The document discusses challenges in implementing rheumatoid arthritis (RA) treatment guidelines in Indonesia. It notes barriers patients face in accessing appropriate care, including delays in diagnosis, variability in provider knowledge and competencies, limited healthcare access, and delays starting disease-modifying antirheumatic drugs (DMARDs). It also discusses challenges implementing guidelines, such as limited guideline availability and accessibility. The main considerations in determining RA treatment are disease activity and damage, patient comorbidities, drug efficacy, safety profiles, and drug availability based on insurance and national formularies. Pain reduction is an important but not sole treatment goal.
Rheumatoid arthritis is a chronic inflammatory disease that affects the joints and causes pain, stiffness, and swelling. It impacts around 1% of the adult population worldwide. While conventional disease-modifying antirheumatic drugs (DMARDs) like methotrexate are usually the first line of treatment, biological DMARDs or biologics targeting molecules like tumor necrosis factor (TNF) are used for cases that are resistant to conventional DMARDs. Biologics have revolutionized RA treatment by providing rapid relief and preventing long-term joint damage. The monoclonal antibody rituximab depletes B cells and is effective for RA by reducing inflammation and rheumatoid factor levels. It is administered as two 1000 mg intravenous
This document provides an overview of the management of rheumatoid arthritis (RA). It discusses the etiology and pathology of RA and describes the diagnostic criteria. It then outlines various treatment approaches for RA including physical therapies, medications like NSAIDs, glucocorticoids, DMARDs, and biologics. Newer targeted biologic therapies that inhibit cytokines like TNF-α, IL-1, IL-6 are discussed. The goals of RA treatment and factors influencing treatment choice are also summarized.
Most people who have rheumatoid arthritis take some type of medication. Medications for RA typically fall into five categories:
Non-steroidal anti-inflammatory drugs (NSAIDs);
steroids;
disease-modifying anti-rheumatic drugs (DMARDS); biologics;
and janus kinase (JAK) inhibitors.
When prescribing a medication, a physician will take into account the patient’s age, disease activity, and other medical conditions, but each patient is unique. Figuring out which medication or combination of medications work best for an individual can be challenging and often requires a process of trial and error.
Rheumatoid arthritis (RA) is a chronic inflammatory disease that affects the joints. Tofacitinib is an oral Janus kinase (JAK) inhibitor approved for the treatment of RA. It works by inhibiting multiple JAK-dependent cytokine pathways implicated in the pathogenesis of RA. Tofacitinib has demonstrated efficacy comparable to biologic DMARDs for achieving disease remission or low disease activity in RA patients. As an oral therapy, tofacitinib offers improved convenience compared to injected biologics and has shown a generally well-tolerated safety profile.
This document summarizes medication use patterns in the Alzheimer's Disease Neuroimaging Initiative (ADNI) cohort. It finds that 85% of ADNI patients took 4 or more daily medications (polypharmacy), and 22% took medications from Beer's list of potentially inappropriate drugs for elderly patients. Memantine treatment was associated with more severe Alzheimer's disease, while cholinesterase inhibitors were prescribed without difference by disease severity. Treatment also differed by gender, age, and education level in both mild cognitive impairment (MCI) and Alzheimer's disease (AD) groups.
The document discusses rheumatoid arthritis (RA) treatment guidelines and challenges in Latin America compared to developed regions. It summarizes RA treatment algorithms in the US, Europe, and Latin America. While the general approaches are similar, Latin America faces issues like a lack of qualified providers, deficient drug availability, and inadequate medical records. It proposes establishing RA as a public health priority in Latin America to improve access to care and treatment.
This document summarizes a presentation on clinical practice tools for identifying potential medication-related problems in the elderly. The presentation discusses several tools including the Beers List, Medication Appropriateness Index, IPET, Zhan-AHRQ, Medication Regimen Appropriateness Index, STOPP/START, IMAP, and NCQA-HEDIS. It provides definitions of related terms and describes each tool, how it was developed, its strengths and limitations. The presentation aims to help clinicians incorporate these tools into practice to improve medication management for elderly patients.
Rheumatoid arthritis is a chronic inflammatory disease that affects the joints and causes pain, stiffness, and swelling. It impacts around 1% of the adult population worldwide. While conventional disease-modifying antirheumatic drugs (DMARDs) like methotrexate are usually the first line of treatment, biological DMARDs or biologics targeting molecules like tumor necrosis factor (TNF) are used for cases that are resistant to conventional DMARDs. Biologics have revolutionized RA treatment by providing rapid relief and preventing long-term joint damage. The monoclonal antibody rituximab depletes B cells and is effective for RA by reducing inflammation and rheumatoid factor levels. It is administered as two 1000 mg intravenous
This document provides an overview of the management of rheumatoid arthritis (RA). It discusses the etiology and pathology of RA and describes the diagnostic criteria. It then outlines various treatment approaches for RA including physical therapies, medications like NSAIDs, glucocorticoids, DMARDs, and biologics. Newer targeted biologic therapies that inhibit cytokines like TNF-α, IL-1, IL-6 are discussed. The goals of RA treatment and factors influencing treatment choice are also summarized.
Most people who have rheumatoid arthritis take some type of medication. Medications for RA typically fall into five categories:
Non-steroidal anti-inflammatory drugs (NSAIDs);
steroids;
disease-modifying anti-rheumatic drugs (DMARDS); biologics;
and janus kinase (JAK) inhibitors.
When prescribing a medication, a physician will take into account the patient’s age, disease activity, and other medical conditions, but each patient is unique. Figuring out which medication or combination of medications work best for an individual can be challenging and often requires a process of trial and error.
Rheumatoid arthritis (RA) is a chronic inflammatory disease that affects the joints. Tofacitinib is an oral Janus kinase (JAK) inhibitor approved for the treatment of RA. It works by inhibiting multiple JAK-dependent cytokine pathways implicated in the pathogenesis of RA. Tofacitinib has demonstrated efficacy comparable to biologic DMARDs for achieving disease remission or low disease activity in RA patients. As an oral therapy, tofacitinib offers improved convenience compared to injected biologics and has shown a generally well-tolerated safety profile.
This document summarizes medication use patterns in the Alzheimer's Disease Neuroimaging Initiative (ADNI) cohort. It finds that 85% of ADNI patients took 4 or more daily medications (polypharmacy), and 22% took medications from Beer's list of potentially inappropriate drugs for elderly patients. Memantine treatment was associated with more severe Alzheimer's disease, while cholinesterase inhibitors were prescribed without difference by disease severity. Treatment also differed by gender, age, and education level in both mild cognitive impairment (MCI) and Alzheimer's disease (AD) groups.
The document discusses rheumatoid arthritis (RA) treatment guidelines and challenges in Latin America compared to developed regions. It summarizes RA treatment algorithms in the US, Europe, and Latin America. While the general approaches are similar, Latin America faces issues like a lack of qualified providers, deficient drug availability, and inadequate medical records. It proposes establishing RA as a public health priority in Latin America to improve access to care and treatment.
This document summarizes a presentation on clinical practice tools for identifying potential medication-related problems in the elderly. The presentation discusses several tools including the Beers List, Medication Appropriateness Index, IPET, Zhan-AHRQ, Medication Regimen Appropriateness Index, STOPP/START, IMAP, and NCQA-HEDIS. It provides definitions of related terms and describes each tool, how it was developed, its strengths and limitations. The presentation aims to help clinicians incorporate these tools into practice to improve medication management for elderly patients.
General prescribing guidelines for Pediatrics geriatrics pregnancy lactating...Koppala RVS Chaitanya
1. The document discusses physiological differences between pediatric and adult patients that are important to consider when selecting and dosing medications.
2. It outlines age classifications for pediatric patients from preterm neonates to adolescents and describes how drug absorption, distribution, metabolism, and excretion can vary significantly across age groups.
3. Selecting appropriate doses and accounting for changing pharmacokinetics is essential for safe and effective pharmacotherapy in pediatric patients.
SEMINAR ON categories of patients of personalized medicine.pptxPawanDhamala1
This document summarizes categories of patients that can benefit from personalized medicine approaches for several conditions. It discusses how personalized medicine can help patients with depression by identifying characteristics that predict treatment responses. For asthma, it notes how genetics studies are helping determine best treatments. It also outlines how genetic information may guide risk prediction and treatment for cardiac arrhythmias. The document then briefly discusses the potential for personalized treatments for migraine, arthritis, and cancer based on patient biomarkers and genetics.
