Rheumatoid Arthritis CUE CARDS

Question 1

What is Rheumatoid Arthritis?

Answer 1

> Chronic, autoimmune and inflammatory
Systemic, although primary target is synovial tissues
Fluctuating disease course of progressive joint destruction, derformity and premature death

Question 2

What increases risk of RA?

Answer 2

Strong genetic predisposition and environmental factors (e.g. smoking)

Question 3

What are the Generalised Symptoms of RA?

Answer 3

> Pain, stiffness and swelling (symmetrical) of peripheral joints

> Joints are warm/erythematous, painful and swollen (small joints of hand, wrist and feet are involved)

> Joint stiffness worse in morning and resolves with activity

> Stiffness and muscle aches may precede joint swelling

Question 4

What are laboratory signs of RA?

Answer 4

> Elevated non-specific inflammatory markers: ESR and CRP

> More specific markers: RF and ACPA

Question 5

Discuss early diagnosis and initiation of treatment of RA

Answer 5

> As no cure exists, the goals of treatment are to: achieve and maintain remission, return to full function, long-term DMARD treatment required

> RA leads to joint damage early in disease process

> Early initiation of treatment: initiation of DMARDs within 3 months after diagnosis is critical - a delay beyond this results in more irreversible joint damage at 5-years

Question 6

What are non-pharmacological therapies of RA?

Answer 6

> Exercise (disease activity not increased by exercise)
Physio
OT
Lifestyle (smoking cessation, diet, weight control)
Education (arthritis self-management course)

Question 7

What is the PBS Criteria of bDMARDs?

Answer 7

> Adequate trial (and failure) of conventional DMARDs
Active disease
Meet response criteria
No more than 5 biological or targeted synthetic DMARDs then lifetime ban

Question 8

What are the management principles of RA?

Answer 8

> Early use of DMARDs minimises early joint damage
Frequent follow-up visits with systematic monitoring of therapy results (6 wkly follow up and uptitrate if no disease control)
Rapidly escalation of therapy
Use of combination therapies (minimise early joint damage)
Use of biological or targeted synthetic agents in patients who fail to respond to DMARDS (improved efficacy)
Use of second-line biological agents after failing the first (improved efficacy)
Proper use of glucocorticoids as ancillary medications (effective but toxic)

Question 9

What 2 Treatment strategies are there for RA?

Answer 9

> ‘Step-Up’ Therapy

> ‘Step-Down’ and Parallel Intensive Approach

Question 10

What is the ‘Step-up’ Therapy?

Answer 10

1. Start with single agent methotrexate (+/- NSAIDs or Corticosteroids)
2. Monitor regularly and if not at target disease activity (remission), increase doses, add extra DMARDs (generally leflunomide, but can be sulfasalazine or hydroxychloroquine)
3. Remission can be achieved with single dose MTX
4. Side effects minimised (if using one drug)
5. Rapid assessment and dose increases/drug additions minimise joint damage

Question 11

What is the ‘Step-Down’ and Parallel Intensive Approach?

Answer 11

> Involves the initial use of combination DMARDs: combo therapy superior at inducing remission and preventing joint damage - fewer patients need bDMARDs (less costly)

> However, potential to over-treat some patients

Question 12

What is the Process of ‘Step-Down’ and Parallel Intensive Approach?

Answer 12

1. Initiate combination therapy and uptitrate doses quickly (MTX, sulfasalazine and hydroxychloroquine)
2. Short follow up and assessment of response/toxicity
3. If remission not achieved: add leflunomide OR switch to biological or targeted synthetic DMARDs
4. If remission achieved (for step-down strategy) - slowly withdraw DMARDs until single agent MTX of hydroxychloroquine