Rheumatoid Arthritis

Transcription

1 Rheumatoid Arthritis Carole Callaghan Principal Pharmacist NHS Lothian

2 Aim To update pharmacists on the current management of rheumatoid arthritis and explore ways to implement pharmaceutical care for this patient group as part of normal working practice.

3 Objectives Describe the common signs and symptoms associated with rheumatoid arthritis. Define the current therapeutic management for both the alleviation of symptoms and for modifying disease progression in rheumatoid arthritis. Identify pharmaceutical care issues and appropriate management solutions when responding to symptoms in patient scenarios. Explore how to implement the principles of a pharmaceutical care needs assessment tool in practice.

4 Rheumatoid Arthritis A chronic systemic inflammatory disease, characterised by potentially deforming symmetrical polyarthritis and extraarticular features.

5 Epidemiology prevalence approx. 1% in UK 3:1 ratio of females:males affected peak onset 40 and 50 years of age genetic, environmental and infective factors involved in disease development

6 Pathogenesis cause remains unknown toxic substances found in synovium destruction of joints immunological disturbances identified RA is an autoimmune disease

7 Pathology disease of the synovium inflammation due to infiltration of lymphocytes, macrophages etc proliferation of cells results in pannus formation

8 Pathology

9 Pathology

10 Symptoms joint pain (usually worse on waking) morning stiffness (can vary in duration) general symptoms e.g. fatigue, malaise, bone ache

11 Signs swelling tenderness reduced range of movement deformities (if untreated over long-term) extra-articular features e.g. nodules, anaemia of chronic disease, pleural effusion

12 Signs

13 Joint involvement hands/wrists elbows/shoulders cervical spine knees ankles/feet unpredictable pattern

14 Investigation Imaging e.g. x-ray, ultrasound, MRI FBC and ESR Other tests e.g RhF, anti-ccp (antibodies)

15 Management (1st stage) lifestyle maintain where possible multidisciplinary e.g. physiotherapy occupational therapy podiatry

16 Management (2nd stage) relief of symptoms

17 NSAIDs more effective than simple analgesics variation in response balance efficacy and toxicity

18 NSAID toxicity related to dose and duration of therapy GI renal and cardiovascular elderly more at risk

19 GI toxicity well documented in literature identifiable risk factors e.g. age, previous history, other medication (steroids, warfarin), alcohol improved use secondary to identifying those at risk and using gastroprotection

20 NSAID summary use lowest dose compatible with symptom relief use gastroprotection in at risk patient reduce and, if possible, withdraw when good response from DMARD

21 COX-2 Inhibitors selectively block COX-2 isoenzyme provide pain relief (as efficacious as NSAIDs) less GI bleeding than NSAIDs (less significant GI symptoms remain e.g. dyspepsia) CV risk??

22 Management (3rd stage) long-term suppressive drug therapy with disease modifying anti-rheumatic drugs (DMARDs)

23 Early DMARD stabilise joint function as early as possible = better outcome greater awareness of NSAID toxicity DMARDs slow disease progression

24 DMARDs efficacy.vs. toxicity methotrexate and sulfasalazine have the best efficacy:toxicity ratio in metaanalyses Increased use of combination therapy TICORA, COBRA, BeST. better than sequential monotherapy

25 DMARDs (cont) DAS28 (Disease Activity Score) Monitoring -swollen joints -tender joints -ESR -patient s general health score -FBC -LFTs -U&Es -BP -urinalysis

26 Systemic corticosteroids not recommended for routine use if necessary, use lowest dose, shortest time monitor due to side effect profile

27 Intra-articular corticosteroids target joint i.e. one or two large joints affected, can avoid systemic steroid maximum number per joint/time but no evidence for this theory evidence lacking for this practice, but patients report benefit

28 TNF - Mode of Action Activated Macrophage Target Cell stnfr stnfr TNF Signal

29 Anti-TNF Biologics - Mode of Action Activated Macrophage Target Cell TNFR Signal stnfr stnfr TNF

30 TNF Four agents currently licensed in UK and SMC approved: infliximab (human antichimeric antibody) etanercept (fusion protein) adalimumab (fully humanised monocloncal antibody) golimumab (human monoclonal antibody)

31 Effects of Blocking TNF Immunology RF, T cell function restored Inflammation Cytokine production in joints (IL1, IL6, TNF) Angiogenesis levels of angiogenesis Joint destruction damage to bone and cartilage Haematology platelets, fibrinogen, restoration of Hb

32 B Cell Involvement in the Pathogenesis of RA

33 Biologic Pathways

34 Nomenclature -ximab Chimeric antibody -zumab Humanised antibody -umab Human antibody -cept Fusion protein

35 Immunogenecity

36 Eligibility Criteria for Biologic Therapy (BSR) DAS28 >5.1 At least 2 previous DMARDs Adequate response at 3 months 3-monthly monitoring

37 Infection Do not initiate in presence of serious active infection or in patients at high risk Discontinue in presence of serious infection

38 Tuberculosis Screen for TB Active TB needs to adequately treated Prophylactic anti-tb therapy for potential latent disease Monitor during/after biologic; treat if required

39 Other Infections Listeria/salmonella Varicella HBV/HCV HIV

40 Vaccination Data limited Influenza and pnuemococcal recommended (many also on MTX) Hep B

41 Malignancy No increased risk of solid tumours or lymphoproliferative disease Investigate/stop therapy Caution in pre-malignant conditions Preventative skin care/ongoing surveillance

42 Rituximab With MTX only (SMC restricted use) Inadequate response or intolerant of other DMARDs, including at least one anti-tnf By specialists in accordance with criteria

43 Safety with Rituximab Delay post-anti-tnf Check immunoglobulins Re-treat on clinical signs Active infection, severe immunocompromised Screen for hepatitis (B & C)

44 Abatacept

45 Abatacept (contd) Selective T cell co-stimulation modulator blocks the co-stimulatory signal required for full T cell activation Not recommended by SMC and reserved for refractory disease. However, this advice superseded by NICE MTA 195 and can now be used in anti-tnf or rituximab failure/intolerant Increase in efficacy after first year of treatment

46 Tocilizumab

47 Tocilizumab (contd) Recommended by SMC for combination therapy only i.e. with MTX ADRs e.g. liver enzymes, neutropenia, lipids etc...

48 Summary RA = inflammatory & destructive symptomatic relief early disease modification