Tofacitinib has been shown to significantly reduce signs and symptoms of RA as monotherapy and in combination with DMARDs. While treatments have improved, unmet needs remain like pain, fatigue, and psychological issues. ORAL Strategy showed tofacitinib + MTX was non-inferior to adalimumab + MTX. Tofacitinib provides an oral option for patients after inadequate response to csDMARDs and has an extensive safety profile from clinical trials and real-world use.
Rheumatoid arthritis is an inflammatory disease characterized by inflammation in the synovium that can lead to joint damage. The goals of treatment are to control inflammation and prevent further injury. Early diagnosis and treatment with disease-modifying antirheumatic drugs (DMARDs) is important to achieve remission and prevent long-term disability. Treatment involves DMARDs, glucocorticoids, exercise and lifestyle changes. Methotrexate is generally first-line for moderate-severe RA while hydroxychloroquine or sulfasalazine may be used for mild RA. Biologics that target cytokines like TNF may be added if initial treatment is ineffective. Prognosis is best when diagnosis and treatment occur early in the
Tactics and techniques in management of Multiple sclerosisAmr Hassan
This document discusses key decision making points in the treatment of multiple sclerosis. It begins with the author's disclosure statement noting they have received honoraria from various pharmaceutical companies. It then outlines the process for diagnosing MS and distinguishing it from other conditions. Several factors that influence the choice of first-line therapy are discussed, including adherence, patient preferences, prognostic factors, disease activity, comorbidities, safety, tolerability, efficacy, and pregnancy plans. Strategies for improving adherence are presented. The risks and categories of various disease-modifying therapies during pregnancy are shown. Methods for stratifying individual patient risk are provided. Definitions of highly active MS are outlined. The document concludes with recommendations on escalating versus inducing therapy based
This document discusses adverse drug reactions (ADRs), including:
1) Defining ADRs and distinguishing them from adverse drug events. ADRs are unintended effects caused directly by a drug, while adverse events can have other causes.
2) Around 5-10% of hospitalized patients experience an ADR, contributing to increased costs and length of stay. ADRs can reduce quality of life and rarely cause death.
3) Pharmacovigilance aims to detect, understand, and prevent ADRs through monitoring, reporting, and research on drug safety. Pharmacists play a key role in pharmacovigilance.
This document provides an overview of pharmacogenomics and its potential applications in clinical practice. It defines pharmacogenomics as the study of how genes impact a person's response to medication. It discusses several key points:
- Over 200 medications reference pharmacogenomic data in their package inserts.
- Enzymes like CYP450 play an important role in metabolizing many medications.
- Pharmacogenomic testing can help guide treatment for conditions like depression and provide dosing recommendations for medications like SSRIs.
- Areas like cardiovascular care and pain management may also benefit from pharmacogenomic testing to optimize medication selection and dosing.
1) Depression has a lifetime prevalence of 10-30% and is the third leading cause of disability worldwide. 2) Only about 33% of patients achieve full remission after their first antidepressant, and 30-45% fail to respond adequately to two treatments. 3) Achieving full remission is important for preventing relapse and reducing risks of suicide, medical comorbidities, and impaired functioning. Treatment resistance is defined as failing to respond to two adequate antidepressant trials.
Case # 29- The depressed man who thought he was out of options. .docxannandleola
Case # 29- The depressed man who thought he was out of options.
Depression has become a common mental disorder in our elderly population. This has caused a global concern for occur, geriatric patients, as depression often results in a significant burden for families as well as communities. Elderly people who suffer from depression may have an inferior baseline and record for medical assessments than those individuals without depression. Despite consistent evidence of the effectiveness of antidepressants for many with depression,
3
particularly those with more severe depression, remission rates are disappointingly low. An AHRQ-sponsored report found that only 46% of patients experienced remission from depression during 6 to 12 weeks of treatment with second-generation antidepressants. One major reason for this issue is non-adherence to medications and treatment plans. Studies have shown that patients' age, race and ethnicity are consistently associated with predictions of outcomes. (Rossom et al., 2016).
This case study involves a 69-year old man whose chief complaint is unremitting, chronic depression. After several years of medications and treatments, he feels hopeless for a recovery from his chronic depression. This assignments seeks to explore his family and social support systems, diagnostic testing, differential diagnosis and pharmacologic treatment options for this patient.
Questions for the client
How have you been sleeping lately?
How many times in the last week have you had feelings of hopelessness?
Are you having thoughts of harming yourself? Do you have a plan?
These questions are an important yet simple place to start when treating patients. Sleep disturbances plague much of the world's population and have shown to be a major indicator for mental health issues. Changes in sleep neurophysiology are often observed in depressive patients, and impaired sleep is, in many cases, the chief complaint of depression (Armitage, 2007). Depressed patients with sleep disturbance are likely to present more severe symptoms and difficulties in treatment. In addition, persistent insomnia is the most common residual symptom in depressed patients and is considered a vital predictor of depression relapse and may contribute to unpleasant clinical outcomes (Hinkelmann et al., 20120. Questions involving feelings of hopelessness and suicidal ideations with or without a plan relate to issues of patient safety. Across psychiatric disorders, hopelessness is associated with suicidal ideation and behavior. A meta-analysis of 166 longitudinal studies (sample size not reported) found that hopelessness was associated with an increased risk of ideation (Ribeiro, Huang, Fox, & Franklin, 2018).
Family and social support system
Family and social support systems are imperative for any patient in recovery. If the patient is agreeable to discussions with family members, then a discussion with his wife would be helpful. Researc.
1. The document discusses the concepts of pharmacogenomics and ayurgenomics. Pharmacogenomics examines how genetics affect individual responses to medications, while ayurgenomics studies the correlation between ayurvedic concepts like doshas and prakriti with the human genome.
2. Early studies found correlations between certain human leukocyte antigen gene variants and specific ayurvedic prakriti types. More recent research examined gene expression differences between kapha and pitta prakriti types in relation to high altitude adaptation.
3. Ayurgenomics offers a way to bridge traditional ayurvedic medicine and modern genetics by providing a scientific understanding of basic ayurvedic concepts and incorporating ayurved
This document discusses medication errors in pediatrics. It defines key terms like adverse drug reactions, side effects, and serious adverse effects. It notes that dosing errors are the most common type of error in pediatrics due to a lack of standard doses for children and the need to calculate individual doses based on weight or age. Tenfold dosing errors are common and often associated with higher toxicity. The document outlines strategies to prevent errors like establishing consensus guidelines, collecting error reports, using standardized dosing notations, limiting verbal orders, and having nurses double check doses and patient identities.
This document discusses pharmacoeconomics, drug compliance, and therapeutic failure. It begins by defining pharmacoeconomics as the analysis of costs and consequences of pharmaceutical products and services. It then discusses various pharmacoeconomic methods like cost-benefit analysis and cost-effectiveness analysis. The document also explains drug compliance, adherence, and the consequences of non-compliance. It notes that non-compliance can result in therapeutic drug failure and increased costs. It concludes by discussing common interventions to improve compliance like patient education and simplifying drug regimens.
Optimizing Patient Care: A Review on Therapeutic Drug Monitoring of some Clin...BRNSSPublicationHubI
Therapeutic drug monitoring (TDM) is a tool for optimizing the prescription in clinical practice to perform the drug assay and interpretation the result to get the constant concentration in the patient bloodstream. TDM was started 60 years ago and the objective of TDM is to maximize the therapeutic effect of therapy by reducing toxicity and efficacy failure by monitoring patient compliance. As we already know that these drugs have a narrow therapeutic window. The scope of TDM in India has additional indications because it will help reduce the drug resistance in patients treated by antimicrobial agents and help decide the highly effective therapy for individual patients. The clinical application of TDM is very useful for pharmacoeconomic study which can be improve the patient adherence. Clinical pharmacologists could increase the utility of TDM with the expert contribution of physicians. This method can improve the individual patient therapy outcome. TDM has two important aspects to study pharmacokinetic and pharmacodynamics. TDM is very useful to decide the dose in renal and hepatic compromised patients. Patient blood profile of an individual patient plays a crucial role to get the optimum therapeutic effect with less toxicity. TDM plays a vital role in the clinical practice of antiepileptic, anti-cancer, antimicrobial, immunosuppressant therapies, and cardiac glycosides and antitubercular agents. In India, the scope of TDM will increase day by day as increase the use of investigational use of drugs and improve the utility of the clinical pharmacology department. In developing countries, TDM has a high chance to grow with high speed.
