The Early arthritis clinic Dr Fahim Khan.MD,MRCP,FRCP,FACP. Consultant Rheumatologist Aut Even Hospital Kilkenny.

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The Early arthritis clinic Dr Fahim
Khan.MD,MRCP,FRCP,FACP.Consultant
RheumatologistAut Even Hospital Kilkenny.
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Early RA hands
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Aims and ambitions

• 1. Rapid and easy access (lt 2 weeks)
• 2. Patient education
• 3. A comprehensive assessment to make an optimal
  diagnosis
• 4. Initiate EARLY optimal therapy
• 5. Prevention of joint damage.

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The Synovium in RA
Normal Synovium
Rheumatoid Synovium
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Early arthritis clinic

• The Early Arthritis Clinic represents a
  structured environment for patients to be
  investigated, reviewed and treated using the
  latest technology (such as US imaging with Power
  Doppler assessment of synovitis).
• This will provide patients with the opportunity
  for rapid symptom control and improved long term
  functional outcome based on an evidence based
  approach to therapy and management of their
  condition.

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Early arthritis clinic--synovitis
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THE MOVEMENT TOWARD EARLY ARTHRITIS CLINICS Emery
and Gough2 pointed out that RA is the most common
cause of potentially treatable disability in
Western countries, based on recognition of
longterm severity of clinical RA. At that time,
general practitioners were advised to give
patients a nonsteroidal antiinflammatory drug for
up to 2 years before the use of disease modifying
antirheumatic drugs (DMARD)3?. 2.Emery P,
Gough A. Why early arthritis clinics? Br J
Rheumatol 1991302412. McCarty DJ 3.Lightfoot
RW, Jr. Treatment of rheumatoid arthritis. In
McCarty DJ, editor. Arthritis and allied
conditions. 10th ed. Philadelphia Lea Febiger
198566876
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EARLY ARTHRITIS IN POPULATION STUDIES Research
concerning early arthritis and early rheumatoid
arthritis (RA) may be thought to have begun in
population-based studies in the late 1950s to
late 1960s. These studies indicated that the
majority of people who had clinical findings of
RA had no evidence of disease 35 years later.,
and that only about 2530 of people in a
population who met criteria for RA had rheumatoid
factor4. 4.Sokka T, Pincus T. A historical
perspective concerning population-based and
clinical studies of early arthritis and early
rheumatoid arthritis. Clin Exp Rheumatol
200321S5S14.
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EARLY TREATMENT IS BENEFICIAL IN RANDOMIZED
CLINICAL TRIALS Observations from randomized
clinical trials (RCT) support early versus
delayed drug treatment in RA. The benefits of
early versus delayed treatment have been
documented in studies of intramuscular gold,
auranofin, sulfasalazine, and hydroxychloroquine
(as reviewed5). 5.Sokka T, Makinen H. Drug
management of early rheumatoid arthritis 2008.
Best Pract Res Clin Rheumatol 20092393102
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IMPROVED LONGTERM OUTCOMES OF RA REFLECT EARLY
AND ACTIVE TREATMENT STRATEGIES Data from
clinical cohorts and observational studies
indicate that status and outcomes of RA patients
have improved over the past decades concomitantly
with implementation of early and active treatment
strategies6-7. 6.Pincus T, Sokka T, Kautiainen
H. Patients seen for standard rheumatoid
arthritis care have significantly better
articular, radiographic, laboratory, and
functional status in 2000 than in 1985. Arthritis
Rheum 200552100919. 7.Sokka T, Kautiainen H,
Mottonen T, Hannonen P. Erosions develop rarely
in joints without clinically detectable
inflammation in patients with early rheumatoid
arthritis. J Rheumatol 20033025804.
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Rheumatoid factor andAnti citrullinated peptide
antibodies
Assays for autoantibodies and acute phase
reactants are helpful in the early diagnosis of
RA. The most reliable early predictors of both
chronic and erosive disease are the presence of
RF and anti-CCP antibodies.8 8,Schellekens GA
Visser H de Jong BA van den Hoogen FH Hazes
JM Breedveld FC van Venrooij WJ The diagnostic
properties of rheumatoid arthritis antibodies
recognizing a cyclic citrullinated peptide
Arthritis Rheum 2000 Jan43(1)155-63.
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Rheumatoid factor andAnti citrullinated peptide
antibodies


