arthritis care

Raising the bar

in rheumatoid arthritis care

Dr Kavita Makan, is a Rheumatologist and Specialist Physician at Chris Hani Baragwanath Academic Hospital and the University of the Witwatersrand. She is president of South African Rheumatism and Arthritis Association. She recently presented a webinar on treatment paradigms in rheumatoid arthritis (RA), hosted by Medical Chronicle and sponsored by Thermo Fisher Scientific.

Dr Kavitha Maharaj

Go to https://bit.ly/3bW3Jti to watch a replay of this webinar and earn your CPD point

THE FOLLOWING IS based on her presentation.

LEARNING OBJECTIVES

• RA is more than a joint disease with multisystem complications and comorbidities • Early recognition and diagnosis is key to ensuring good outcomes • Early referral to a rheumatologist if suspect inflammatory arthritis • Early introduction of DMARDs reduces risk of damage and disability • Use a ‘Treat to Target’ approach to achieve remission or low disease activity • (LDA) • A multidisciplinary approach is imperative for optimal outcomes • New treatments have increased options for controlling disease – biosimilars and

JAK-inhibitors.

RA is common, complex and changing. It is the commonest inflammatory arthritis (0.5%–1% population prevalence). There is heterogeneity in its presentation,

RA has a predilection for synovial joints but is a systemic disease. Cardiovascular morbidity and mortality in RA is similar to diabetes.

Early recognition and diagnosis is important. Joint damage occurs early and progresses rapidly. Seventy five per cent of early RA patients have radiographic erosions, >80% on MRI.

Prevention of damage early preserves function. RA not a fixed phenotype but a continuum.

Radiographic changes in RA can be seen early on in the disease process. Ultrasonography is a useful tool in early diagnosis. It identifies inflammation in early undifferentiated arthritis to assist with diagnosis. It also predicts radiographic progression – thus response to therapy and relapse risk after discontinuation of treatment.

Early referral to rheumatologist increases probability of Disease-modifying antirheumatic drugs (DMARD)-free remission in RA patients. Assessment at ≥12 weeks was associated with HR of 1.87 for not achieving DMARD-free remission and a 1.3 times higher rate of joint destruction over six years vs assessment in <12 weeks.

The updated classification criteria are helpful for diagnosing early RA. Two requirements are the patient must have at least one joint with definite clinical synovitis (swelling) and that synovitis is not better explained by another disease.

Early and aggressive use of DMARDs reduces risk of damage and disability. It does the following: • Allows better disease control • Creates possibility of drug-free remission - A major predictor of remission was to have very early RA, along with being on a

DMARD within three months from disease onset - Early remission is associated with improved survival in patients with inflammatory polyarthritis – in terms of

The Norfolk Arthritis Register • Prevents disability – better functional scores • Slows x-ray progression - There are long-term benefits in preventing structural damage.

Longer symptom duration is associated with lower chance of DMARD-free sustained remission. Earlier clinical remission is associated with better survival. Early treatment prevents structural damage.

‘Treat to Target’ is a strategy to use, and includes: • Frequent assessments of patients (monthly) • Calculation of a composite disease activity score • Escalation of treatment if pre-defined target not met • Assess comorbidities and patient factors (reinforce education/compliance).

The target for every patient should be remission or low disease activity.

Conventional DMARDs used early can control disease if used appropriately. Methotrexate is the anchor drug. Leflunomide in combination with methotrexate has good safety and efficacy profile in refractory RA and acceptable in resource-poor settings. Monitoring for druginduced side effects and toxicity is essential at every visit.

A multidisciplinary approach is essential to successful management of RA. Patient education about the disease, treatment and outcomes, comorbidities, pain, disability, work and social participation is important. A multidisciplinary team might include: • Occupational therapy • Physiotherapy • Podiatry • Lifestyle modifications (RA and comorbidities) • Weight control • Dental care.

Exercise should be at a moderatehigh intensity, aerobic and strength training, as long as there is no increase pain or disease activity. A Mediterranean diet high in omega-3 fatty acids, vegetables and antioxidants is recommended. Smoking cessation is important in these patients.

TAKE-HOME MESSAGES

Consider RA the disease, complications (drugs and condition) and comorbidities.

Remember the three’s of inflammatory arthritis, and refer early to a rheumatologist. Stiffness – early morning joint stiffness lasting more than 30 minutes. Swelling – persistent swelling of one joint or more, especially hand joints. Squeezing – squeezing the joints is painful in inflammatory arthritis.

Early diagnosis and treatment with DMARDs improves outcomes and survival.

Tight control using a ‘Treat to Target’ approach is crucial to achieving the ultimate goal of sustained drug-free remission or low disease activity. Treatment should be individualised, with shared decision making between patient and doctor using a multidisciplinary approach. Biosimilars and Janus kinase inhibitors (JAK-inhibitors) have entered the SA space and provide greater options for patients with RA.