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Management RA
Management of Rheumatoid Arthritis
| Question | Answer |
|---|---|
| What are the signs and symptoms of rheumatoid arthritis? | Early morning stiffness lasting for more than 1 hour, symmetrical joint pain, swelling of 5+ joints, symptoms present for >6 weeks, malaise, fatigue, weight loss, depression, fever. |
| What joints does RA typically affect? | Metacarpophalangeal (MCP), proximal interphalangeal (PIP) and metatarsophalangeal (MTP) joints |
| What biomarkers are used in diagnosing RA? | ESR (erythrocyte sedimentation rate - increased) CRP (C reactive protein protein - increased) Presence of RF (rheumatoid factor) Antibodies to cyclic citrullinated peptide |
| True or false: Rheumatoid factor is present in everyone with RA | False; RF is present in about 70% of patients with RA |
| True or flase: RF can be detected throughout all stages of the disease | False; RF is difficult to detect in early stages of the disease |
| What other factors are useful in diagnosing RA? | Family history of RA, bony erosions in X-ray of hands, feet, wrists, presence of rheumatoid nodules |
| What are the co-morbidities that increase the mortality rate of RA? | Cardiovascular disease, infections (rapidly progress the disease progression of RA) |
| What are the treatment goals for RA? | Remission (absence of joint swelling, reduction of inflammatory markers, symptomatic relief) Improve QOL Maintain joint and muscle function Reduce ADR's from drug therapy, reduce onset of co-morbidities, prevent complications to other organs |
| What are the Non-pharmacological interventions for RA? | Physiotherapy, exercise, diet, reduce alcohol intake, smoking cessation, immunisations up to date, omega-3 fatty acid supps (2.7 g daily) |
| What is the role of Fish oil in RA? | 2-3g d of isolated DHA/EPA Reduces joint pain, duration of morning stiffness, fatigue time, # of swollen joints, use of analgesics |
| What are the four classes of drugs used in management of RA? | Analgesics (NSAIDS and Paracetamol) Corticosteroids (systemic and intra-articular) Synthetic Disease Modifying Anti-Rheumatic drugs Biological Disease Modifying Anti-Rheumatic Drugs |
| What are the key factors that determine drug therapy use in RA? | Disease progression/severity Prognosis Patient factors (age, childbearing status, presence of comorbidities) |
| What is the initial therapy for someone with suspected RA? | Simple analgesics (NSAIDs, paracetamol) Fish oil supp Patient education Exercise and diet modification Ice/Heat producs for symptom relief Referrals to other HP's (physio, OT, podiatry etc) Assess weight, BMI, fatigue, sleep quality impact on ADL |
| What is the role of NSAIDs in RA treatment? | Treats acute synovitis to reduce swelling, stiffness and inflammation Choice depends on risk v benefit (age, renal function, co-morbidities) Can use with paracetamol Avoid with anticoags and corticosteroid |
| Which patients are recommended to use PPI prophylaxis if using an NSAID for RA? | Aged 65 + with a history of peptic ulcer disease |
| As outlined in the treatment algorithm, what is the next step if patient swelling persists and NSAIDS are still required after 6 weeks? | Refer to rheumatologist/specialist for advanced therapy. Combination DMARDS (methotrexate, hydroxychloroquine, sulfasalazine), leflunomide, cyclosporin, biological agents, anti TNF's, anakinra, rituximab. |
| What is the role of corticosteroids in RA? | Symptom control whilst waiting for sDMARDS to kick in, or controlling a flare up |
| What is the role of synthetic DMARDS in RA? | Reduce synovial inflammation and prevent joint damage. Introduced at time of diagnosis to quickly eradicate inflammation . Often used in combination therapy. |
| Which sDMARDS are used as first line treatments in mild to moderate RA? | Sulfasalazine and hydroxychloroquine Hydroxychloroquine used if allergy to sulfasalazine and G6PD deficiency. Hydroxychloroquine is less effective but less toxic compared to sulfasalazine. |
| When is methotrexate used? | In moderate to severe RA. Can be used alone or in combination with other sDMARDS/bDMARDS. Weekly dosing. Co-administered with folic acid. High dose methotrexate will interact with NSAIDS. |
| When us leflunomide used? | When methotrexate isn't suitable for the patient. |
| When are bDMARDS used? | When patient doesn't respond to sDMARDS. Often used in combination with methotrexate. |
| Name the bDMARDS | TNF-a inhibitors, rituximab, abatacept, anakinra, tocilizumab, tofacitinib |
| Which bDMARDS are first line at this stage of RA treatment? | TNF-a inhibitors |
| Name the TNF-a inhibitors | Adalimumab, certolizumab, etanercept, golimumab, infliximab |
| When are rituximab, abatercept, anakinra, tocilizumab, tofacitinib used? | When patient doesn't respond to TNF-a inhibitor treatment. Tofacitinib - when TNF/MTX combination fails, alternative to rituximab. |
| Why is folic acid supplementation required when treating RA with methotrexate? | To reduce anti-folate side effects associated with methotrexate. |
| What is monitored for patients with RA? | Efficacy of treatment (number of tender/swollen joints, duration of morning stiffness, ESR, CRP, Impact of daily living, presence of co-morbidities, ADR's/toxicity of treatment, FBC, lipids, LFTs, CrCL |
Created by:
LDM
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