Transcript Continuum of Low Back Pain: Patient and Provider

Evidence-Informed Best Practice
RA and OA
Dr. Diane Lacaille
Objectives
Describe the rationale for key recommendations for best
practice care for Rheumatoid Arthritis and Osteoarthritis
according to the BC Guidelines.
www.bcguidelines.ca
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Early Treatment of RA
with DMARDs
NECESSARY
SAFE
EFFECTIVE
EARLY Treatment of RA with DMARDs
E EARLY DIAGNOSIS AND TREATMENT OF RA
A AGGRESSIVE USE OF DMARDS ALTERS THE COURSE OF RA
R REMISSION IS THE NEW TARGET OF RA TREATMENT
L LONG TERM USE OF DMARDS
Y YES, DMARDS ARE SAFE WHEN MONITORED REGULARLY
This is the new standard of care.
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RA is Not a Benign Disease
If not controlled, RA inflammation leads to:
 joint damage and joint deformities
 progressive loss of physical function
 work disability (32-50% after 10 years of RA)
 premature mortality, mainly from cardiovascular disease (50%
increase in risk of death from CVD)
All these outcomes are preventable.
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Persistent Joint Swelling Leads to
Joint Damage & Deformities
=>
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Early Diagnosis & Treatment of RA
E
A
R
L
Y
Early diagnosis
Recognizing signs of inflammation – clues pointing to RA
 Early morning stiffness > 30 minutes
 Worse pain in the morning and post immobility
 Swelling of small joints
 Pain or tenderness on squeezing the MTPs, MCPs or wrists
 Symmetrical involvement
 Systemic symptoms, such as fatigue
Ruling out other diagnosis
 Septic arthritis, especially if monoarthritis
 Crystal arthritis, such as gout or pseudogout
 Joint aspiration for acute monoarthritis to R/O infection
or when crystal arthritis is suspected
 Transient inflammatory arthritis, i.e. viral
lasts 6 weeks or less
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Early Diagnosis & Treatment of RA
E
A
R
L
Y
Early treatment of RA
Capture the window of opportunity
 Early treatment with DMARDs alters the disease course.
 Joint damage occurs early (within months) and is
irreversible.
 RA is more responsive to treatment early on.
 Early treatment increases the chances of remission.
New onset RA requires urgent care
 DMARDs should be started within 2 months of symptoms.
 Referral to a rheumatologist for new onset RA should be
seen within 4 weeks. State ‘new onset of RA’ on referral.
 Rheumatologists prefer early referrals.
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Aggressive use of DMARDs Alters
the course of RA
E
A
R
L
Y
What are DMARDs?
 Disease Modifying Anti-Rheumatic Drugs
 They improve symptoms and prevent joint damage.
 Methotrexate, Sulfasalazine, Hydroxychloroquine,
Gold, Cyclosporine, Leflunomide and biologic agents.
Think RA, think DMARDs
 All RA patients with active inflammation should be
on a DMARD.
NSAIDs and prednisone are not enough
 NSAIDs improve symptoms but fail to prevent joint damage.
 Prednisone should not be used alone because
of long term toxicities
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Aggressive Use of DMARDs Alters
the Course of RA
E
A
R
L
Y
 DMARDs alter the course of RA by:
• Preventing joint damage and deformities
• Reducing physical and work disability
• Preventing premature mortality
 Aggressive use of DMARDs means:
• Starting DMARDs early
• Using DMARDs continuously, often in combination
• Evaluating response every 1 to 3 months
• Modifying DMARD therapy until the target is reached
• Aiming to eradicate inflammation
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Remission is the new target of
RA treatment
E
A
R
L
Y
The goal of RA treatment is no longer to simply control symptoms,
but to eradicate inflammation.
The target of DMARD therapy is no signs of active
inflammation i.e.,
• No swollen joints
• Normal ESR or CRP
• Little to no radiographic progression
Although remission is the target, minimal disease activity may be an
acceptable alternative, when remission is not possible, especially in
established long-standing disease, or when
co-morbidities or other patient factors limit
DMARD options.
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Long-term use of DMARDs
E
A
R
L
Y
 DMARDs should be used continuously, throughout the
disease.
 When sustained remission is achieved, DMARDs may
be slowly decreased to find a lower dose that maintains
remission.
 DMARD discontinuation is not recommended because
of high risk of flare off DMARDs.
 All RA requires DMARD, the earlier the better, but even
late RA requires DMARDs to reduce further damage.
