipshe attributes this to sports

2 months later 1 week swelling of kneehellipGP treats with an NSAID

3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running

Increasing am stiffness fatigue

Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most

common types - 1 of population

Psoriatic arthritis

Ankylosing spondylitis

Polyarticular goutpseudogout (calcium

pyrophosphate disease)

Reactive arthritis

Postviral arthritis

Enteropathic arthritis

1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003

Investigation of Suspected

Inflammatory Arthritis

Investigation of Inflammatory Arthritis Complete blood cell count (CBC)

Erythrocyte sedimentation rate (ESR) or

C-reactive protein (CRP) level

Urinalysis

Rheumatoid factor (RF)

Radiographs of hands and feet

New test now available

Anti-cyclic citrullinated peptide (anti-CCP)

1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346

IMPACT OF

RHEUMATOID ARTHRITIS

Disability

Limited activitieswork loss

Substantial morbidity

Increased mortality

Brief Delay of Therapy

Predicts Remission 2 Years

Fin-RA Co Study

Treatment Delay

Est

imate

d P

erc

en

t R

em

issi

on

Adjusted for age at BSL sex shared epitope RF and

ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002

11

35

p=0010

0

10

20

30

40

50

60

70

Single Treatment

gt 4 Months

lt 4 Months

REFERRAL To Local Rheumatologist

Patient Name

Address

City Postal Code

Telephone H) W)

Date of Birth Health Card Number

Reason for Referral Suspected Inflammatory Arthritis

When did symptoms start

How many swollen joints

Which joints

Other information

Laboratory and X-ray Results (Please attach pertinent results)

Signature of Referring Physician

Physician Number

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Case History 36 year old marathon runner notices

that the balls of her feet are sore when she awakenshellipshe attributes this to sports

2 months later 1 week swelling of kneehellipGP treats with an NSAID

3 months later right 2nd PIP 3rd MCP bilateral swells and fingers become stiffhellipshe goes to see GP realizing that this now canrsquot be due to running

Increasing am stiffness fatigue

Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most

common types - 1 of population

Psoriatic arthritis

Ankylosing spondylitis

Polyarticular goutpseudogout (calcium

pyrophosphate disease)

Reactive arthritis

Postviral arthritis

Enteropathic arthritis

1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003

Investigation of Suspected

Inflammatory Arthritis

Investigation of Inflammatory Arthritis Complete blood cell count (CBC)

Erythrocyte sedimentation rate (ESR) or

C-reactive protein (CRP) level

Urinalysis

Rheumatoid factor (RF)

Radiographs of hands and feet

New test now available

Anti-cyclic citrullinated peptide (anti-CCP)

1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346

IMPACT OF

RHEUMATOID ARTHRITIS

Disability

Limited activitieswork loss

Substantial morbidity

Increased mortality

Brief Delay of Therapy

Predicts Remission 2 Years

Fin-RA Co Study

Treatment Delay

Est

imate

d P

erc

en

t R

em

issi

on

Adjusted for age at BSL sex shared epitope RF and

ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002

11

35

p=0010

0

10

20

30

40

50

60

70

Single Treatment

gt 4 Months

lt 4 Months

REFERRAL To Local Rheumatologist

Patient Name

Address

City Postal Code

Telephone H) W)

Date of Birth Health Card Number

Reason for Referral Suspected Inflammatory Arthritis

When did symptoms start

How many swollen joints

Which joints

Other information

Laboratory and X-ray Results (Please attach pertinent results)

Signature of Referring Physician

Physician Number

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Types of Inflammatory Arthritis Rheumatoid arthritis (RA) - one of the most

common types - 1 of population

Psoriatic arthritis

Ankylosing spondylitis

Polyarticular goutpseudogout (calcium

pyrophosphate disease)

Reactive arthritis

Postviral arthritis

Enteropathic arthritis

1 Quinn MA et al In Hochberg MC et al (eds) Rheumatology New York Mosby 2003

Investigation of Suspected

Inflammatory Arthritis

Investigation of Inflammatory Arthritis Complete blood cell count (CBC)

