Rheumatoid Arthritis: Primary care Initiativefor improved Diagnosis and outcomes

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C L I N I C I A N E D U C A T O R V O L U M E 3

SIDE B is for patients

SIDE A is for clinicians

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Fusiform swelling of the hand

RHEUMATOID ARTHRITIS (RA) FACTSRA is a chronic, progressive, systemic inflammatory disease •Characterizedby: – Progressive destruction of synovial joints with loss of

cartilage and bony erosions – Symptoms that begin in the small joints of the fingers, wrists,

and feet – Warm, swollen, tender joints that are painful and difficult to

move – Loss of physical function and quality of life – Disability and underemployment with rapid loss of work

productivity and job loss •Affects1.3millionAmericans •Peakageofonset:40to60years •Twoto4timesmorecommoninwomenthanmen •Patientsare7timesaslikelytohavegreater-than-moderate

disabilitythanage-orsex-matchedindividuals •Lifeexpectancyreducedby5to15years –RAaccountsfor22%ofalldeathsfromarthritisandother

rheumatic conditions

It is never too late to stop further damage

RA IS A DISEASE OF THE ENTIRE BODYHeart: •Cardiovasculardisease(CVD)occursonaverage10yearsearlierin

RApatientsthaninthegeneralpopulationwithoutRA •PericarditisisnotuncommonLungs: Increased risk for multiple pulmonary comorbidities •Pleuritismayoccur,ortissuesmaybecomestifforovergrown •InterstitiallungdiseaseInfections: RApatientshavea6-to9-foldincreaseintherateofseriousinfections, including tuberculosis Malignancy: RAdoublestheriskformalignancy,particularlylymphomaGastrointestinal (GI): RApatientshaveaveryhighincidenceofGIbleeding,whichmaybeattributabletononsteroidalanti-inflammatorydrug(NSAID)andsteroiduseduringtherapyNervous system: ThedeformityofanddamagetojointsinRAmayleadtoentrapment of nerves, leading to serious consequences •MaypresentwithcarpaltunnelsyndromeOsteoporosis: Generalizedbonelossmayresultfromimmobility,theinflammatoryprocess,and/ortreatmentssuchassteroids •Periarticulardemineralizationmayresultfrommediatorsof

inflammation

PRIMARY CARE: EARLY DETECTION IS CRITICALTo prevent the progressive destruction of synovial joints and improve long-termoutcomes,RAmustbedetectedwithin3monthsofonset. •RAhasrapidonset;bonyerosionsaredetectablebyMRIwithin

6weeks •Rateofprogressionismorerapidinthefirstyearthaninthe

second and third •Within2years,mostindividualswilldevelopbonyerosions,and

mostofthose(~80%)willgoontodeveloplong-termdisability •Successfulmanagementrequiresapartnershipbetweenthe

primary care clinician and the rheumatologist

Benefitsofearlydetection: •DecreasedRAseverity,disability,andmortalitywitheffective

treatments,suchasdisease-modifyingantirheumaticdrugs(DMARDs)

•LowerratesofRAcomplications •Decliningratesoflower-extremityorthopedicsurgicalprocedures •Controlofinflammationmaydecreasecardiacandmalignancyrisks

DIAGNOSIS OF RAInitial referral to a rheumatologist is advised if the patient has any of the followingsymptoms: (See last panel for a diagnosis decision tree) •Atleast3swollenjoints •Positive“squeeze”testacrossmetacarpophalangeal/

metatarsophalangeal joints •Morningstiffness≥30minutes

Even if a patient has fewer than 3 swollen joints, a preliminary diagnosis of “possible RA” may be made, and the patient should be referred to a rheumatologist for a definitive diagnosis.

