Evidence-Informed Best Practices
Rheumatoid Arthritis
Osteoarthritis
Dr. Diane Lacaille
Objective
Describe the rationale for key recommendations for best
practice care for Rheumatoid Arthritis and Osteoarthritis
according to the BC Guidelines.
www.bcguidelines.ca
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Rationale for recommendations in guidelines
 Rheumatoid Arthritis
 Early diagnosis and early treatment with DMARDs
 Prevention of joint damage
 Management of co-morbidities
 Monitoring of disease activity
 Osteoarthritis
 Reduction of pain
 Improvement of function
 Optimization of conservative care
 Appropriate and timely referral for surgical intervention
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EARLY Treatment of RA with DMARDs
E EARLY DIAGNOSIS AND TREATMENT OF RA
A AGGRESSIVE USE OF DMARDS ALTERS THE COURSE OF RA
R REMISSION IS THE NEW TARGET OF RA TREATMENT
L LONG TERM USE OF DMARDS
Y YES, DMARDS ARE SAFE WHEN MONITORED REGULARLY
This is the new standard of care.
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RA is Not a Benign Disease
If not controlled, RA inflammation leads to:
 joint damage and joint deformities
 progressive loss of physical function
 work disability (32-50% after 10 years of RA)
 premature mortality, mainly from cardiovascular disease (50%
increase in risk of death from CVD)
All these outcomes are preventable.
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Persistent Joint Swelling Leads to
Joint Damage & Deformities
=>
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Early Diagnosis & Treatment of RA
E
A
R
L
Y
Early diagnosis
Recognizing signs of inflammation – clues pointing to RA
 Early morning stiffness > 30 minutes
 Worse pain in the morning and post immobility
 Swelling of small joints
 Pain or tenderness on squeezing the MTPs, MCPs or wrists
 Symmetrical involvement
 Systemic symptoms, such as fatigue
Ruling out other diagnosis
 Septic arthritis, especially if monoarthritis
 Crystal arthritis, such as gout or pseudogout
 Joint aspiration for acute monoarthritis to R/O infection
or when crystal arthritis is suspected
 Transient inflammatory arthritis (viral) < 6 weeks
 Other inflammatory arthritis, also Rx with DMARDs
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Early Diagnosis & Treatment of RA
E
A
R
L
Y
Early treatment of RA
Capture the window of opportunity
 Early treatment with DMARDs alters the disease course.
 Joint damage occurs early (within months) and is
irreversible.
 RA is more responsive to treatment early on.
 Early treatment increases the chances of remission.
New onset RA requires urgent care
 DMARDs should be started within 2 months of symptoms.
 Referral to a rheumatologist for new onset RA should be
seen within 4 weeks. State ‘new onset of RA’ on referral.
 Rheumatologists prefer early referrals.
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Aggressive use of DMARDs Alters
the course of RA
E
A
R
L
Y
What are DMARDs?
 Disease Modifying Anti-Rheumatic Drugs
 They improve symptoms and prevent joint damage.
 Methotrexate, Sulfasalazine, Hydroxychloroquine,
Gold, Cyclosporine, Leflunomide and biologic agents.
Think RA, think DMARDs
 All RA patients with active inflammation should be
on a DMARD.
NSAIDs and prednisone are not enough
 NSAIDs improve symptoms but fail to prevent joint damage.
 Prednisone should not be used alone because
of long term toxicities
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Role of steroids in RA
 Minimize steroids dose and duration, because of
long term risks, esp. cardiovascular diseases
 Oral steroids do have a role:
 Small doses (< 10 mg daily), over short periods
 Bridging therapy, while waiting for DMARDs
 Early on at time of RA onset, but avoid prior to
rheumatologist referral for diagnosis bcse masks signs.
 To control flare-ups
 Intramuscular (40 mg depomedrol) and intraarticular are good alternatives to oral.
 If steroids are needed to control disease, then
DMARDs need to be adjusted
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Aggressive Use of DMARDs Alters
the Course of RA
E
A
R
L
Y
 DMARDs alter the course of RA by:
• Preventing joint damage and deformities
• Reducing physical and work disability
• Preventing premature mortality
 Aggressive use of DMARDs means:
• Starting DMARDs early
• Using DMARDs continuously, often in combination
• Evaluating response every 1 to 3 months
• Modifying DMARD therapy until the target is reached
• Aiming to eradicate inflammation
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Remission is the new target of
RA treatment
E
A
R
L
Y
The goal of RA treatment is no longer to simply control symptoms,
but to eradicate inflammation.
The target of DMARD therapy is no signs of active
inflammation i.e.,
• No swollen joints
• Normal ESR or CRP
• Little to no radiographic progression
Although remission is the target, minimal disease activity may be an
acceptable alternative, when remission is not possible, especially in
established long-standing disease, or when
co-morbidities or other patient factors limit
DMARD options.
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Long-term use of DMARDs
E
A
R
L
Y
 DMARDs should be used continuously, throughout the
disease.