Personalized Therapies for OA: Can Biomarkers Get Us There?OARSI
This document discusses the potential for using biomarkers to enable personalized therapies for osteoarthritis (OA). It defines key terms like personalized therapies, biomarkers, phenotypes, and endotypes. The presenter argues that biomarkers could help identify the right treatment for individual OA patients by enabling prognostic and predictive enrichment in clinical trials. However, moving biomarkers from discovery to clinical validation and use involves a long process including assay development, testing biological links and hypotheses, and conducting randomized controlled trials. Several studies are highlighted that have discovered potential new biomarkers and are beginning to test biological links and hypotheses regarding how biomarkers may reflect disease processes and response to treatments.
an important ppt for medical students and prescribing clinicians of medicine..... which deals with the methodology of right prescribing...... enjoy reading.... <3.... satya
This study analyzed 150 prescriptions of patients with rheumatoid arthritis treated at a tertiary care hospital in India. The study found:
1. Hydroxychloroquine was the most commonly prescribed drug (20.1%), followed by paracetamol (18.6%). Combination therapy using 3 or more drugs was preferred over monotherapy.
2. The majority of patients were female (91.3%) and the average age was 50 years old. Common comorbidities included hypertension (60%), diabetes (26.6%), and asthma (13.3%).
3. A total of 552 drugs were prescribed and 221 drug-drug interactions were identified. The highest number of interactions occurred with
Management strategies in multiple sclerosisAmr Hassan
This document discusses key decision making points in the treatment of multiple sclerosis (MS). It begins with an overview of the diagnostic criteria for MS and algorithms for clinical follow up of patients with a first attack or those at risk of converting to clinically definite MS. It then covers factors to consider when choosing a first-line disease modifying therapy, including adherence, patient preferences, prognostic factors, disease activity, comorbidities, safety, tolerability, efficacy, and pregnancy plans. Specific MS comorbidities and pregnancy categories for various therapies are also summarized. The document concludes with discussions on definitions of suboptimal response, treatment algorithms, escalation versus induction strategies, and considerations for discontinuing disease modifying therapies.
Effect of rosuvastatin on rheumatoid arthritis clinical disease activity inde...Alexander Decker
This document summarizes a study that evaluated the effects of the drug rosuvastatin on clinical disease activity and functional disability in patients with rheumatoid arthritis. The study involved a randomized, double-blind, placebo-controlled trial of 40 rheumatoid arthritis patients treated with either rosuvastatin 10mg or a placebo for 8 weeks. The study found that while rosuvastatin reduced measures of disease activity and functional disability to a clinically relevant degree, the changes were not statistically significant compared to the placebo group. The study concluded that rosuvastatin may provide benefit as an adjuvant therapy for rheumatoid arthritis, but a larger, longer study is needed.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
More Related Content
Similar to Challenges and gaps of RA management in Indonesia
General prescribing guidelines for Pediatrics geriatrics pregnancy lactating...Koppala RVS Chaitanya
1. The document discusses physiological differences between pediatric and adult patients that are important to consider when selecting and dosing medications.
2. It outlines age classifications for pediatric patients from preterm neonates to adolescents and describes how drug absorption, distribution, metabolism, and excretion can vary significantly across age groups.
3. Selecting appropriate doses and accounting for changing pharmacokinetics is essential for safe and effective pharmacotherapy in pediatric patients.
SEMINAR ON categories of patients of personalized medicine.pptxPawanDhamala1
This document summarizes categories of patients that can benefit from personalized medicine approaches for several conditions. It discusses how personalized medicine can help patients with depression by identifying characteristics that predict treatment responses. For asthma, it notes how genetics studies are helping determine best treatments. It also outlines how genetic information may guide risk prediction and treatment for cardiac arrhythmias. The document then briefly discusses the potential for personalized treatments for migraine, arthritis, and cancer based on patient biomarkers and genetics.
Tofacitinib has been shown to significantly reduce signs and symptoms of RA as monotherapy and in combination with DMARDs. While treatments have improved, unmet needs remain like pain, fatigue, and psychological issues. ORAL Strategy showed tofacitinib + MTX was non-inferior to adalimumab + MTX. Tofacitinib provides an oral option for patients after inadequate response to csDMARDs and has an extensive safety profile from clinical trials and real-world use.
Rheumatoid arthritis is an inflammatory disease characterized by inflammation in the synovium that can lead to joint damage. The goals of treatment are to control inflammation and prevent further injury. Early diagnosis and treatment with disease-modifying antirheumatic drugs (DMARDs) is important to achieve remission and prevent long-term disability. Treatment involves DMARDs, glucocorticoids, exercise and lifestyle changes. Methotrexate is generally first-line for moderate-severe RA while hydroxychloroquine or sulfasalazine may be used for mild RA. Biologics that target cytokines like TNF may be added if initial treatment is ineffective. Prognosis is best when diagnosis and treatment occur early in the
Tactics and techniques in management of Multiple sclerosisAmr Hassan
This document discusses key decision making points in the treatment of multiple sclerosis. It begins with the author's disclosure statement noting they have received honoraria from various pharmaceutical companies. It then outlines the process for diagnosing MS and distinguishing it from other conditions. Several factors that influence the choice of first-line therapy are discussed, including adherence, patient preferences, prognostic factors, disease activity, comorbidities, safety, tolerability, efficacy, and pregnancy plans. Strategies for improving adherence are presented. The risks and categories of various disease-modifying therapies during pregnancy are shown. Methods for stratifying individual patient risk are provided. Definitions of highly active MS are outlined. The document concludes with recommendations on escalating versus inducing therapy based
This document discusses adverse drug reactions (ADRs), including:
1) Defining ADRs and distinguishing them from adverse drug events. ADRs are unintended effects caused directly by a drug, while adverse events can have other causes.
2) Around 5-10% of hospitalized patients experience an ADR, contributing to increased costs and length of stay. ADRs can reduce quality of life and rarely cause death.
3) Pharmacovigilance aims to detect, understand, and prevent ADRs through monitoring, reporting, and research on drug safety. Pharmacists play a key role in pharmacovigilance.
This document provides an overview of pharmacogenomics and its potential applications in clinical practice. It defines pharmacogenomics as the study of how genes impact a person's response to medication. It discusses several key points:
- Over 200 medications reference pharmacogenomic data in their package inserts.
- Enzymes like CYP450 play an important role in metabolizing many medications.
- Pharmacogenomic testing can help guide treatment for conditions like depression and provide dosing recommendations for medications like SSRIs.
- Areas like cardiovascular care and pain management may also benefit from pharmacogenomic testing to optimize medication selection and dosing.
1) Depression has a lifetime prevalence of 10-30% and is the third leading cause of disability worldwide. 2) Only about 33% of patients achieve full remission after their first antidepressant, and 30-45% fail to respond adequately to two treatments. 3) Achieving full remission is important for preventing relapse and reducing risks of suicide, medical comorbidities, and impaired functioning. Treatment resistance is defined as failing to respond to two adequate antidepressant trials.
Case # 29- The depressed man who thought he was out of options. .docxannandleola
Case # 29- The depressed man who thought he was out of options.
Depression has become a common mental disorder in our elderly population. This has caused a global concern for occur, geriatric patients, as depression often results in a significant burden for families as well as communities. Elderly people who suffer from depression may have an inferior baseline and record for medical assessments than those individuals without depression. Despite consistent evidence of the effectiveness of antidepressants for many with depression,
3
particularly those with more severe depression, remission rates are disappointingly low. An AHRQ-sponsored report found that only 46% of patients experienced remission from depression during 6 to 12 weeks of treatment with second-generation antidepressants. One major reason for this issue is non-adherence to medications and treatment plans. Studies have shown that patients' age, race and ethnicity are consistently associated with predictions of outcomes. (Rossom et al., 2016).
This case study involves a 69-year old man whose chief complaint is unremitting, chronic depression. After several years of medications and treatments, he feels hopeless for a recovery from his chronic depression. This assignments seeks to explore his family and social support systems, diagnostic testing, differential diagnosis and pharmacologic treatment options for this patient.
Questions for the client
How have you been sleeping lately?