Erythrocyte sedimentation rate (ESR) or

C-reactive protein (CRP) level

Urinalysis

Rheumatoid factor (RF)

Radiographs of hands and feet

New test now available

Anti-cyclic citrullinated peptide (anti-CCP)

1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346

IMPACT OF

RHEUMATOID ARTHRITIS

Disability

Limited activitieswork loss

Substantial morbidity

Increased mortality

Brief Delay of Therapy

Predicts Remission 2 Years

Fin-RA Co Study

Treatment Delay

Est

imate

d P

erc

en

t R

em

issi

on

Adjusted for age at BSL sex shared epitope RF and

ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002

11

35

p=0010

0

10

20

30

40

50

60

70

Single Treatment

gt 4 Months

lt 4 Months

REFERRAL To Local Rheumatologist

Patient Name

Address

City Postal Code

Telephone H) W)

Date of Birth Health Card Number

Reason for Referral Suspected Inflammatory Arthritis

When did symptoms start

How many swollen joints

Which joints

Other information

Laboratory and X-ray Results (Please attach pertinent results)

Signature of Referring Physician

Physician Number

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Investigation of Suspected

Inflammatory Arthritis

Investigation of Inflammatory Arthritis Complete blood cell count (CBC)

Erythrocyte sedimentation rate (ESR) or

C-reactive protein (CRP) level

Urinalysis

Rheumatoid factor (RF)

Radiographs of hands and feet

New test now available

Anti-cyclic citrullinated peptide (anti-CCP)

1 ACR Subcommittee on Rheumatoid Arthritis Guidelines Arthritis Rheum 200246328-346

IMPACT OF

RHEUMATOID ARTHRITIS

Disability

Limited activitieswork loss

Substantial morbidity

Increased mortality

Brief Delay of Therapy

Predicts Remission 2 Years

Fin-RA Co Study

Treatment Delay

Est

imate

d P

erc

en

t R

em

issi

on

Adjusted for age at BSL sex shared epitope RF and

ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002

11

35

p=0010

0

10

20

30

40

50

60

70

Single Treatment

gt 4 Months

lt 4 Months

REFERRAL To Local Rheumatologist

Patient Name

Address

City Postal Code

Telephone H) W)

Date of Birth Health Card Number

Reason for Referral Suspected Inflammatory Arthritis

When did symptoms start

How many swollen joints

Which joints

Other information

Laboratory and X-ray Results (Please attach pertinent results)

Signature of Referring Physician

Physician Number

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

IMPACT OF

RHEUMATOID ARTHRITIS

Disability

Limited activitieswork loss

Substantial morbidity

Increased mortality

Brief Delay of Therapy

Predicts Remission 2 Years

Fin-RA Co Study

Treatment Delay

Est

imate

d P

erc

en

t R

em

issi

on

Adjusted for age at BSL sex shared epitope RF and

ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002

11

35

p=0010

0

10

20

30

40

50

60

70

Single Treatment

gt 4 Months

lt 4 Months

REFERRAL To Local Rheumatologist

Patient Name

Address

City Postal Code

Telephone H) W)

Date of Birth Health Card Number

Reason for Referral Suspected Inflammatory Arthritis

When did symptoms start

How many swollen joints

Which joints

Other information

Laboratory and X-ray Results (Please attach pertinent results)

Signature of Referring Physician

Physician Number

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Brief Delay of Therapy

Predicts Remission 2 Years

Fin-RA Co Study

Treatment Delay

Est

imate

d P

erc

en

t R

em

issi

on

Adjusted for age at BSL sex shared epitope RF and

ACR Criteria fulfilledMottonen et al Arth Rheum 46 894 2002

11

35

p=0010

0

10

20

30

40

50

60

70

Single Treatment

gt 4 Months

lt 4 Months

REFERRAL To Local Rheumatologist

Patient Name

Address

City Postal Code

Telephone H) W)

