Rheumatoid Arthritis in 21st       centuryWhere are we heading?    Farhan Tahir M.D.Rheumatic Disease Associates
What this talk is about•   How we reached in to the biologic era•   Why is there a need for biologic therapy•   What are t...
How we reached in to the biologic era
What this talk is about•   How we reached in to the biologic era•   Why is there a need for biologic therapy•   What are t...
Case Study• Laura came into my office for an urgent appointment more  than a year ago. A bright, 25 years old woman, a uni...
• It was obvious she had rheumatoid arthritis (RA). Tender  synovitis in several joints of the hands. She was  rheumatoid ...
• Six months later she had graduated from university but  her condition became worse. She was facing sick leave in  her ne...
What this talk is about•   How we reached in to the biologic era•   Why is there a need for biologic therapy•   What are t...
What this talk is about•   How we reached in to the biologic era•   Why is there a need for biologic therapy•   What are t...
Erythrocyte sedimentation rate (ESR)C-reactive protein levelIgM and IgA rheumatoid factor positivity Antiperinuclearantibo...
Genetic predisposition
Remember joint damage is progressive
Progressive Joint Damage
Ultrasonograhic assessment
What this talk is about•   How we reached in to the biologic era•   Why is there a need for biologic therapy•   What are t...
Introduction to Biologic TherapyAchieve goals of treatment• Individualize treatment options• Initiate treatment early• Ind...
Optimizing the dosage
Maintenance of remission
Introduction of Ultrasound
Detecting Neovascularization
What this talk is about•   How we reached in to the biologic era•   Why is there a need for biologic therapy•   What are t...
Identify non responders
Joint damage even with anti TNF
Sonograhpgic Doppler flow in non          responder
Options for Anti TNF failures
What this talk is about•   How we reached in to the biologic era•   Why is there a need for biologic therapy•   What are t...
RA impacts work capacity
RA impacts cardiovascular health
What this talk is about•   How we reached in to the biologic era•   Why is there a need for biologic therapy•   What are t...
What this talk is about•   How we reached in to the biologic era•   Why is there a need for biologic therapy•   What are t...
Role of TNF in controlling       infection               •   CID 2005:41 (Suppl 3) • Ehlers
“TNF-o-meter”Finding the right balance
List of recommended vaccines
List of Contraindicated vaccines
Summary• Early diagnosis and treatment• Aggressive monitoring to prevent joint  damage• Aim for maintenance of remission a...
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
Rheumatoid Arthritis in biologic era
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  • A, Macrophage- derived TNF- as costimulus for T cells. B, T cell–derived TNFactivates macrophages for anti mycobacterial activity. C, TNF, recruits mononuclear cells and organises granulomas. D, Anti-TNF therapy results in g ranuloma breakdown and dissemination of mycobacteria
  • Rheumatoid Arthritis in biologic era

    1. 1. Rheumatoid Arthritis in 21st centuryWhere are we heading? Farhan Tahir M.D.Rheumatic Disease Associates
    2. 2. What this talk is about• How we reached in to the biologic era• Why is there a need for biologic therapy• What are the targets of biologic therapy• Measures of clinical and radiological activity• Clinical and radiological remission is it “Reality or Fiction”• What if anti TNF therapy fails• Looking beyond joints and impact on society• Weighing risk and benefits of treatment• Surveillance of co morbidities• Summary
    3. 3. How we reached in to the biologic era
    4. 4. What this talk is about• How we reached in to the biologic era• Why is there a need for biologic therapy• What are the targets of biologic therapy• Measures of disease activity and prognosis• Customizing therapy to individual patient• Clinical and radiological remission is it “Reality or Fiction”• Monitoring efficacy of treatment• Looking beyond joints and impact on society• Weighing risk and benefits of treatment• Surveillance of co morbidities• Summary
    5. 5. Case Study• Laura came into my office for an urgent appointment more than a year ago. A bright, 25 years old woman, a university student with a bright future . Healthy until recently when suddenly one morning, she could not get out of bed and was unable to dress because her fingers and wrists were swollen, tender, and stiff.• She had spent some days in bed, then moved back to her parents because she was unable to manage on her own. When I first saw her, she had been ill for about two months, and was just getting worse and worse day-by-day. She had lost 3 kg and was pale, desperate, and tired.
    6. 6. • It was obvious she had rheumatoid arthritis (RA). Tender synovitis in several joints of the hands. She was rheumatoid factor positive, had elevated C-reactive protein and slight anemia. Erosions appeared on her initial ultrasound exam.• Without delay, she was started on prednisone and methotrexate (MTX) 7.5 mg per week. Two weeks later, when I saw her in the clinic, she was smiling and had returned to the university. She got an injection in a swollen finger joint and I increased the dosage of MTX to 15mg. I assured her she can get appointment within 2 days in case of any swollen joints needs to be injected.
