Rheumatoid Arthritis Flashcards
What is RA and what does it effect?
- RA is an autoimmune disease that targets synovial tissues in diarthrodial joints
What are the systemic features of RA
- fever
- fatigue
- anaemia
- elevated acute phase reactants (ESR, CRP)
- malaise
- myalgia
- depression
When should a patient be referred from primary care?
- suspected persistent synovitis
- small joints of the hands or feet are affected
- more than one joint is affected
- there has been a delay of 3 months or longer between onset of symptoms and seeking
medical advice
What investigations FOR diagnosis are carried out?
- Blood test for rheumatoid factor in adults with suspected RA with synovitis on clinical examination
- Consider measuring anti-CCP antibodies in adults with suspected RA if they are
negative for rheumatoid factor - X-ray the hands and feet in adults with suspected RA and persistent synovitis.
What investigations should be done following a RA diagnosis?
(asap)
- measure anti-CCP antibodies, unless already measured to inform diagnosis
- X-ray the hands and feet to establish whether erosions are present, unless X-rays were
performed to inform diagnosis
- measure functional ability using, for example, the Health Assessment Questionnaire
(HAQ), to provide a baseline for assessing the functional response to treatment.
What should be done to further investigate if anti-CCP antibodies are present or there are erosions on x-ray?
- advise the person that they have an increased risk of radiological progression but not
necessarily an increased risk of poor function, and - emphasise the importance of monitoring their condition, and seeking rapid access to
specialist care if disease worsens or they have a flare.
What are the aims of treatment in RA?
- aim of achieving a target of remission or low disease activity
- may involve trying multiple cDMARDs and other biological DMARDs with different mechanisms of action
What is the initial pharmacological management offered to newly diagnosed RA patients?
- first line treatment with conventional DMARD monotherapy using oral methotrexate, leflunomide or sulfasalazine as soon as possible and ideally within 3 months of onset of
persistent symptoms.
-Hydroxychloroquine can be used as an alternative first line in mild disease - escalate dose as tolerated
*Consider short-term bridging treatment with glucocorticoids (oral,
intramuscular or intra-articular) when starting a new cDMARD
- Offer additional cDMARDs (oral methotrexate, leflunomide, sulfasalazine or
hydroxychloroquine) in combination in a step-up strategy when the treatment
target (remission or low disease activity) has not been achieved despite dose
escalation
What further pharmacological therapy is offered after initial therapy if inadequate response to cDMARDs?
(Biologics)
Upadacitinib OR sarilumab with methotrexate, is recommended as an option for treating active rheumatoid arthritis in adults whose disease has responded inadequately to intensive therapy with a combination of cDMARDs, only if:
- disease is severe (a disease activity score [DAS28] of more than 5.1)
- can be used as monotherapy if methotrexate not tolerated
- continue treatment only if moderate response at 6 months
*can also add/change Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept, all in combination with methotrexate or as monotherapy with a DAS28 greater than 5.1 and
disease has not responded to intensive therapy with a combination of conventional DMARDs
In what case should pharmacological treatment with biologics be carried out after 6 months?
- Continue treatment only if there is a moderate response measured using EULAR criteria at 6 months after starting therapy.
- After initial response within 6 months, withdraw treatment if a moderate EULAR response is not maintained.
- Start treatment with the least expensive drug (taking into account administration costs, dose needed and product price per dose). This may need to be varied for some people because of differences in the mode of administration and treatment schedules.
Is Anakinra recommended for use in RA?
- NO
- Do not offer the combination of TNF-α inhibitor therapy and anakinra for RA.
What other immunomodulatory therapies are there?
- Tofacitinib with methotrexate in DAS28 >5.1 (cannot be used as monotherapy)
- Baricitinib with methotrexate in DAS28 >5.1 (CAN be used as monotherapy
- Remsima (infliximab biosimilar) for subcutaneous injection
When should Rituximab be used?
- in inadequate response or intolerance to biological DMARDs, and rituximab is suitable
- Rituximab in combination with methotrexate is recommended as an option for the treatment of adults with severe active rheumatoid arthritis who have had an inadequate response to, or are intolerant of, other DMARDs, including at least one TNF inhibitor. Treatment with rituximab should be given no more frequently than every 6 months.
When should rituximab therapy be continued?
- Treatment with rituximab in combination with methotrexate should be continued only if there is an adequate response following initiation of therapy and if an adequate response is maintained following retreatment with a dosing interval of at least 6 months. An adequate response is defined as an improvement in DAS28 of 1.2 points or more.
When should Tocilizumab be used?
Tocilizumab in combination with methotrexate is recommended as an option for the treatment of rheumatoid arthritis in adults if:
- the disease has responded inadequately to one or more TNF inhibitor treatments and to rituximab
- and the manufacturer provides tocilizumab with the discount agreed as part of the patient access scheme.
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