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