Rheumatoid Arthritis: its symptoms, diagnosis, and recent treatment advances. The presentation will include a patient advocate's experiences in successfully living with the condition.

1. Living with Rheumatoid Arthritis
Presented by:
Lauren Kennish, MD
Rheumatologist
May 6, 2015

2. Lecture Outline
• What is Rheumatoid Arthritis (RA)?
• How is it diagnosed?
• What are the symptoms of RA?
• What are the treatment options?
• How do we live well with RA?
• What is new on the horizon?

3. What is Rheumatoid Arthritis?
• RA is an autoimmune disease
• Autoimmune disease:
Immune system incorrectly targets your own
tissues and organs
Antibodies form and attack cells
Inflammation/Swelling
Damage/Disease

4. What is Rheumatoid Arthritis?
• Type of inflammatory arthritis = pain,
swelling and stiffness in the joints
• Systemic – can affect whole body
• Chronic condition
• Can damage cartilage,
bone
• Mild Severe
Arthritis.org, 12/2013
flare relapse
remission

5. What is RA?
• Prevalence: 0.5-1% population, about 1.5 million
• Diagnosis age: Average
30-60 years old
• Females (3x) > Males
Helmick et al. A&R, 2008.

6. What Causes RA?
• Largely unknown
• Theories:
 Genetics
+
 Environment
• Possible Triggers
 Infection
• Gut/Gum bacteria
 Smoking
 Obesity
 Stress
 Female hormones

7. How is RA Diagnosed?
• History, Symptoms, Exam
• Blood tests
 Rheumatoid factor, anti-CCP, anti-MCV
 Inflammatory markers – ESR, CRP
Medscape.com

8. How is RA Diagnosed?
• Imaging
 Xray
 MRI
 Ultrasound
Copyright ACR, 2013

9. What are the Symptoms of RA?
• Joint pain and swelling
 Small joints, symmetric
• Morning stiffness
 > 1 hour
• Difficulty with activities
Copyright ACR, 12/2013
Arthritis.org, 12/2013

10. What are the Symptoms of RA?
• Joint Damage
Copyright ACR, 12/2013

11. What are the Symptoms of RA?
• Fatigue
• Anemia
• Skin nodules
• Inflammation –
 Eyes
 Blood vessels
 Lungs
 Heart
Copyright ACR, 12/2013

12. Associated Autoimmune Diseases
• Sjogren’s Syndrome
• Hashimoto’s Thyroiditis (Hypothyroidism)
Webmd.com

13. Associated Conditions
• Osteoarthritis
• Fibromyalgia
Webmd.com, 2013Copyright ACR, 2013

14. Associated Conditions
• Osteoporosis
• Heart Disease
 Atherosclerosis -> high
cholesterol, heart attack
• Increased risk of:
 Infections
 Cancer

15. Related Types of Arthritis
• Spondyloarthritis
 Psoriatic Arthritis
 Ankylosing Spondylitis
 Reactive Arthritis
Copyright ACR, 2013

16. How is RA Treated?
• There is no cure yet
• BUT…
• Many treatment options to decrease
symptoms and associated conditions
• Can lead active, healthy lives

17. How is RA Treated?
• Goal:
 Reduce symptoms
 Maintain remission
 Prevent flares, complications
 Prevent joint damage, disability
 Maintain quality of life
• Treatment is tailored to individual
 Based on symptoms, concurrent conditions, lifestyle
 Treatment is usually continuous
 Combination of medication and non-medical therapy
• EARLY treatment is KEY

18. How is RA Treated?
• Use:
 Temporary relief of pain and stiffness
• Mechanism:
 Anti-inflammatory
• Side effects:
 Stomach ulcers, kidney/liver problems, high blood
pressure, heart disease
NSAIDs: Non-Steroidal Anti-Inflammatory Drugs

19. How is RA Treated?
• Suppresses immune system cells from
forming and making antibodies to
tissues
• Modifies disease
• Oral, Injection
• Requires close
monitoring
Immunosuppressive Therapy

20. How is RA Treated?
• Use:
 Joint pain and swelling
• Mechanism:
 Anti-inflammatory, Immune suppressing
• Potential side effects:
 Weight gain, mood change, infections, diabetes,
high blood pressure, osteoporosis, cataracts
Steroids / Prednisone

21. How is RA Treated?
• Widely used, first-line medications
• Methotrexate
• Leflunomide (Arava)
• Sulfasalazine
• Hydroxychloroquine (Plaquenil)
Disease Modifying Anti-Rheumatic Drugs

22. How is RA Treated?
• Use:
 Joint pain
 Swelling, Stiffness
 Reduce risk of progression and joint damage
 Prevent flares
• Mechanism:
 Immune suppressing, Disease modifying
• Potential side effects:
 Stomach upset, infection, hair loss, oral ulcers, rash, low
blood counts, inflammation of liver or lungs, vision
problems
DMARDs

