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Hot Topics in Rheumatology

Hot Topics in Rheumatology. Prof. MG Molloy. Overview. Rheumatoid Arthritis Psoriatic Arthritis Vasculitides: SLE Osteoarthritis Osteoporosis. Rheumatoid arthritis. RA is a condition involving inflammation of the joints It has the potential to result in serious joint damage

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Hot Topics in Rheumatology

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  1. Hot Topics in Rheumatology Prof. MG Molloy

  2. Overview • Rheumatoid Arthritis • Psoriatic Arthritis • Vasculitides: SLE • Osteoarthritis • Osteoporosis

  3. Rheumatoid arthritis • RA is a condition involving inflammation of the joints • It has the potential to result in serious joint damage • It may come on suddenly or appear slowly over time • Its symptoms may include pain, swelling, stiffness in the joints, and general tiredness

  4. Rheumatoid Arthritis • Damage occurs early in most patients • 50% show joint space narrowing or erosions in the first 2 years • By 10 years, 50% of young working patients are disabled • Death comes early • Multiple causes • Compared to general population • Women lose 10 years, men lose 4 years

  5. Who is affected by RA? • RA is one of the most common forms of inflammatory arthritis • Affects about 1% of the world’s population • Occurs 2 to 3 times more often in women than in men • In most cases it develops between the ages of 25 and 50

  6. RA: Multisystem disease • Extra-articular: • Cardiac • coronary heart disease • Pulmonary • fibrosis • Haematological • Anaemia • Ophthalmology • Dermatology • Renal

  7. Cardiac disease in RA • Mortality in RA is unchanged in 40yrs despite DMARDS • Patients unlikely to report symptoms of angina • Not all IHD risk is due to traditional risk factors nor drugs such as Pred use, HRT DM etc • Control BP, cholesterol etc • High index of suspicion: cardiology referral

  8. Management RA

  9. Medications for RA • Nonsteroidal anti-inflammatory drugs (NSAIDs) • Corticosteroids • Disease-modifying antirheumatic drugs (DMARDs) • Biologics • Combination

  10. DMARD options • Hydroxychloroquine • Sulphasalazine • Methotrexate • Azathioprine • Slow onset, reasonably effective • Leflunomide • Pyrimidine inhibitor • Effect and side effects similar to those of MTX

  11. DMARDs Combination or monotherapy • No superiority of traditional combination DMARD therapy over monotherapy • Some trials did not control for glucocorticoid use • Review of studies since 2000 have shown that step-up therapy of Leflunomide +MTX is superior but, with significant toxicity

  12. Methotrexate • Commonest DMARD • 30 year experience • Monitoring: monthly FBC, ESR, CRP, Bioprofile, LFTs • Complications: • Haem:Neutropenia, thrombocytopenia, ? Leukemia • Liver dysfunction

  13. New Biologics • Infliximab ( chimeric monoclonal antibody to TNF) • Etanercept (soluble TNF receptor) • Adalimumab (humanised monoclonal antibody to TNF) • Rituximab (anti-CD 20 ) • Anti-Interleukin 6 (in clinical trials for JRA)

  14. Biologic agents in RA • Indication: Refractory RA • Prior to commencing: CXR, Mantoux • Contraindications/Precautions: • Previous TB, COPD, Chronic infections, HIV

  15. Biologic agents in RA • Monitoring: • Monthly bloods: FBC, ESR, CRP, Bioprofile • Regular physical examination • Beware infection • NB: Normal WCC, ESR, CRP does not exclude infection

  16. New drugs • Rituximab (anti- CD 20)- in use • Epratuzumab anti-CD22 – better risk profile than ritux • Anti-CD4 – was good but CD4 counts dropped so low trials stopped • Efalizumab – anti-CD11a –used in psoriasis, no good in PSA • CTLA4-Ig (in trials)- binds CD80/86 and blocks cell activation • Alefacept- binds LFA-3 • Anti-RANKL • SOCS • IL1-trap • Anti-IL6 receptor antibody • Soluble IL-15 receptor antagonist – 62% ACR 20 scores in high dose group • Other targets – IL-12, IL-17, IL-18, IL-23, IL-27,IFN alpha and gamma

  17. Summary RA • RA – early treatment = better outcome • MTX good monotherapy in many patients • Combo therapy of traditional DMARDs is possibly superior but conflicting studies • Biologics =higher expectations • Currently combo biologics +MTX better than biologic monotherapy • Are biologics capable of inducing remission in early disease – then do we switch to mainteance therapy with MTX – unknown yet • Anti – CCP antibody - predictor of erosive disease course

  18. Spondyloarthropathies Ankylosing Spondylitis Psoriatic arthropathy

  19. Ank Spond

  20. Ank Spond • Diagnosis: • Clinical: Backpain and stiffness: EMS • Age 20-40yrs male • Xray: late changes • Treatment: • Exercises, NSAIDS • Biologics

  21. Gout & PseudogoutCrystal arthropathies

  22. Gout uric acid deposition • Clinical • Monoarticular • The most painful arthropathy • Treatment • NSAIDS • Allopurinol: prophylaxis • Colchicine: • Nausea, vomting, diarrhoea

  23. Pseudo-gout • 2nd, 3rd MCPs, wrists, shoulders, knees, feet • Associations: • Haemochromatosis • Age • Treatment • Underlying disease • NSAIDS

  24. Vasculitides SLE

  25. SLE

  26. Management of SLE

  27. Osteoarthritis

  28. Osteoarthritis

  29. Osteoporosis

  30. Osteoporosis • Diagnosis

  31. Osteoporosis • Management

  32. Thankyou

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