Date of Birth Health Card Number

Reason for Referral Suspected Inflammatory Arthritis

When did symptoms start

How many swollen joints

Which joints

Other information

Laboratory and X-ray Results (Please attach pertinent results)

Signature of Referring Physician

Physician Number

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

REFERRAL To Local Rheumatologist

Patient Name

Address

City Postal Code

Telephone H) W)

Date of Birth Health Card Number

Reason for Referral Suspected Inflammatory Arthritis

When did symptoms start

How many swollen joints

Which joints

Other information

Laboratory and X-ray Results (Please attach pertinent results)

Signature of Referring Physician

Physician Number

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Key Messages

Disability and joint damage occur early in RA

Short delay in therapy may have a long term effect on increasing joint damage

Early aggressive therapy with combination DMARDs andor biologic agents may have a long term effect on reducing joint damage

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Case Study

67 yo woman

TIA resolved put on ASA

Malaise myalgias weight loss low grade fever

few months

Left arm feels weak achy with use

Left subclavian bruit on exam

ESR 86 CRP 58

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

GCA- (Giant Cell Arteritis)

Clinical Features amp Epidemiology

Mean age is 70

75 females

Onset often abrupt

Wide spectrum of symptoms

PMR in 40 - 60

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

GIANT CELL ARTERITIS Clues

gt 50 yo

NEW headache

Jaw claudication or arm claudication

Sudden visual loss diplopia

Systemically ill with many markers of systemic

inflammation increased CRP Ferritin ESR

Approach

TREAT and then biopsy

You have 2 weeks to get the biopsy

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Treatment of GCA

Prednisone 40-60 mgday

iv pulse methylprednisolone for patients with

visual symptoms

Treat full dose 4-6 weeks then reduce by 10

every 2 weeks more slowly once 20 mgday has

been reached

Alternate day therapy NOT recommended

Add ASA 80 mg

Steroid sparing drugs- MTX Tocilizumab

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Side Effects Corticosteroids

Osteoporosis

Osteoporosis Society of Canada (OSC)

recommends Bisphosphonate therapy for

all patients who take gt75 mgday of

Prednisone for gt3 months

Calcium 1200-1500 mgday and Vitamin D

1000 uday

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

The Patient on Biologics

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

MCQ-1

Which of the following is false

Biologic agents have been associated with which

all of the following

1 increased risk of infection

2 increased risk of demyelinating disease

3 increased risk of MI and CVA

4 increased risk of skin cancers

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Mini Case 1

61 year old male with RA Tx with Adalimumab

MTX Diclofenac Presents to ER with cellulitus

left leg WBC 122 Temp 38 He is due for

Adalimumab SC injection in 2 days

What should you do

1 Start Abrsquos and tell him to take his Adalimumab as usual

2 Start Abrsquos and tell him to hold Adalimumab until infection

is clear

3 Advise to stop Adalimumab permanently since it has

increased his infection risk

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Infections Anti-TNF Agents

All TNF antagonists have warnings about

serious infections in package insert

Administration of any of the anti-TNF

therapies should be discontinued if the

patient develops serious infection or sepsis

and should not be initiated in patients with

active infection

Education of Pts And GPrsquos is key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Recommended management of

anti-TNF biologics in infection

Simple upper respiratory tract viral infections No modification of treatment

More severe viral infection (influenza herpes

zosterhellip) or severe bacterial infection (fever

bacteremia systemic infection recurrent

infectionhellip) Anti-TNF therapy should be temporarily discontinued

Appropriate antibiotic or antiviral therapy

Resumption of anti-TNF after resolution of the infection

Taylor PC Presented at ACR Clinical Symposium

November 2007

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key

Take away Points

Biologics Safety Treatment of IA patients with Biologic therapy is generally safe

and well tolerated

Rare important events have been seen with all TNF antagonists

Serious infections

TB and other opportunistic infections (more common with mAbrsquos)

Lymphomas

Demyelinating events CHF Lupus-like reactions Hepatic and Hematologic abnormalities

Screening for TB recommended in all patients

Vigilance required re infectious and malignant complications

Patient and physician education key