Arheumatologistwillmakeadefinitivediagnosisbasedonthefollowingcriteria: 1. Morningstiffness 2. Arthritisin3ormorejointareas 3. Arthritisofhandjointsorballsofthesmallertoejoints 4. Symmetricarthritis

THE RA TEAMSuccessfulmanagementofRAwillrequirelong-termteaminvolvement.The primary care clinician will be responsible for identifying possible casesofRAandreferral. •Earlyreferraltoarheumatologistiscritical

•Earlytreatmentbytheprimarycareclinicianisintendedtorelievepain and enhance mobility

–NSAIDs – Short courses of prednisone – On occasion, opioids

•Tofacilitatetheevaluationofthepatient,itisadvisabletoobtain: –Rheumatoidfactor(RF) o30%-70%ofpatientsarepositive –Anti-CCPantibody o40%-60%ofpatientsarepositive oPatientwhoisRFandanti-CCPnegativemaystillhaveRA –C-reactiveprotein –Erythrocytesedimentationrate –CBC –LFT –X-raysofthehands,wrists,andfeet

•Monitorforalarmsigns(infection,dyspnea,neckpain,rheumatoideyedisease,painfulredeye)

HochbergMC,SilmanAJ,SmolenJS,WeinblattME,WeismanMH,eds.Rheumatology.3rded.NewYork,NY:Mosby;2003:757-763.AmericanCollegeofRheumatologyFactSheet.http://www.rheumatology.org/public/factsheets/diseases_and_conditions/ra.asp?aud=pat.AccessedSeptember10,2009.MacLeanCH,LouieR,LeakeB,etal.Qualityofcareforpatientswithrheumatoidarthritis.JAMA.2000;284(8):984-992.

DeaneK.ManagingcomorbiditiesinRA.J Musculoskel Med.2006;23(suppl):S24-S31.BöttcherJ,PfeilA.DiagnosisofperiarticularosteoporosisinrheumatoidarthritisusingdigitalX-rayradiogrammetry.Arthritis Res Ther.2008;10(1):103.

McQueenFM,StewartN,CrabbeJ,etal.Magneticresonanceimagingofthewrist in early rheumatoid arthritis reveals a high prevalence of erosions at four monthsaftersymptomonset.Ann Rheum Dis.1998;57(6):350-356.BykerkVP,KeystoneEC.RAinprimarycare:20clinicalpearls.J Musculoskelet Med.2004;21:133-146.

EmeryP,BreedveldFC,DougadosM,KaldenJR,SchiffMH,SmolenJS.Earlyreferralrecommendationfornewlydiagnosedrheumatoidarthritis:evidencebaseddevelopmentofaclinicalguide.Ann Rheum Dis.2002;61(4):290-297.Adaptedfrom:HochbergMC,SilmanAJ,SmolenJS,WeinblattME,WeismanMH,eds.Rheumatology.3rded.NewYork,NY:Mosby;2003.ArnettFC,EdworthySM,BlochDA,etal.TheAmericanRheumatismAssociation1987revisedcriteriafortheclassificationofrheumatoidarthritis.Arthritis Rheum.1988;31(3):315-324.

BridgesSL.SpottingaggressiveRAearly:thephysicalexamination,testing,andimaging.J Musculoskelet Med.2006;23(supplNov):S10-S14.

CVD10 Years Earlier

6-9 x ↑ SeriousInfection Rate

2 x ↑ Rate of Malignancy

↑ PulmonaryDisease

↑ GI Bleeding

↑ Osteoporosis

4Months

2Years

10-20Years

RA Sx Onset

Bony Erosions 70%-80%

Long-term Disability80%

Rheumatology:DMARD/

BiologicsRx

PCP:EarlyIdentification & Rheumatology

Referral at ≤3Months

PCP:Long-termComorbidityManagement

The “squeeze test” is a simple, but reliable diagnostic test for early RA

O

O

PRIMARY CARE

Initial diagnosisReferral to

rheumatologistImmunizationsPPD/ChestX-ray

Monitorfortoxicitiesand disease progression

Monitorforalarmsigns

RHEUMATOLOGY

ConfirmdiagnosisInitiate early,

aggressiveDMARDtherapy

COLLABORATION

OVERVIEWThis Clinician Educator is designed to aid primary care clinicians in recognizing theearly signsof rheumatoidarthritis (RA)anddeterminingwhen to referapatient toarheumatologist. Side A discusses the role of the primary care clinician in the earlydiagnosisofRA,anddescribeshowtheprimarycarecliniciancanworkintandemwiththepatient’srheumatologist toeffectivelymanagethisdisease.SideB isdesignedtohelppatientsunderstandRA.