How many times in the last week have you had feelings of hopelessness?
Are you having thoughts of harming yourself? Do you have a plan?
These questions are an important yet simple place to start when treating patients. Sleep disturbances plague much of the world's population and have shown to be a major indicator for mental health issues. Changes in sleep neurophysiology are often observed in depressive patients, and impaired sleep is, in many cases, the chief complaint of depression (Armitage, 2007). Depressed patients with sleep disturbance are likely to present more severe symptoms and difficulties in treatment. In addition, persistent insomnia is the most common residual symptom in depressed patients and is considered a vital predictor of depression relapse and may contribute to unpleasant clinical outcomes (Hinkelmann et al., 20120. Questions involving feelings of hopelessness and suicidal ideations with or without a plan relate to issues of patient safety. Across psychiatric disorders, hopelessness is associated with suicidal ideation and behavior. A meta-analysis of 166 longitudinal studies (sample size not reported) found that hopelessness was associated with an increased risk of ideation (Ribeiro, Huang, Fox, & Franklin, 2018).
Family and social support system
Family and social support systems are imperative for any patient in recovery. If the patient is agreeable to discussions with family members, then a discussion with his wife would be helpful. Researc.
1. The document discusses the concepts of pharmacogenomics and ayurgenomics. Pharmacogenomics examines how genetics affect individual responses to medications, while ayurgenomics studies the correlation between ayurvedic concepts like doshas and prakriti with the human genome.
2. Early studies found correlations between certain human leukocyte antigen gene variants and specific ayurvedic prakriti types. More recent research examined gene expression differences between kapha and pitta prakriti types in relation to high altitude adaptation.
3. Ayurgenomics offers a way to bridge traditional ayurvedic medicine and modern genetics by providing a scientific understanding of basic ayurvedic concepts and incorporating ayurved
This document discusses medication errors in pediatrics. It defines key terms like adverse drug reactions, side effects, and serious adverse effects. It notes that dosing errors are the most common type of error in pediatrics due to a lack of standard doses for children and the need to calculate individual doses based on weight or age. Tenfold dosing errors are common and often associated with higher toxicity. The document outlines strategies to prevent errors like establishing consensus guidelines, collecting error reports, using standardized dosing notations, limiting verbal orders, and having nurses double check doses and patient identities.
This document discusses pharmacoeconomics, drug compliance, and therapeutic failure. It begins by defining pharmacoeconomics as the analysis of costs and consequences of pharmaceutical products and services. It then discusses various pharmacoeconomic methods like cost-benefit analysis and cost-effectiveness analysis. The document also explains drug compliance, adherence, and the consequences of non-compliance. It notes that non-compliance can result in therapeutic drug failure and increased costs. It concludes by discussing common interventions to improve compliance like patient education and simplifying drug regimens.
Optimizing Patient Care: A Review on Therapeutic Drug Monitoring of some Clin...BRNSSPublicationHubI
Therapeutic drug monitoring (TDM) is a tool for optimizing the prescription in clinical practice to perform the drug assay and interpretation the result to get the constant concentration in the patient bloodstream. TDM was started 60 years ago and the objective of TDM is to maximize the therapeutic effect of therapy by reducing toxicity and efficacy failure by monitoring patient compliance. As we already know that these drugs have a narrow therapeutic window. The scope of TDM in India has additional indications because it will help reduce the drug resistance in patients treated by antimicrobial agents and help decide the highly effective therapy for individual patients. The clinical application of TDM is very useful for pharmacoeconomic study which can be improve the patient adherence. Clinical pharmacologists could increase the utility of TDM with the expert contribution of physicians. This method can improve the individual patient therapy outcome. TDM has two important aspects to study pharmacokinetic and pharmacodynamics. TDM is very useful to decide the dose in renal and hepatic compromised patients. Patient blood profile of an individual patient plays a crucial role to get the optimum therapeutic effect with less toxicity. TDM plays a vital role in the clinical practice of antiepileptic, anti-cancer, antimicrobial, immunosuppressant therapies, and cardiac glycosides and antitubercular agents. In India, the scope of TDM will increase day by day as increase the use of investigational use of drugs and improve the utility of the clinical pharmacology department. In developing countries, TDM has a high chance to grow with high speed.
Personalized Therapies for OA: Can Biomarkers Get Us There?OARSI
This document discusses the potential for using biomarkers to enable personalized therapies for osteoarthritis (OA). It defines key terms like personalized therapies, biomarkers, phenotypes, and endotypes. The presenter argues that biomarkers could help identify the right treatment for individual OA patients by enabling prognostic and predictive enrichment in clinical trials. However, moving biomarkers from discovery to clinical validation and use involves a long process including assay development, testing biological links and hypotheses, and conducting randomized controlled trials. Several studies are highlighted that have discovered potential new biomarkers and are beginning to test biological links and hypotheses regarding how biomarkers may reflect disease processes and response to treatments.
an important ppt for medical students and prescribing clinicians of medicine..... which deals with the methodology of right prescribing...... enjoy reading.... <3.... satya
This study analyzed 150 prescriptions of patients with rheumatoid arthritis treated at a tertiary care hospital in India. The study found:
1. Hydroxychloroquine was the most commonly prescribed drug (20.1%), followed by paracetamol (18.6%). Combination therapy using 3 or more drugs was preferred over monotherapy.
2. The majority of patients were female (91.3%) and the average age was 50 years old. Common comorbidities included hypertension (60%), diabetes (26.6%), and asthma (13.3%).
3. A total of 552 drugs were prescribed and 221 drug-drug interactions were identified. The highest number of interactions occurred with
Management strategies in multiple sclerosisAmr Hassan
This document discusses key decision making points in the treatment of multiple sclerosis (MS). It begins with an overview of the diagnostic criteria for MS and algorithms for clinical follow up of patients with a first attack or those at risk of converting to clinically definite MS. It then covers factors to consider when choosing a first-line disease modifying therapy, including adherence, patient preferences, prognostic factors, disease activity, comorbidities, safety, tolerability, efficacy, and pregnancy plans. Specific MS comorbidities and pregnancy categories for various therapies are also summarized. The document concludes with discussions on definitions of suboptimal response, treatment algorithms, escalation versus induction strategies, and considerations for discontinuing disease modifying therapies.
Effect of rosuvastatin on rheumatoid arthritis clinical disease activity inde...Alexander Decker
This document summarizes a study that evaluated the effects of the drug rosuvastatin on clinical disease activity and functional disability in patients with rheumatoid arthritis. The study involved a randomized, double-blind, placebo-controlled trial of 40 rheumatoid arthritis patients treated with either rosuvastatin 10mg or a placebo for 8 weeks. The study found that while rosuvastatin reduced measures of disease activity and functional disability to a clinically relevant degree, the changes were not statistically significant compared to the placebo group. The study concluded that rosuvastatin may provide benefit as an adjuvant therapy for rheumatoid arthritis, but a larger, longer study is needed.
Similar to Challenges and gaps of RA management in Indonesia (20)
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
2. • Patients journey (apa saja hambatan pasien untuk bisa mendapatkan
pengobatan yang sesuai, terkecuali masalah harga)
• Implementasi guideline (apakah kita mengimplementasi guideline yang
ada, jika iya/tidak alasannya kenapa, guideline mana yang kita ikuti,
berapa banyak dokter yang mengikuti guideline)
• Apa saja tantangan/hambatan yang dijumpai dalam penerapan
guideline untuk tatalaksana AR ?
• Apa yang menjadi pertimbangan utama dalam menentukan tatalaksana
pasien AR ?
• Apakah nyeri yang berkurang atau membaik menjadi poin yang paling
utama dalam pencapaian goal of treatment di AR ?
Our topic
3. Rheumatoid arthritis (RA) is a systemic autoimmune disease
that causes joint inflammation and progressive erosion of
bone, leading to joint misalignment, loss of function, and
disability.
RA affects more 600.000 than million Indonesian adults.
Onset occurs most often between the ages of 30 and 50 years.
Women and older adults are more commonly affected.
Health Impact of Rheumatoid Arthritis
Donahue KE, Jonas D, Hansen RA, et al. Comparative Effectiveness Review No. 55. Available at
www.effectivehealthcare.gov/dmardsra.cfm.