    7. 7. • Six months later she had graduated from university but her condition became worse. She was facing sick leave in her new job. She was she was started on Etanercept in combination with MTX. It worked. She went into remission again.• For the whole year, there is no progression of joint damage but recently her disease flared again. Many joints are affected causing severe problems in her daily life. She is switched to infliximab (Remicade) which is efficacious for now but what if arthritis showed its ugly face again.
    8. 8. What this talk is about• How we reached in to the biologic era• Why is there a need for biologic therapy• What are the targets of biologic therapy• Measures of disease activity and prognosis• Customizing therapy to individual patient• Clinical and radiological remission is it “Reality or Fiction”• Monitoring efficacy of treatment• Looking beyond joints and impact on society• Weighing risk and benefits of treatment• Surveillance of co morbidities• Summary
    9. 9. What this talk is about• How we reached in to the biologic era• Why is there a need for biologic therapy• What are the targets of biologic therapy• Measures of clinical and radiological activity• Clinical and radiological remission is it “Reality or Fiction”• What if anti TNF therapy fails• Looking beyond joints and impact on society• Weighing risk and benefits of treatment• Surveillance of co morbidities• Summary
    10. 10. Erythrocyte sedimentation rate (ESR)C-reactive protein levelIgM and IgA rheumatoid factor positivity Antiperinuclearantibody positivityRadiologic scoresDuration of morning stiffnessRA-associated HLA–DRB1p04 genes
    11. 11. Genetic predisposition
    12. 12. Remember joint damage is progressive
    13. 13. Progressive Joint Damage
    14. 14. Ultrasonograhic assessment
    15. 15. What this talk is about• How we reached in to the biologic era• Why is there a need for biologic therapy• What are the targets of biologic therapy• Measures of clinical and radiological activity• Clinical and radiological remission : is it Reality or Fiction?• What if anti TNF therapy fails• Looking beyond joints and impact on society• Weighing risk and benefits of treatment• Surveillance of co morbidities• Summary
    16. 16. Introduction to Biologic TherapyAchieve goals of treatment• Individualize treatment options• Initiate treatment early• Induction and maintenance of remission• Use biologic as steroid and DMARD sparing agents• Plan ahead for failure and withdrawal of therapy
    17. 17. Optimizing the dosage
    18. 18. Maintenance of remission
    19. 19. Introduction of Ultrasound
    20. 20. Detecting Neovascularization
    21. 21. What this talk is about• How we reached in to the biologic era• Why is there a need for biologic therapy• What are the targets of biologic therapy• Measures of clinical and radiological activity• Clinical and radiological remission is it “Reality or Fiction”• What if anti TNF therapy fails• Looking beyond joints and impact on society• Weighing risk and benefits of treatment• Surveillance of co morbidities• Summary
    22. 22. Identify non responders
    23. 23. Joint damage even with anti TNF
    24. 24. Sonograhpgic Doppler flow in non responder
    25. 25. Options for Anti TNF failures
    26. 26. What this talk is about• How we reached in to the biologic era• Why is there a need for biologic therapy• What are the targets of biologic therapy• Measures of clinical and radiological activity• Clinical and radiological remission is it “Reality or Fiction”• What if anti TNF therapy fails• Looking beyond joints and impact on society• Weighing risk and benefits of treatment• Surveillance of co morbidities• Summary
    27. 27. RA impacts work capacity
    28. 28. RA impacts cardiovascular health
    29. 29. What this talk is about• How we reached in to the biologic era• Why is there a need for biologic therapy• What are the targets of biologic therapy• Measures of clinical and radiological activity• Clinical and radiological remission is it “Reality or Fiction”• What if anti TNF therapy fails• Looking beyond joints and impact on society• Weighing risk and benefits of treatment• Surveillance of co morbidities• Summary
    30. 30. What this talk is about• How we reached in to the biologic era• Why is there a need for biologic therapy• What are the targets of biologic therapy• Measures of clinical and radiological activity• Clinical and radiological remission is it “Reality or Fiction”• What if anti TNF therapy fails• Looking beyond joints and impact on society• Weighing risk and benefits of treatment• Surveillance of co morbidities• Summary
    31. 31. Role of TNF in controlling infection • CID 2005:41 (Suppl 3) • Ehlers
    32. 32. “TNF-o-meter”Finding the right balance
    33. 33. List of recommended vaccines
    34. 34. List of Contraindicated vaccines
    35. 35. Summary• Early diagnosis and treatment• Aggressive monitoring to prevent joint damage• Aim for maintenance of remission and functional capacity• Surveillance of infections and comorbidites
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