INTENDED AUDIENCEThistoolisintendedforprimarycareclinicians.

FACULTYVivian Bykerk, MD AssistantProfessorandDirector,EarlyArthritisProgram,UniversityofToronto;AssistantDirector,DivisionofAdvancedTherapeutics,MountSinaiHospital, Toronto,Canada

Joyce P. Carlone, MN, RN, CFNP, CCRC NursePractitioner,DivisionofRheumatology,EmoryUniversity,Atlanta,GA

Martin M. Miner, MD Co-Director,Men’sHealthCenter,TheMiriamHospital,Providence,RI

DISCLOSUREIt isthepolicyofTheChathamInstitutetoensurebalance,independence,objectivity,andscientificrigorinallofitseducationalprograms.Allfaculty,planners,andmanagerswho affect the content of medical education activities sponsored by The ChathamInstitute are required to disclose to the audience any real or apparent conflict ofinterestrelatedtotheactivity.Faculty,planners,andmanagersnotcomplyingwiththedisclosurepolicywillnotbepermittedtoparticipateinthisactivity.Disclosureinformationisprovidedbelow.

Vivian Bykerk, MDSpeaker Bureaus:AbbottLaboratories,Roche,WyethPharmaceuticalsAdvisory Boards:AbbottLaboratories,Bristol-MyersSquibbCompany,Roche, sanofi-aventisU.S.LLC,Schering-PloughCorporation,WyethPharmaceuticalsConsultant:AbbottLaboratories,Bristol-MyersSquibbCompany,Roche, Schering-PloughCorporation,WyethPharmaceuticalsResearch Grants:AbbottLaboratories,Centocor,Inc.,PfizerInc,Roche, Wyeth Pharmaceuticals

Joyce P. Carlone, MN, RN, CFNP, CCRCSpeaker Bureaus: Wyeth PharmaceuticalsAdvisory Boards and Consultant:UCBPharma,Inc.

Martin M. Miner, MDNorealorapparentconflictstoreport

Daniel Duch, PhD, MedicalDirector Cynthia Fontán, MPA, EducationManagerTheChathamInstituteNorealorapparentconflictstoreport

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What is rheumatoid arthritis (RA)?•RAisachronicdiseasethatdamagesthejointsofthebody.Chronicdiseasesarelonglasting(greaterthan3months)anddonot easily or quickly go away

•RAaffectswomenmorethantwiceasmuchasmen.Althoughitmay occur at any age, it usually starts in patients when they are between40and60yearsold

•RAcausescontinuingdamageformostpatients,andmustbeoptimally managed throughout life

What are the symptoms?EarlysignsofRAinclude:•Swellingorstiffnessinthejointsofthehands•Painorachinginthehandsandwrists•Morningstiffnessthatlastsforatleastahalfhour,andmayoften

last for several hours•Youmaynotbeabletogripthingsasstronglyasyouusedto•Later,RAmayaffectmanyjointsinthebody,includingthefeet,

ankles, knees, hips, elbows, and shoulders

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Are other parts of the body affected besides the joints?

Other organs that may be affected if RA is not treated early:

Eyes: dryness and damage to delicate structures

Lungs: much greater risk of getting serious infections and other complications

Heart disease: may occur about 10yearssoonerthaninpeoplewithoutRA

Stomach: high risk of bleeding

Double the risk of some types of cancer, so increased screening is advisable

JointsAffected:

Jaw

Spine

Shoulder

Elbow

Hip

Knee

Ankle,foot, toes

Wrist,hand,fingers Early diagnosis and

treatment may prevent these complications.

ImmuneCell

Target Cell

What causes RA?•ItisnotknownwhatcausesRA,butitisan autoimmune disease.