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Yes DMARDs are safe
when monitored regularly
E
A
R
L
Y
Benefits
Risks
Benefits of early DMARDs outweigh their risks
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EARLY is the new standard of care
 Family physicians play a critical role in
early diagnosis and treatment of RA.
 DMARDs should be prescribed in all RA
patients and should be started early.
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Treatment of RA
the standard of care has changed
DMARDs
NSAIDS
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Recommendations are based on the
following references:
Guidelines and Protocols Advisory Committee. Rheumatoid Arthritis: Diagnosis and
Management. British Columbia Medical Association. 2006. www.bcguidelines.ca
American College of Rheumatology Ad Hoc Committees on Clinical Guidelines.
Guidelines for the management of rheumatoid arthritis. Arthritis Rheum.1996,39:713-22.
American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Guidelines
for the management of rheumatoid arthritis: 2002 Update. Arthritis Rheum 2002;46:328346.
Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008
recommendations for the use of nonbiologic and biologic disease-modifying
antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum 2008;59:762-84.
Bykerk V, replace with 2010 CRA RA guidelines
Smolen JS, Aletaha D, Bijlsma JW, et al. Treating rheumatoid arthritis to target:
recommendations of an international task force.
Ann Rheum Dis 2010;69:631–637
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Osteoarthritis
Osteoarthritis (OA)
Features suggestive of OA:
 Absence of inflammatory features: morning stiffness < 30 min;
gelling < 5 min; minimal swelling & heat; no redness.
 Pain worse with activity, better with rest
 Advanced OA => constant pain including at rest
 Absence of systemic symptoms
 Gradual onset
 History of prior injury (e.g. knee), prior deformity / malalignement
 Joint distribution: hips, knees, C & L spine, hands: DIP, PIP, 1st
CMC, 1st MTP.
 Bony enlargement, crepitus, malalignement
 If joint swelling, synovial fluid non-inflammatory, no crystals.
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Joint Distribution
Black= joints most commonly affected
Grey= joints often affected
White= joints usually not affected
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Other Diagnoses to Exclude




Septic arthritis (acute monoarthritis requires joint aspiration)
Crystal arthritis: gout, pseudogout (CPPD) (joint aspiration)
Inflammatory arthritis: esp. psoriatic arthritis
Non-articular : e.g. bursitis (trochanteric, pes anserine),
tendonitis (shoulder, elbow)
 Bone pain (multiple myeloma, metastasis)
 Soft tissue pain syndromes
 Referred pain
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Investigations
 X Rays
› Provide clinical information
› Can be normal in early OA
› Often don’t correlate with degree of pain
› Knee Xrays must be ordered weight bearing (PA, lat, skyline)
› Hip (OA hip series: incl. lateral view and upper 1/3 femur)
 Absence of inflammatory markers (CBC, CRP normal)
 Labs can be useful to rule out other conditions (e.g. thyroid
disease) or to assess for comorbidities prior to Rx (e.g. Cr, LFT)
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Management - Considerations
 Severity of pain (with activity, at rest, interferes with sleep)
 Impact on function (ADLs, IADLs)
 Impact on participation (work, family obligations, social activities,
leisure)
 Impact on independence
 Psychosocial issues (pain amplification, coping strategies,
depression, adherence to treatment, social support)
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Management – Non pharmacological
 Patient education
 Self-management (pain, limited physical function, stress,
exercise, coping, pacing)
 Weight management – support, dietician
 Exercise
 Physiotherapy: prescribe specific therapeutic exercise program
 Walking aids
 Occupational therapy: Orthotics, footwear, braces, ADL aids,
ergonomic modifications at work
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Management - Pharmacological
 Acetaminophen:
› regular schedule vs. prn
› up to 4 gm/day, less if liver disease
 NSAIDs:
› Gastroprotection if high GI risk
› Consider cardiovascular risk factors
› Topical NSAIDs
 Glucosamine and chondroitin sulfate:
› Not recommended, insufficient evidence of efficacy
 Intra-articular steroids
 Hyaluronic acid – limited benefit, can cause inflammatory reaction
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Management – Indications for Surgery
 Failure of conservative management (trial acetaminophen,
NSAIDs, intraarticular injection steroids, physiotherapy, regular
exercise program)
 Inadequate pain control (pain at rest, significant pain with
walking, pain interfering with sleep, incr. need for narcotics)
 Impact on function (limited ADLs, limitations in meaningful
activities – work, family, leisure)
 Threat to independence
 Significant deformities (e.g. FD, valgus knees, loss IR hip, LLD)
 Xray flags: acetabular protrusion, femoral head collapse,
progressive bone loss,
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Summary
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