Living with Rheumatoid Arthritis

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, 2013 Copyright 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