4. The goal of RA treatment is to:
Control pain & inflammation
Limit progressive damage
Reduce disease activity or induce remission
Maintain function
Treatment of Rheumatoid Arthritis
Donahue KE, Jonas D, Hansen RA, et al. Comparative Effectiveness Review No. 55. Available at www.effectivehealthcare.gov/dmardsra.cfm.
5. Disease-modifying anti-rheumatic drugs (DMARDs) interfere
with rheumatoid disease processes by blocking the production
or activity of the immune cells and their products that cause
inflammation and damage.
Treatment with DMARDs is increasing with the expectation that
they will lead to better disease control and more remissions.
Steroids—both low-dose systemic and intra-articular
formulations—are used as adjuncts to DMARD treatment.
DMARDs
6. Disease-modifying anti-rheumatic drugs (DMARDs) are in
common use for rheumatoid arthritis (RA), and several have
been approved by the U.S. Food and Drug Administration
for this indication.
DMARDs may be oral or biologic drugs.
The consensus of clinical experience has made
methotrexate, an oral DMARD, the first-line drug of choice
for treating RA.
DMARDs in Rheumatoid Arthritis Treatment (1 of 2)
Donahue KE, Jonas D, Hansen RA, et al. Comparative Effectiveness Review No. 55. Available at www.effectivehealthcare.gov/dmardsra.cfm.
7. Oral disease-modifying anti-rheumatic drugs (DMARDs) are small-
molecule chemical drugs.
The mechanism of action of each of these drugs is not well defined and is
unknown in some cases.
Biologic DMARDs block the activity of immunostimulatory
cytokines and other cell-signaling molecules.
Biologic DMARDs are genetically engineered antibodies and proteins.
Tumor necrosis factor-alpha blockers are the most typical members of
this drug class.
Other targets are interleukins 1 and 6 and the transmembrane proteins
CD20 and CD28.
DMARDs in Rheumatoid Arthritis Treatment (2 of 2)
Donahue KE, Jonas D, Hansen RA, et al. Comparative Effectiveness Review No. 55. Available at
www.effectivehealthcare.gov/dmardsra.cfm.
8. Patients journey
• Apa saja hambatan pasien untuk bisa mendapatkan pengobatan yang
sesuai ?
• Keterlambatan diagnosis
• Keragaman pengetahuan dan kompetensi
• Akses ke fasilitas kesehatan yang tersedia KR
• Sistim rujukan
• Keterlambatan memulai DMARDs
• Pengetahuan dokter
• Ketersediaan DMARDs di faskes
• Kelemahan dalam follow up
• Timing
• Eskalasi
• Treat to target
9. Oral Disease-Modifying anti-rheumatic Drugs
Name Target of Activity
Hydroxychloroquine T-lymphocytes (?)
Leflunomide Pyridine synthesis
Methotrexate Dihydrofolate reductase; folate metabolism
Sulfasalazine Uncertain; multifactorial, including impairment of lymphocyte function and
cytokine synthesis
Oral DMARDs Included in the Comparative Effectiveness Review
Donahue KE, Jonas D, Hansen RA, et al. Comparative Effectiveness Review No. 55. Available at www.effectivehealthcare.gov/dmardsra.cfm.
10. Biologic DMARDs Included in the Comparative Effectiveness Review
Donahue KE, Jonas D, Hansen RA, et al. Comparative Effectiveness Review No. 55. Available at www.effectivehealthcare.gov/dmardsra.cfm.
Biologic Disease-Modifying anti-rheumatic Drugs
Name Trade Name Target of Activity
Adalimumab Humira® TNF-α
Certolizumab pegol Cimzia® TNF-α
Etanercept Enbrel® TNF-α
Golimumab Simponi® TNF-α
Infliximab Remicade® TNF-α
Abatacept Orencia® CD28
Anakinra Kineret® IL-1
Rituximab Rituxan® CD20
Tocilizumab Actemra®
RoActemra®
IL-6 receptor
Abbreviations: IL = interleukin; TNF-α = tumor necrosis factor-alpha
11. Implementasi guideline
• Apakah kita mengimplementasi guideline yang ada?
• Ya sebagian kecil
• Jika iya/tidak alasannya kenapa
• Akses terhadap update guideline
• Guideline mana yang kita ikuti
• IRA. EULAR, ACR, ARA ?, CRA ?
• Berapa banyak dokter yang mengikuti guideline?
• Belum ada survey.
• Rheumatologist umumnya sesuai
12. EULAR RECOMMENDATION FOR THE
MANAGEMENT OF RA
(Phase 1)
Smolen JS, et al. Ann Rheum Dis 2013;0:1-18
13. EULAR RECOMMENDATION FOR THE
MANAGEMENT OF RA
(Phase 2)
Smolen JS, et al. Ann Rheum Dis 2013;0:1-18
14. EULAR RECOMMENDATION FOR THE
MANAGEMENT OF RA
(Phase 3)
Smolen JS, et al. Ann Rheum Dis 2013;0:1-18
16. Tantangan
• Hambatan yang dijumpai dalam penerapan guideline
untuk tatalaksana AR ?
• Ketersediaan guideline
• Aksesibilitas
• Ketersediaan obat yang dianjurkandalam guideline
17. Apa yang menjadi pertimbangan utama dalam
menentukan tatalaksana pasien AR ?
• Kondisi pasien :
• Disease activity
• Disease damage
• Comorbidity
• Aspek DMARDs
• Efficacy, safety profile, drug interaction
• Ketersediaan obat dalam formularium:
• FORNAS
• Formularium Rumah Sakit
• Dukungan finansial / insurance
18. The strength of evidence for each of the following findings is low:
Patients with moderate rheumatoid arthritis (RA) had better overall
improvement and better functional status than patients with severe RA.
However, patients with severe RA had the greatest degree of
improvement from baseline.
In treatment with methotrexate (MTX), as the age of patients increased,
the likelihood of major clinical improvement decreased slightly; however,
overall age did not affect efficacy or risk of adverse effects.
Patient Characteristics on Outcomes of DMARD Treatment
Donahue KE, Jonas D, Hansen RA, et al. Comparative Effectiveness Review No. 55. Available at
www.effectivehealthcare.gov/dmardsra.cfm.
19. Biologics showed no apparent influence on the risk of cardiovascular
events in the elderly (≥65 years of age).
Toxicity of MTX was more likely in patients with greater renal impairment.
High-risk comorbidities (cardiovascular disease, diabetes, malignancies,
and renal impairment) did not increase the risk of serious adverse events
or infections in patients treated with b-DMARDs.
Concomitant antidiabetic, antihypertensive, or statin medications given
to patients treated with b-DMARDs did not increase the risk of adverse
events.
20. Head-to-Head Comparisons of Oral DMARDs for Rheumatoid Arthritis
Donahue KE, Jonas D, Hansen RA, et al. Comparative Effectiveness Review No. 55. Available at www.effectivehealthcare.gov/dmardsra.cfm.
Comparison
N Studies; Patients
Reduced Symptoms or
Disease Activity
Limiting Radiographic
Progression Improved Function
Improved Quality of
Life
SSZ vs. MTX*
3; 1,001
(disease duration <3
years)
NSD (DAS)
SOE = Moderate
NSD
SOE = Moderate
NSD
(3 RCTs; 479 patients)
SOE = Moderate
NR
LEF vs. MTX*
2; 1,481
NSD (ACR20 rates)
SOE = Low
NSD
SOE = Low
Greater improvement with
LEF at 12 months (HAQ) but
less than the MCID
SOE = Low
Greater with LEF at 12
months
(SF-36 physical
component )
SOE = Low
LEF vs. SSZ
1; 358
SOE = Insufficient
NSD
SOE = Low
Greater improvement with
LEF (HAQ) to 24 months
SOE =Low
NR
*Methotrexate was used at 7.5 to 25 mg per week in the reported studies.
ACR20 = American College of Rheumatology 20-percent improvement criteria; DAS = disease activity score; HAQ = Health Assessment Questionnaire; LEF =
leflunomide; MCID = minimum clinically important difference; MTX = methotrexate;
NR = not reported; NSD = no statistically significant difference; RCT = randomized controlled trial; SOE = strength of evidence; SSZ = sulfasalazine
21. Head-to-Head Comparisons of Combination Treatment With Oral DMARDs
Intervention
N Studies;
Patients Comparator
Patient
Characteristics
Reduced Symptoms
or Disease Activity
Limiting
Radiographic
Progression Improved Function‡
SSZ plus
MTX*
4; 709
SSZ or MTX*
monotherapy
DMARD-naïve,
early RA†
NSD
SOE = Moderate
NSD
SOE = Moderate
NSD
SOE = Moderate
2 or 3 oral
DMARDs in
combination
(MTX*, SSZ,
HCQ)
2; 273
1 or 2 oral
DMARDs
Patients with
longstanding
active RA
3 oral DMARDs are
favored over 2 to
improve disease
activity.
