IMPROVING EARLY DIAGNOSIS AND
TREATMENT OF RHEUMATOID
ARTHRITIS
Michael Lockwood, MD, FACP, FACR
Rheumatology
Indiana University Health Arnett
Presentation of Case
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March 1994: 48 yo w F smoker, joint pain and swelling, RF 74
June 1994 started hydroxychloroquin
September 1994 feeling much better
May 1998 started methotrexate
April 2002 found benefit with COX 2 Selective NSAIDs
August 2002 deformity and nodulosis
2005 methotrexate was increased
May 2006: DAS 4.02, Hand films
January 2007: Infliximab started
Could a different outcome have been achieved?
11/25/1996
8/19/2006
Rheumatoid Arthritis Cure
Why is it important?
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Severe disability after 20 year: 19%
Lifetime Costs: $225,000 - $370, 000
Excess Deaths: Mortality Ratio = 2.26
Excess Cardiovascular events = 4x
Increases risk of coronary artery disease = Type 2 diabetes
Wolfe, A&R 37(4), p. 481
Rheumatoid Arthritis
Approach to Therapy
Timing
Before 4 months:
Combination 42%
Single Drug 35%
After 4 months
Combination 42%
Single Drug 11%
Mottonen, A&R, vol. 46, pp.894-98
Korpela, A&R vol. 50, pp 2072-81
Rheumatoid Arthritis
Advantage of Early Assessment
Timing
Van der Linden, A&R Vol. 62 pp 3537-3547
Rheumatoid Arthritis
History
• Onset: Weeks to Months
– Can be Palindromic onset
– Can have pauciarticular onset
• Constitutional features
– Morning stiffness lasting for hours
• Functional Questions
Rheumatoid Arthritis
Epidemiology
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Women:Men 3:1
Peak onset age 30-55
Incidence 30/100,000
Prevalence
– 1% Caucasians
– 0.1% rural Africans
Rheumatoid Arthritis
Physical
Rheumatoid Arthritis
Physical
Rheumatoid Arthritis
Deformities
Ulnar Deviation
Swan neck deformities
Boutenaire deformities
Rheumatoid Arthritis
Deformities
Bayonet Deformities
MTP Subluxation
Rheumatoid Arthritis
Deformities
Atlantoaxial Instability
MRI
Rheumatoid Arthritis
Extraarticular Involvement
Rheumatoid Nodules
Rheumatoid Arthritis
Extraarticular Involvement
Rheumatoid Vasculitis
Rheumatoid Arthritis
Extraarticular Involvement
Pulmonary
•Pleurasy
Rheumatoid Factor
Antibodies to Fc portion of IgG
75-80% of Patients have during course of disease
Useful for prognosis
Cyclic Citrullinated Peptide
Antibodies (anti CCP)
Schellekens, A&R, Vol 43, pp. 155-163
Rheumatoid Arthritis
X-Ray
Rheumatoid Arthritis
X-Ray
Rheumatoid Arthritis
Classification 1987 Criteria
Arnett, A&R, Vol 31, pp. 315-324
Rheumatoid Arthritis
Classification 2010 Criteria
Aletaha, A&R, Vol 62, pp. 2569-2581
Rheumatoid Arthritis
Pathology
Pathogenesis of Rheumatoid Arthritis
Choy, E. H.S. et al. N Engl J Med 2001;344:907-916
Rheumatoid Arthritis
Pannus
Rheumatoid Arthritis
Approach to Therapy
Triple Drug Therapy
Triple Drug: 77% get 50
% improvement
Methotrexate: 33%
Plaquenil/Sulfasalazine:
40%
O’Dell, NEJM vol. 334, pp 1287-1291
Cytokine Signaling Pathways Involved in Inflammatory Arthritis
Choy, E. H.S. et al. N Engl J Med 2001;344:907-916
Rheumatoid Arthritis
How do we proceed?
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Aggressive approach, <5 yr disease, monthy followup
DAS calculated monthly
Aggressively escalating therapy
Goal: DAS remission or low disease activity
Results: ACR 50 = 84% vs 40% standard tx.
– Decrease erosions
– Total Costs less
Grigor, Lancet, Vol. 364, pp. 263-269
Rheumatoid
Arthritis
Implementation
DAS scoring &
aggressive
approach in a
community
rheumatology
practice
DAS 28 Scoring
Arnett #
DAS
Date
Last Name
First Name
Comment
Pain Count
Birth Date
DAS28 < 2.6 Remission
DAS28 2.6 to < 3.2 Low Disease Activity
Sw elling Count
DAS28 3.2 to 5.1 Moderate disease Activity
VAS Patient
DAS28 >5.1 High Disease Activity
WSR
Patient Assessment of Disease Activity
Not Active
at all
Extremely
Active
I________________________________________________________________I
Physician Assessment
Pain
Swelling
Problem 1
A 32 year old man presents with fatigue, low back pain and
morning stiffness lasting 15 minutes. He notes that the
back pain seems to get worse as he works through his
day. He is a machinist at a local factory. What should
you do next?
A. Start a Medrol (methylprednisolone) dose pack
B. Check a rheumatoid factor (RF), cyclic citrullinated
peptide antibody (CCP), and an antinuclear antibody
(ANA)
C. Refer to physical therapy for back strengthening and
instruction in back protection
D. Get a lumbar sacral xray 3 views
E. Get a MRI of the back.
Problem 2
A 26 year old women presents with a 4 week history
of swelling and tenderness of all of the MCPs,
PIPs and the MTPs of the feet. This is confirmed
on physical examination. There are no other
stigmata on examination. Her labs are
remarkable for a sed rate of 35 but a negative
rheumatoid factor (RF), CCP, and ANA. Her hand
a feet xrays are normal. Her most likely
diagnosis is:
A. Systemic lupus erythematosus
B. Rheumatoid arthritis
C. Psoriatic arthritis
D. Fibromyalgia
Problem 3
What treatment would you initiate for the above
patient?
A. Monotherapy with methotrexate,
hydroxychloroquin, or sulfasalazine but
follow serial DAS (disease activity score)
and treat to target.
B. Combination therapy with methotrexate,
hydroxychloroquin, and sulfasalazine but
follow serial DAS (disease activity score)
and treat to target.
C. Combination therapy with methotrexate
and a TNF blocker but follow serial DAS
and treat to target.
Problem 4
A 45 year old women presents with swelling and pain in the joints of 8
months duration, morning stiffness lasting several hours, and she finds
it difficult to do her work. She has swelling and tenderness in most of
the MCPs, PIPs, and MTPs. There is also swelling of the wrist, ankles,
elbows, and one knee. Her sed rate is 60, and she has a high titre
positive rheumatoid factor and cyclic citrullinated peptic (CCP). The
ANA is 1:160. Her hand films do show joint space narrowing in one of
the MCP and there is an erosion of a couple of the PIP. What treatment
would you initiate for the patient?
A. Monotherapy with methotrexate, hydroxychloroquin, or sulfasalazine
but follow serial DAS (disease activity score) and treat to target
B. Combination therapy with methotrexate, hydroxychloroquin, and
sulfasalazine but follow serial DAS (disease activity score) and treat to
target.
C. Combination therapy with methotrexate and a TNF blocker but follow
serial DAS and treat to target