23. How is RA Treated?
• Use:
 Joint pain, swelling, stiffness
 Reduces risk of progression and joint damage
 Prevents flares
• Mechanism:
 Specifically targets molecules
of the immune system, Immune
suppressing
• Potential side effects:
 Infection, rash, allergy, low blood counts, heart failure,
neurologic condition, skin cancer
Biologics

24. How is RA Treated?
• TNF inhibitors:
 Etanercept (Enbrel)
 Adalimumab (Humira)
 Infliximab (Remicade)
 Certolizumab (Cimzia)
 Golimumab (Simponi)
• Abatacept (Orencia)
• Tocilizumab (Actemra)
• Rituximab (Rituxan)
• Anakinra (Kineret)
Biologics
Nature.com, 2013

25. How is RA Treated?
• Arthrocentesis = joint injections
 Steroids
 Hyaluronic Acid
• Surgery:
 Joint replacement
 Joint fusion
 Tendon repair
Interventional Treatment

26. How is RA Treated?
• Exercise
 Low-moderate activities
 Stretching, strengthening
 Yoga, Pilates, Tai Chi
• Physical Therapy
• Bracing
• Acupuncture
Additional Treatment

27. How to Live Well with RA?
• How to:
 Maintain control of disease to prevent flares
 Avoid complications and associated risks
 Cope with the disease
 Feel healthy
• To lead an active, high-quality life

28. How to Live Well with RA?
Follow-up with Rheumatologist Regularly:
• 2-6 months for monitoring
• Even if feeling well
• Recognize symptoms of flares
• Get treated early
• Take medications consistently

29. Follow-up with Your Doctors:
• Follow regularly for preventative care
 Internist/Primary care
• Follow with Specialists
 Ophthalmologist, Orthopedist, Cardiologist
• Planned surgery
 Best when low activity
How to Live Well with RA?

30. How to Live Well with RA?
Reduce Risk of Infections:
• Increased risk of infection
• Up to date with vaccines
 Influenza, Pneumonia, Shingles
• Wash hands frequently
• Stay away from people who are sick
• Get evaluated sooner rather than later

31. How to Live Well with RA?
Healthy Lifestyle and Selfcare:
• Exercise
• Don’t smoke
• Heat/Cold therapy
• Topical therapies
• Modify activities

32. How to Live Well with RA?
Healthy Lifestyle:
• Manage fatigue
 Get enough sleep
 Rest during the day
 Plan your time effectively
 Medications
 Exercise
• Treat depression
 Reduce stress
 Social support
 Positive attitude Arthritis.org.

33. How to Live Well with RA?
Healthy Lifestyle:
• Healthy well balanced diet
• Mediterranean diet
• Weight loss
• Calcium, Vitamin D
• Omega-3 fatty acids
• ? Avoid certain foods
• Alternative treatments/supplements –
not well studied

34. How to Live Well with RA?
Planned Pregnancy:
• Ideally when in remission
• Many medications have to be stopped
before pregnancy
• Higher risk of preterm birth
• Usually symptoms improve during
pregnancy

35. What’s New with RA?
• Tofacitinib (Xeljanz) – JAK inhibitor
 Use: Similar to biologics in effectiveness and side
effects
 Mechanism:
• Oral disease modifying medication
• Targets inflammation signaling
pathway
• Biosimilars
• Blood tests
 14-3-3 ETA test for early diagnosis
 Vectra-DA test for RA activity
Nature.com
cell

36. What’s New with RA?
• 65+ new medications in development for RA!
http://www.ahdbonline.com/issues/2014
•Barcitinib – JAK1/2 inhibitor –
Phase IIb trial
•Decernotinib – JAK 3 inhibitor
– Phase II trial
•Mavrilimumab – anti-GM-CSF
receptor – Phase II trial
•Sarilumab – Il-6 inhibitor –
Phase III
•Secukinumab – Il-17 inhibitor
– Phase III

37. What’s New with RA?
• Ongoing research:
 Why RA develops
 Biomarkers to better diagnose and predict
response to medication
 Curative treatments

38. What’s New at SMG?
• Best Practices in Managing Patients
with Rheumatoid Arthritis Learning
Collaborative
 American Medical Group Foundation
 Advance the care of those with rheumatoid
arthritis for better diagnosis, treatment and
monitoring

39. For More Information
• Arthritis Foundation
 www.arthritis.org
• National Institute of Arthritis and
Musculoskeletal and Skin Diseases
 www.niams.nih.gov
• American College of Rheumatology
 www.rheumatology.org

40. • Patient Perspectives
• Questions?

41. Thank you!
Lauren Kennish, MD
Summit Medical Group
Rheumatology
908-277-8640
www.summitmedicalgroup.com
Facebook/SummitMedicalNJ
Twitter: @SummitMedicalNJ