SOE = Moderate
NR
Difference less than
MCID
SOE = Moderate
* Methotrexate was used at 7.5 to 25mg per week in the reported studies.
† Early rheumatoid arthritis is defined as <3 years.
‡ Health-related quality of life was not reported.
DMARD = disease-modifying anti-rheumatic drug; HCQ = hydroxychloroquine; LEF = leflunomide;
MCID = minimum clinically important difference; MTX = methotrexate; NR = not reported; NSD = no statistically significant
difference; RA = rheumatoid arthritis; SOE = strength of evidence; SSZ = sulfasalazine
Donahue KE, Jonas D, Hansen RA, et al. Comparative Effectiveness Review No. 55. Available at www.effectivehealthcare.gov/dmardsra.cfm.
22. Head-to-Head Comparisons of Biologic DMARDs
In patients with active RA (>3 years), with failed or inadequate disease response to DMARDs who did not receive an
anti–TNF-α DMARD, head-to-head comparisons of DMARDs produced the following results:
Intervention Comparator
Symptoms or
Disease Activity*
(N Studies; N Patients)
Function
(N Studies; N Patients)
Quality of Life
(N Studies; N Patients)
Etanercept Infliximab
Faster response with etanercept, but
NSD in the longer term
(6; 5,883) SOE = Low
2 of 3 studies reported NSD
(3; 2,239) Insufficient
Insufficient
Etanercept Adalimumab
ACR70 at 6 months showed NSD
(1; 2,326) SOE = Low
NSD
(1; 707) SOE = Low
NSD
(1; 707) SOE = Low
Adalimumab Infliximab
Symptom response (ACR20 at 6
months) and DAS at 1 year greater
with adalimumab
(2; 3,033) SOE = Low
Greater improvement at 12
months with adalimumab but
not greater than the MCID
(1; 707) SOE = Low
SF-36 physical component at 12
months favors adalimumab
(1; 707) SOE = Insufficient
Abatacept Infliximab
Greater decrease in DAS and greater
remission rate, both at 1 year, with
abatacept.
(3; 3,464) SOE = Low
NSD at 1 year
(1; 431) SOE = Low
SF-36 physical component at 1 year
favors abatacept but not greater
than the MCID
(1; 431) SOE = Low
*Radiographic progression not reported.
Donahue KE, Jonas D, Hansen RA, et al. Comparative Effectiveness Review No. 55. Available at www.effectivehealthcare.gov/dmardsra.cfm.
23. Head-to-Head Comparisons of Oral and Biologic DMARDs
Intervention
(N Studies,
N Patients) Comparator Symptoms or Disease Activity
Radiographic
Evidence of
Progression Functional Capacity
In patients with longstanding active RA who required a change in therapy*:
Biologic DMARDs
as a class
Oral DMARDs
as a class Higher chance of remission with biologics
than with oral DMARDs
SOE = Moderate
NR Insufficient
1 retrospective cohort study
N = 1,083
Biologic DMARDs Oral DMARDs
Higher response rates for biologic DMARDs
SOE = Moderate
NR Insufficient
4 RCTs, 2 cohort studies
N = 3,696
* Health-related quality of life was not reported.
DMARD = disease-modifying anti-rheumatic drug; NR = not reported; RA = rheumatoid arthritis; RCT = randomized controlled trial; SOE = strength of evidence
Donahue KE, Jonas D, Hansen RA, et al. Comparative Effectiveness Review No. 55. Available at www.effectivehealthcare.gov/dmardsra.cfm.
24. DMARD Combinations Versus Monotherapies
Intervention* Comparator
Symptoms or
Disease Activity
(N Studies;
N Participants)
Radiographic
Progression
(N Studies;
N Participants)
Function
(N Studies;
N Participants)
Quality of Life
(N Studies;
N Participants)
Biologic
DMARD plus
MTX†
Biologic
DMARD
Monotherapy
(5 RCT, 4 cohort; 9,804)
Combination is
more effective
SOE = Moderate
(2; 1, 495)
Less change with a
combination
SOE = Moderate
(2; 1,495)
Combination
treatment is more
effective
SOE = Moderate
(2; 1,495)
Combination
treatment is more
effective.
SOE = Low
Biologic
DMARD plus
MTX or SSZ
MTX† or SSZ
Monotherapy
(7; 4,482)
Combination is
more effective
SOE = High
(7; 4,482)
Less change with
combination
SOE = Moderate
(7 RCT, 1 cohort; 7,516)
Combination
treatment is more
effective
SOE = High
(7 RCT, 1 cohort;
7, 516)
Combination
treatment is more
effective
SOE = Moderate
* Patients with active disease whose disease did not respond to an oral DMARD did not benefit from including that oral
DMARD in combination with a biologic DMARD.
† MTX was used at a dose of 7.5 to 25mg per week in the reported studies.
In patients with longstanding active rheumatoid arthritis with inadequate disease control, head-to-head comparisons of
combined DMARDs and DMARD monotherapy were conducted.
Donahue KE, Jonas D, Hansen RA, et al. Comparative Effectiveness Review No. 55. Available at www.effectivehealthcare.gov/dmardsra.cfm.
25. DMARD Combinations Versus Monotherapies
In patients with early rheumatoid arthritis who had not been treated with methotrexate (MTX), or who had
not received MTX in the previous 3 months, head–to–head comparisons of combination therapy and MTX
monotherapy were examined for effects on function and quality of life.
Intervention Comparator Patient Characteristics
Function
(N Studies;
N Participants)
Quality of Life
(N Studies;
N Participants)
Biologic DMARD
plus MTX*
MTX* monotherapy
Early RA†
MTX Naïve or not recently
on MTX*
(2; 1,495)
Combination is more
effective.
SOE = Moderate
(2; 1,495)
Combination is more
effective.
SOE = Low
* Methotrexate was used at 7.5 to 25mg per week in the reported studies.
† Early RA is defined as disease of as less than 3 years’ duration.
DMARD = disease-modifying anti-rheumatic drug; MTX = methotrexate; RA = rheumatoid arthritis; SOE = strength of evidence
Donahue KE, Jonas D, Hansen RA, et al. Comparative Effectiveness Review No. 55. Available at www.effectivehealthcare.gov/dmardsra.cfm.
26. Comparative Benefits of Oral and Biologic DMARDs in Early RA
Patient Characteristics Intervention Comparator
Reduced Symptoms or
Disease Activity
Limiting
Radiographic
Progression Improved Function
Patients with early
RA*
2 to 3 oral DMARDs
plus corticosteroids
Oral DMARD
Monotherapy
Combination is more
effective at 28 but not 52
weeks.
(2; 354) SOE = Low
Combination is more
effective
(2; 354)
SOE = Low
Combination is
more effective† (2;
354)
SOE = Low
MTX-naïve patients
with aggressive early
RA
MTX‡ Adalimumab,
Etanercept
Results are similar
(2; 1,431)
SOE = Moderate
Biologic DMARD is
more effective at
limiting progression.
(2; 1,431)
SOE = Low
Results are similar
with MTX and
adalimumab§
(2; 1,431)
SOE = Low
MTX-naïve patients
with aggressive early
RA
MTX‡ plus biologic
DMARD
Biologic DMARD
Monotherapy
Combination is more
effective
(also improves remission
rates)
(1; 799) SOE = Low
Combination is more
effective.
(1; 799)
SOE = Low
NR§
* Early RA is disease of less than 3 years’ duration.
† Combination treatment is also more effective at improving quality of life.
‡ Methotrexate was used at a dose of 7.5 to 25mg per week in the reported studies.
§ Quality-of-life outcomes were not reported.
Donahue KE, Jonas D, Hansen RA, et al. Comparative Effectiveness Review No. 55. Available at www.effectivehealthcare.gov/dmardsra.cfm.
27. Combining methotrexate (MTX) or other oral disease-modifying anti-
rheumatic drugs (DMARDs) with a biologic DMARD does not alter the
adverse event rate found with the biologic DMARD alone.