10Jansen LM van
Schaardenburg D van der Horst-Bruinsma I van
der Stadt RJ de Koning MH Dijkmans BA The
predictive value of peptide antibodies in early
arthritis. J Rheumatol 2003 Aug 30(8)1691-5.
Listing J Rau R Muller B Alten R
Gromnica-Ihle E Hagemann D Zink A J Rheumatol
2000 Sep 27(9)2100-9

• Testing for the combination of anti-CCP
  antibodies and IgM RF may be better for excluding
  the diagnosis of RA than is achievable by testing
  for either antibody alone 9.
• Among patients with early oligo- or
  polyarthritis, anti-CCP testing appears to be of
  predictive value in the IgM-RF negative
  subgroup.10

9.Bas S Genevay S Meyer O
Gabay Anti-cyclic citrullinated peptide
antibodies, IgM and IgA rheumatoid factors in the
diagnosis and prognosis of rheumatoid arthritis.
Rheumatology (Oxford) 2003 May
42(5)677-80
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Conventional DMARDs Currently available therapies

• General anti-inflammatory and/or
  anti-proliferative activity
• DMARDs have the potential to slow or prevent
  joint damage
• Lack a direct analgesic effect
• Have a slow onset of action (weeks to several
  months)
• Most common conventional DMARDs1
• Methotrexate
• Leflunomide
• Sulfasalazine
• Hydroxychloroquine

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Biological agents The additional dimension in RA
treatment
Symptomatic relief only
Some retardation of joint damage AND alleviation
ofdisease signs and symptoms

• Traditional NSAIDs
• COX-2 inhibitors
• Corticosteroids
• Analgesics

• BIOLOGICS
• cytokine-targeted therapies
• anti-TNF agents
• IL-6R inhibitor
• IL-1 inhibitor
• cell-targeted therapies
• T-cell co-stimulation modulator
• B-cell depleting agent

• DMARDs
• Disease-modifying anti-rheumatic drugs (e.g.
  methotrexate)

P06/03/09
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Referral Criteria for EAC

• Symptoms present for at least 4 weeks but less
  than 1 year
• Early morning stiffness of gt 30 mins
• AND ANY ONE OF THE FOLLOWING
• 3 or more swollen joints
• Tender/involved metacarpophalangeal joints
• Tender/involved metatarsophalangeal joints

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Early arthritis clinic(EAC) Aut Even Hospital
KilkennyA Review of 44 patients Data

• In the early arthritis clinic( EAC)at Aut Even
  Hospital Kilkenny, we looked at total of 44
  patients who were referred to the EAC with an
  average time at
• Minimum 1 DAY TO Maximum 10 DAYS after referral.
• Symptom classification 39/44 patients presented
  with joint pains,swelling of hands(metacarpo-phala
  ngeal joints) and feet (Metatarso-phalangeal
  joints) and stiffness lasting over 30 minutes.
• 2-3 synovial swelling of hands/feet at
  presentation on clinical examination in 27 out of
  44 patients

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EACAUT EVEN HOSPITAL

• FBS, LFTS, Renal profile on referral were normal.
• ESR/CRP--- Raised in 39/44 patients
• Rheumatoid Factor(R.F) positive in 38/44
  patients
• Anti Cyclic Citrullinted Peptide Antibody Test
  (Anti CCP Ab) performed in 26/44 , positive in
  26/26 patients.
• Anti Nuclear Antibody Test(ANA ) Performed in
  15/44 patients, weakly positive in 13/15
  patients.

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EACAUT EVEN HOSPITAL

• Diagnosis Rheumatoid arthritis in 44/44 patients
• DMARD STARTED AFTER REFERRAL23 DAYS (3WEEKS 2
  DAYS)
• InitialDMARD used Methotrexate in 41/44
  patients. Hydroxychloroquine used in 3/44
  patients.
• Biologics added to Methotrexate Enbrel, Humira
  in 7/44 patients.
• Follow up at 8 weeks after DMARD/Biologics
  prescribed with improvement in DAS 28 SCORE of
  2.97

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1,Initial NEW patient assessment in
E.A.C. 2, Early diagnosis of Rheumatoid
Arthritis. 3,Decision taken to initiate earlier
use of DMARD therapy to prevent long term joint
damage.
EAC Framework (New Referrals) General
Practitioner, Other Speciality referred to
rheumatology clinics.
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THANK YOU

• QUESTIONS ?
• DR FAHIM KHAN