This means that the body attacks itself

•Thebody’simmunesystemisusedbythebodytofightoffinfections caused by invading bacteria and viruses

•InautoimmunediseaseslikeRA,thebodyrespondsasifitsnormal tissues are invading target cells, and attacks them

•GeneticsmayplayapartinthedevelopmentofRA,butmanypeoplewhogetRAdonothaveanyrelativeswiththedisease

What happens when RA causes an autoimmune response? When an immune response is triggered, inflammation occurs in the areasthatareattackedbytheimmunesystem.

•Inflammationcausesrednessandwarmth,swelling,stiffness,and pain in the affected joints

•Iftheautoimmuneresponseisnotslowedorstopped,itcanpermanently damage the affected joints and other tissues

Can RA be prevented?BecausewedonotknowwhyRAhappens,thereisnowaytopreventthedisease.

•Early diagnosis and aggressive treatment are the best ways to fight RA

•Treatmentisfirstfocusedonreducinginflammationandrelieving pain

•WhenadiagnosisofRAisconfirmed,treatmentalsoaimsatstopping or slowing joint damage and damage to other parts of the body

Treatment With Disease-modifiying Antirheumatic Drugs (DMARDs) Improves Long-term Outcomes

Healthy Joint Damaged Joint

DestructionofCartilage

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Without DMARDs, problems increase rapidly

With DMARDs, fewer problems

How can RA be stopped?TherehasbeenalargeimprovementinthedrugsusedtotreatRA.

•Aclassofdrugsreferredtoasdisease-modifiying antirheumatic drugs (DMARDs)actstosloworstoptheprogressionofRAtomore advanced stages of the disease

•Ifyoulookatthegraphabove,youwillseethatwhenaDMARDisnotused(theredline),theproblemscausedbyRAincreaserapidly,especiallyinthefirst2years

•However,whentreatedwithDMARDs(theblueline),thediseaseprogresses much more slowly, and fewer problems occur

•DMARDssuchasmethotrexate,hydroxychloroquine,sulfasalazine,orbiologicDMARDsaremostoftenusedto controlRA

Q: I have some pain in my hands. How can I tell if I have RA?

A: IfyouthinkyoumayhaveRA,youneedtotellyourhealthcareprovider.He/Shewillexamineyouandaskthefollowingquestions:

•Whathurtsasyougetoutofbedinthemorning? •Howlongdoesittaketofeelaslimberasyou’regoingto

feelfortheday? •Whenisyourpaintheworst(AMorPM)? •Doyousmoke? •DoanymembersofyourfamilyhaveRA? •Canyou –Turnfaucethandles? –Holdahairbrush/toothbrush? –Dress/batheindependently? –Fixyourownbreakfast? –Walkoutdoorsonflatground? •Howisyourenergylevel? •Importantcluestodiagnoseotherdiseases –Fever? –Nightsweats? –Unexpectedweightloss? –Rash,tickexposure? –Recentcontactwithsickchildren?Youmayalsofilloutthequestionnaireonpanel8B,whichwillhelpindiagnosingthecauseofyourdiscomfort.

Q: What happens next?

A: IfyourhealthcareproviderthinksyoumayhaveRA,he/shewillprescribemedicationtoreducethepainandinflammationinthejoints.He/Shewillalsoreferyoutoarheumatologist, which isadoctorwhospecializesinRAandrelateddiseases.

TherheumatologistwillconfirmthediagnosisofRAandprescribe appropriate medication to slow or stop the autoimmuneprocess.

DependingontheextentofinjurycausedbyRA,youmaybereferredtoaphysicaloroccupationaltherapist,orapodiatrist.

Rheumatoid Arthritis Resources and InformationThe American College of Rheumatology http://www.rheumatology.org/

The Arthritis Foundation http://www.arthritis.org/

The National Library of Medicine/Medline Plus http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm

The Mayo Clinic http://www.mayoclinic.com/health/rheumatoid-arthritis/DS00020

GordonDA,HastingsDE.Clinicalfeaturesofrheumatoidarthritis.In:HochbergMC,SilmanAJ,SmolenJS,WeinblattME,WeismanMH,eds.

Rheu

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y.3rded.NewYork,NY:Mosby;2003:765-780.Withpermission.

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