Strength of Evidence = Low
Combining MTX and biologic DMARDs demonstrates a better
tolerability profile than MTX alone.
Strength of Evidence = Low
Evidence is insufficient to estimate differences in rates of specific
adverse events between the biologic and oral DMARDs.
Comparative Adverse Effects of Combining DMARDs
Donahue KE, Jonas D, Hansen RA, et al. Comparative Effectiveness Review No. 55. Available at www.effectivehealthcare.gov/dmardsra.cfm.
28. Withdrawal due to adverse events
Time to withdrawal
Infusion and injection-site reactions
Infections
Malignancy
Mortality
Cardiovascular and cerebrovascular events
Rare but serious adverse events: demyelination,
autoimmunity, pancytopenia, and hepatotoxicity
Adverse Effects of Interest in the Comparative Effectiveness Review
Donahue KE, Jonas D, Hansen RA, et al. Comparative Effectiveness Review No. 55. Available at www.effectivehealthcare.gov/dmardsra.cfm.
29. Apakah nyeri yang berkurang atau membaik menjadi poin yang
paling utama dalam pencapaian goal of treatment di AR ?
• Dari sisi pasien jawabannya: YA
• NYERI merupakan KELUHAN UTAMA disamping STIFFNESS pada pasien
dengan RA
• Dari sisi dokter : disease control
• Disease activity (inflammation)
• Function
• Disease damage
30. The natural history of rheumatoid arthritis (RA) and the role of
disease-modifying anti-rheumatic drugs (DMARDs) in reducing
symptoms and improving disease control
The potential benefits and adverse effects of DMARDs
Changes in lifestyle that can help relieve RA symptoms, such as
diet and exercise
Patient and family preferences and values regarding treatment
What To Discuss With Your Patients and Their Family
Donahue KE, Jonas D, Hansen RA, et al. Comparative Effectiveness Review No. 55. Available at www.effectivehealthcare.gov/dmardsra.cfm.
31. How to monitor Tt in RA?
• Disease activity is assessed by several parameters…
• Duration of morning stiffness
• Tender joints count
• Swollen joints count
• Observer global assessment
• Patient global assessment
• Visual analogue scale for pain
• Health assessment questionnaire
• ESR
• NSAID pill count etc
• Patient on MTX, SSZ or leflunamide show clinical improvement in 6-8 wks.
• Patient should be observed for 6 months before declaring a DMARD ineffective.
32. How long should Tt. be continued?
• Once remission is achieved , maintenance dose for long period is recommended.
• Relapse occurs in 3-5 months (1-2 months in case of MTX) if drug is discontinued
in most instances.
• DMARDs are discontinued by patients because of toxicity or secondary
failure(common after 1-2 yrs) and such patients might have to shift over different
DMARDs over 5-10 yrs.
• Disease flare may require escalation of DMARD dose with short course of
steroids.
Health Impact of Rheumatoid Arthritis
Rheumatoid arthritis (RA) is an autoimmune disease that causes joint inflammation and progressive erosion of bone, leading to joint misalignment, loss of function, and disability.
RA affects 1.3 million American adults. Onset occurs most often between the ages of 30 and 50 years. Women and older adults are more commonly affected.
Reference:
Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Rheumatoid Arthritis in Adults: An Update. Comparative Effectiveness Review No. 55 (Prepared by the RTI International―University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality; April 2012. AHRQ Publication No. 12-EHC025-EF. Available at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.
Treatment of Rheumatoid Arthritis
The goal of RA treatment is to control pain, control inflammation, limit progressive damage, and reduce disease activity or induce remission.
Disease-modifying anti-rheumatic drugs (DMARDs) interfere with rheumatoid disease processes by blocking the production or activity of the immune cells and their products that cause inflammation and damage. Treatment with DMARDs is increasing with the expectation that they will lead to better disease control and more remissions. Corticosteroids—both low-dose systemic and intra-articular formulations—are used as adjuncts to DMARD treatment.
Reference:
Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Rheumatoid Arthritis in Adults: An Update. Comparative Effectiveness Review No. 55 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality; April 2012. AHRQ Publication No. 12-EHC025-EF. Available at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.
DMARDs in Rheumatoid Arthritis Treatment (1 of 2)
Disease-modifying anti-rheumatic drugs (DMARDs) are in common use for rheumatoid arthritis (RA), and several have been approved by the U.S. Food and Drug Administration for this indication. DMARDs may be oral or biologic drugs.
The consensus of clinical experience has made methotrexate, a oral DMARD, the first-line drug of choice for treating RA.
Reference:
Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Rheumatoid Arthritis in Adults: An Update. Comparative Effectiveness Review No. 55 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center). Rockville, MD: Agency for Healthcare Research and Quality; April 2012. AHRQ Publication No. 12-EHC025-EF. Available at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.
DMARDs in Rheumatoid Arthritis Treatment (2 of 2)
Oral disease-modifying anti-rheumatic drugs (DMARDs) are small-molecule chemical drugs. The mechanism of action of each of these drugs is not well defined and is unknown in some cases.
Biologic DMARDs block the activity of immunostimulatory cytokines and other cell-signaling molecules. They include genetically engineered antibodies and proteins. Tumor necrosis factor-alpha blockers are the most typical members of this drug class. Other targets are interleukins 1 and 6 and the transmembrane proteins CD20 and CD28.
Reference:
Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Rheumatoid Arthritis in Adults: An Update. Comparative Effectiveness Review No. 55 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality; April 2012. AHRQ Publication No. 12-EHC025-EF. Available at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.
Oral DMARDs Included in the Comparative Effectiveness Review
The oral disease-modifying anti-rheumatic drugs that have been studied for treatment of rheumatoid arthritis and were included in the comparative effectiveness review are:
Hydroxychloroquine: Its target of activity is uncertain but likely is T-lymphocytes.
Leflunomide: Its target of activity is pyridine synthesis.
Methotrexate: Its target of activity is dihydrofolate reductase and folate metabolism.
Sulfasalazine: Its target of activity is uncertain but may be multifactorial, including impairment of lymphocyte function and cytokine synthesis.
Reference:
Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Rheumatoid Arthritis in Adults: An Update. Comparative Effectiveness Review No. 55 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality; April 2012. AHRQ Publication No. 12-EHC025-EF. Available at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.
Biologic DMARDs Included in the Comparative Effectiveness Review
The biologic disease-modifying anti-rheumatic drugs (DMARDs) that have been studied for treatment of rheumatoid arthritis and were included in the comparative effectiveness review are:
The biologic DMARDs that target tumor necrosis factor-alpha (TNF-α) include adalimumab (Humira), certolizumab pegol (Cimzia), etanercept (Enbrel), golimumab (Simponi), and infliximab (Remicade).
Other biologic DMARDs included in the review target immune system components other than TNF-α. They are:
Abatacept (Orencia): Its target of activity is CD28.
Anakinra (Kineret): Its target of activity is interleukin 1.
Rituximab (Rituxan): Its target of activity is CD20.
Tocilizumab (Actemra, RoActemra): Its target of activity is the interleukin-6 receptor.
Reference:Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Rheumatoid Arthritis in Adults: An Update. Comparative Effectiveness Review No. 55 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality; April 2012. AHRQ Publication No. 12-EHC025-EF. Available at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.
Other Findings: Influence of Patient Characteristics on Outcomes of DMARD Treatment
The strength of evidence for each of the following findings is low:
- Patients with moderate rheumatoid arthritis (RA) had better overall improvement and better functional status than patients with severe RA. However, patients with severe RA had the greatest degree of improvement from baseline.
- In treatment with methotrexate (MTX), as the age of patients increased, the likelihood of major clinical improvement decreased slightly; however, overall age did not affect efficacy or risk of adverse effects.
- Biologics showed no apparent influence on the risk of cardiovascular events in the elderly (≥65 years of age).
- Toxicity of MTX was more likely in patients with greater renal impairment.
- High-risk comorbidities (cardiovascular disease, diabetes, malignancies, and renal impairment) did not increase the risk of serious adverse events or infections in patients treated with anakinra.
- Concomitant antidiabetic, antihypertensive, or statin medications given to patients treated with anakinra did not increase the risk of adverse events.