 When sustained remission is achieved, DMARDs may
be slowly decreased to find a lower dose that maintains
remission.
 DMARD discontinuation is not recommended because
of high risk of flare off DMARDs.
 All RA requires DMARD, the earlier the better, but even
late RA requires DMARDs to reduce further damage.
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Yes DMARDs are safe
when monitored regularly
E
A
R
L
Y
Benefits
Risks
Benefits of early DMARDs outweigh their risks
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EARLY is the new standard of care
 Family physicians play a critical role in
early diagnosis and treatment of RA.
 DMARDs should be prescribed in all RA
patients and should be started early.
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Treatment of RA
the standard of care has changed
DMARDs
NSAIDS
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Management of Established RA
Objective:
Suppress inflammation, prevent joint damage
Task
Family Doctor
Rheumatologist
Monitor
Q 2-6 months
Q 6-12 months
Assess disease activity
(Joint Count + Blood
Work)
Review Meds, S/E
Adherence/ Dosage
Refer to PT/OT
Review/adjust meds
Rating of Disease
Activity for decisionmaking
Assess Joint Damage
Pain Relief
same
Refer PT/OT, surgery
Review for Comorbidities
Screen and Treat
Screen and Treat
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Consider chronic disease implications
Comorbidities
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Dealing with Chronic Pain
Psychosocial Issues
Increased infection risk
Immunizations
Osteoporosis
Cardiovascular Disease
Smoking Cessation
Weight Management
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Osteoarthritis
Osteoarthritis (OA)
Features suggestive of OA:
 Absence of inflammatory features: morning stiffness < 30 min;
gelling < 5 min; minimal swelling & heat; no redness.
 Pain worse with activity, better with rest
 Advanced OA => constant pain including at rest
 Absence of systemic symptoms
 Gradual onset
 History of prior injury (e.g. knee), prior deformity / malalignement
 Joint distribution: hips, knees, C & L spine, hands: DIP, PIP, 1st
CMC, 1st MTP.
 Bony enlargement, crepitus, malalignement
 If joint swelling, synovial fluid non-inflammatory, no crystals.
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Joint Distribution
Black= joints most commonly affected
Grey= joints often affected
White= joints usually not affected
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Other Diagnoses to Exclude
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Septic arthritis (acute monoarthritis requires joint aspiration)
Crystal arthritis: gout, pseudogout (CPPD) (joint aspiration)
Inflammatory arthritis: esp. psoriatic arthritis
Non-articular : e.g. bursitis (trochanteric, pes anserine),
tendonitis (shoulder, elbow)
 Bone pain (multiple myeloma, metastasis)
 Soft tissue pain syndromes
 Referred pain
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Investigations
 X Rays
› Provide clinical information
› Can be normal in early OA
› Often don’t correlate with degree of pain
› Knee Xrays must be ordered weight bearing (PA, lat, skyline)
› Hip (OA hip series: incl. lateral view and upper 1/3 femur)
 Absence of inflammatory markers (CBC, CRP normal)
 Labs can be useful to rule out other conditions (e.g. thyroid
disease) or to assess for comorbidities prior to Rx (e.g. Cr, LFT)
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Management - Considerations
 Severity of pain (with activity, at rest, interferes with sleep)
 Impact on function (ADLs, IADLs)
 Impact on participation (work, family obligations, social activities,
leisure)
 Impact on independence
 Psychosocial issues (pain amplification, coping strategies,
depression, adherence to treatment, social support)
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Patient Education (OA and RA)
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Guidelines
Patient Support
Family Support
Community Support
Patient Self Management (coping with pain and
other arthritis symptoms, stress, lifestyle changes
e.g. exercise).
 Arthritis Self Management Program (ASMP) and
CDSMP.
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Management – Non pharmacological
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Patient education
Self-management
Weight management – support, dietician
Exercise (ROM, strengthening, aerobic)
Physiotherapy: prescribe specific therapeutic exercise program
Walking aids
Occupational therapy: Orthotics, footwear, braces, splints, ADL
aids, ergonomic modifications at work
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Management - Pharmacological
 Acetaminophen:
› regular schedule vs. prn
› up to 4 gm/day, less if liver disease
 NSAIDs:
› Gastroprotection if high GI risk
› Consider cardiovascular risk factors
› Topical NSAIDs
 Glucosamine and chondroitin sulfate:
› Not recommended, insufficient evidence of efficacy
 Intra-articular steroids
 Hyaluronic acid – limited benefit, can cause inflammatory reaction
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Summary
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Differentiating inflammatory from non-inflammatory arthritis
Importance of early diagnosis and DMARD treatment in RA
Monitoring of disease activity to achieve treatment target
Goal of preventing joint damage, consequences of inflammation
Management of pain, improvement of function in OA
Weight management, exercise and rehab in OA
Multidisciplinary care of arthritis
Appropriate and timely referral for surgery
Management of co-morbidities, esp. cardiovascular diseases
Need for shared approach to care
Importance of patient education and self-management
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