Chris Deighton

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  • Chris Deighton

    1. 1. New treatments: expert response Dr Chris Deighton Department of Rheumatology Derbyshire Royal Infirmary
    2. 2. Exciting times for inflammatory arthritis <ul><li>Rheumatology Futures Group </li></ul><ul><li>National Audit Office </li></ul><ul><li>NICE RA Guidelines </li></ul><ul><li>Department of Health Commissioning Pathway for Inflammatory Arthritis </li></ul><ul><li>New drugs available and more coming </li></ul><ul><li>Making better use of old drugs </li></ul>
    3. 3. How would we want to treat Norman these days? <ul><li>Symptom control </li></ul><ul><li>Slow the disease down </li></ul><ul><li>Multidisciplinary approach </li></ul><ul><li>Damage = Inflammation × Time </li></ul>
    4. 4. Severity (Arbitrary Units) 0 Duration of Disease (years) 5 10 15 20 25 30 What components of the disease are we trying to modify? Early RA Intermediate Late Graph: Adapted from: Kirwan JR. J Rheumatol. 2001;28:881-886. Inflammation Disability Radiographs
    5. 6. Recommendation 1 <ul><li>Refer for a specialist opinion any person with suspected persistent synovitis of undetermined cause. Refer urgently if any of the following apply: </li></ul><ul><ul><li>The small joints of the hands and feet are affected </li></ul></ul><ul><ul><li>More than one joint is affected </li></ul></ul><ul><ul><li>There has been a delay of 3 months or longer between onset of symptoms and seeking medical advice </li></ul></ul>
    6. 7. Recommendation 1 <ul><li>Refer for a specialist opinion any person with suspected persistent synovitis of undetermined cause. Refer urgently if any of the following apply: </li></ul><ul><ul><li>The small joints of the hands and feet are affected </li></ul></ul><ul><ul><li>More than one joint is affected </li></ul></ul><ul><ul><li>There has been a delay of 3 months or longer between onset of symptoms and seeking medical advice </li></ul></ul>
    7. 8. Median Sharp score Lard LR, Visser H, Speyer I, et al. Am J Med. 2001;111:446-451. Delayed treatment (median treatment lag time, 123 days; n=109) Early treatment (median treatment lag time, 15 days; n=97) Treatment: The “Window of Opportunity”
    8. 9. Recommendation 2 <ul><li>In people with newly diagnosed active RA, offer a combination of DMARDs (including methotrexate and at least one other DMARD, plus short-term glucocorticoids) as first-line treatment as soon as possible, ideally within three months of the onset of persistent synovitis </li></ul>
    9. 10. Recommendation 2 <ul><li>In people with newly diagnosed active RA, offer a combination of DMARDs (including methotrexate and at least one other DMARD , plus short-term glucocorticoids ) as first-line treatment as soon as possible, ideally within three months of the onset of persistent synovitis </li></ul>
    10. 11. Why a combination of DMARDs? <ul><li>Combination Therapy </li></ul><ul><li>Step up therapy </li></ul><ul><ul><li>Addition of combination of DMARDs after failure of monotherapy </li></ul></ul><ul><li>Step down therapy </li></ul><ul><ul><li>Aggressive combination therapy at induction </li></ul></ul><ul><ul><li>SZP, MTX + Prednisolone (Cobra, BeSt) </li></ul></ul><ul><ul><li>SZP, MTX and HCQ (Fin-RA, TICORA) </li></ul></ul>
    11. 12. Why steroids?
    12. 13. Recommendation 3 <ul><li>In people with recent onset active RA, measure CRP and key components of disease activity (using a composite score such as DAS28) monthly until treatment has controlled the disease to a level previously agreed with the person with RA </li></ul>
    13. 14. Important paper <ul><li>Van der Kooij SM et al. Limited efficacy of conventional DMARDs after initial methotrexate failure in patients with recent-onset rheumatoid arthritis treated according to the Disease Activity Score. Ann Rheum Dis 2007;66:1356-62. </li></ul>
    14. 16. How would we want to treat Norman these days? <ul><ul><li>identify the disease ASAP </li></ul></ul><ul><ul><li>treat active disease aggressively ASAP </li></ul></ul><ul><ul><li>monitor him closely and suppress inflammation </li></ul></ul><ul><ul><li>get him onto effective treatment when other treatments are not working or are toxic </li></ul></ul><ul><ul><li>identify the most appropriate time for expensive but efficacious treatments </li></ul></ul>
    15. 17. Exciting times for inflammatory arthritis <ul><li>Rheumatology Futures Group </li></ul><ul><li>National Audit Office </li></ul><ul><li>NICE RA Guidelines </li></ul><ul><li>Department of Health Commissioning Pathway for Inflammatory Arthritis </li></ul><ul><li>New drugs available and more coming </li></ul><ul><li>Making better use of old drugs </li></ul>

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