Reference:
Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Rheumatoid Arthritis in Adults: An Update. Comparative Effectiveness Review No. 55 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality; April 2012. AHRQ Publication No. 12-EHC025-EF. Available at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.
Summary of Results: Head-to-Head Comparisons of Oral DMARDs for Rheumatoid Arthritis
Studies of oral disease-modifying anti-rheumatic drugs (DMARDs) include head-to head-comparisons, but the number of studies and patients examined is limited and the strength of evidence in support of the findings is low or moderate. For some outcomes, the evidence is insufficient for a conclusion or the outcomes were not studied.
Reference:
Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Rheumatoid Arthritis in Adults: An Update. Comparative Effectiveness Review No. 55 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality; April 2012. AHRQ Publication No. 12-EHC025-EF. Available at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.
Summary of Results: Head-to-head Comparisons of Combination Treatment With Oral DMARDs
Studies of oral disease-modifying anti-rheumatic drugs (DMARDs) include head-to-head comparisons of DMARDs used in combination and compared with monotherapy or other DMARD combinations. Patient populations included those with early rheumatoid arthritis who had not been treated with DMARDs, and those patients with longstanding active rheumatoid arthritis and inadequate response to treatment. The number of studies and patients examined is limited, but where available, the strength of evidence in support of the findings is moderate. Some outcomes were not reported in all studies.
Reference:
Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Rheumatoid Arthritis in Adults: An Update. Comparative Effectiveness Review No. 55 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality; April 2012. AHRQ Publication No. 12-EHC025-EF. Available at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.
Summary of Results: Head-to-Head Comparisons of Biologic DMARDs
Head-to-head comparisons of biologic DMARDs were evaluated for the effectiveness review. Patient populations in the included studies were patients with active RA for longer than 3 years whose disease not did respond or inadequately responded to DMARDs but had not previously treated with an anti–TNF-α DMARD. This table presents a summary of the results of those studies, organized according to the interventions compared in each study. Disease activity and symptom response, functional status, and quality-of-life outcomes were reported. Radiographic evidence of progression was not reported in the studies. The evidence is limited for all comparisons; thus, the strength of evidence is low or insufficient.
Abbreviations:
ACR70 = American College of Rheumatology 70-percent improvement criteria; ACR20 = American College of Rheumatology 20-percent improvement criteria; DAS = Disease Activity Score; DMARD = disease-modifying anti-rheumatic drug; MCID = minimum clinically important difference; NSD = no statistically significant difference; RA = rheumatoid arthritis; SOE = strength of evidence; TNF-α = tumor necrosis factor-alpha
Reference:
Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Rheumatoid Arthritis in Adults: An Update. Comparative Effectiveness Review No. 55 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality; April 2012. AHRQ Publication No. 12-EHC025-EF. Available at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.
Summary of Results: Head-to-Head Comparisons of Oral and Biologic DMARDs
The reviewed studies included direct comparisons of oral and biologic disease-modifying anti-rheumatic drugs (DMARDs) used to treat patients with longstanding active rheumatoid arthritis who required a change in therapy. A retrospective cohort study of 1,083 patients found that as a class, biologic DMARDs resulted in more remissions when compared with oral DMARDs as a class. The systematic review found that biologic DMARDs achieved a higher response rate than oral DMARDs. The strength of evidence for this finding is moderate.
Four randomized controlled trials and two retrospective cohort studies evaluated 3,696 patients in comparisons of biologic DMARDs with oral DMARDs. Higher symptom response rates were found with biologic DMARDs. The strength of the evidence for this conclusion is moderate.
Radiographic evidence of progression was not reported in the studies presented here, and evidence for findings of effect on functional capacity was insufficient to permit conclusions.
Reference:
Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Rheumatoid Arthritis in Adults: An Update. Comparative Effectiveness Review No. 55 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality; April 2012. AHRQ Publication No. 12-EHC025-EF. Available at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.
Summary of Results: DMARD Combinations Versus Monotherapies
In patients with longstanding active rheumatoid arthritis with inadequate disease control, head-to-head comparisons were made of combined DMARDs and DMARD monotherapy. Overall, combination treatment with biologic DMARDs and an oral DMARD is more effective than either used as monotherapy. Disease activity, radiographic progression, functional status, and quality of life all are greater improved with the combination therapy. The strength of evidence for these findings varies among the specific outcomes, with most supported by moderate or high strength of evidence.
Abbreviations:
DMARD = disease-modifying anti-rheumatic drug; MTX = methotrexate; RA = rheumatoid arthritis; RCT = randomized controlled trial; SOE = strength of evidence; SSZ = sulfasalazine
Reference:
Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Rheumatoid Arthritis in Adults: An Update. Comparative Effectiveness Review No. 55 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality; April 2012. AHRQ Publication No. 12-EHC025-EF. Available at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.
Summary of Results: DMARD Combinations Versus Monotherapies
In patients with early rheumatoid arthritis who had not been treated with methotrexate (MTX), or who had not received MTX in the previous 3 months, head–to–head comparisons of combination therapy and MTX monotherapy were examined for effects on function and quality of life. Combination therapy was more effective in achieving improvements in function and quality of life. The strength of evidence is moderate for functional status and low for quality of life.
Reference:
Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Rheumatoid Arthritis in Adults: An Update. Comparative Effectiveness Review No. 55 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality; April 2012. AHRQ Publication No. 12-EHC025-EF. Available at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.
Summary of Results: Comparative Benefits of DMARDs for Patients With Early RA
Some clinical research has focused on treatment of patients with early rheumatoid arthritis, defined for this comparative effectiveness review as less than 3 years’ duration of disease. This table presents a summary of the results of those studies, organized according to the patient characteristics and by the interventions compared in the study. Disease activity and symptom response, radiographic evidence of progression, and functional status were reported. Quality-of-life outcomes were not reported in the studies. The strength of evidence is moderate for one conclusion, finding that methotrexate and adalimumab or etanercept produce similar effects on symptoms. The evidence is limited for all other comparisons, making the strength of evidence low.
Abbreviations:
DMARD = disease-modifying anti-rheumatic drug; MTX = methotrexate; NR = not reported; RA = rheumatoid arthritis; SOE = strength of evidence
Reference:
Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Rheumatoid Arthritis in Adults: An Update. Comparative Effectiveness Review No. 55 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality; April 2012. AHRQ Publication No. 12-EHC025-EF. Available at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.
Comparative Adverse Effects of Combining DMARDs
Combining methotrexate (MTX) or other oral disease-modifying anti-rheumatic drugs (DMARDs) with a biologic DMARD does not alter the adverse event rate found with the biologic DMARD alone. The strength of evidence for this finding is low.
Combining MTX and biologic DMARDs demonstrates a better tolerability profile than MTX alone. The strength of evidence for this finding is low.
Evidence is insufficient to estimate differences in rates of specific adverse events between the biologic and oral DMARDs.
Reference:
Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Rheumatoid Arthritis in Adults: An Update. Comparative Effectiveness Review No. 55 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality; April 2012. AHRQ Publication No. 12-EHC025-EF. Available at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.
Adverse Effects of Interest in the Comparative Effectiveness Review
For analysis of the clinical study evidence, reviewers focused on these adverse effects measurements:
- Withdrawal due to adverse events
- Time to withdrawal
- Infusion and injection-site reactions
- Infections
- Malignancy
- Mortality
- Cardiovascular and cerebrovascular events
- Rare but serious adverse events: demyelination, autoimmunity, pancytopenia, and hepatotoxicity
Reference:
Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Rheumatoid Arthritis in Adults: An Update. Comparative Effectiveness Review No. 55 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality; April 2012. AHRQ Publication No. 12-EHC025-EF. Available at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.
What To Discuss With Your Patients and Their Caregivers
In discussions with patients who have rheumatoid arthritis (RA) and their caregivers, topics related to the comparative effectiveness review evidence include the natural history of RA, the role of disease-modifying anti-rheumatic drugs (DMARDs) in reducing symptoms and improving disease control, the potential benefits and adverse effects of DMARDs, changes in lifestyle that can help relieve symptoms (e.g., diet and exercise), and patient and caregiver preferences and values regarding treatment.
Reference:
Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Rheumatoid Arthritis in Adults: An Update. Comparative Effectiveness Review No. 55 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality; April 2012. AHRQ Publication No. 12-EHC025-EF. Available at www.effectivehealthcare.ahrq.gov/dmardsra.cfm.