Inflammatory Arthritis - RA

Monitoring - RA
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Monitoring of the patient's illness and his or her response to treatment varies with disease severity, activity, and the drug regimen used, but all patients need to be followed up indefinitely. Patients whose disease is in remission may be seen semiannually, with the frequency of laboratory or other monitoring dictated by the drug program. Patients with early disease, flares, or persistently active disease require more frequent physician visits until disease control is established.
 
At each visit the physician must assess whether the disease is active . Symptoms of inflammatory (as contrasted with mechanical) joint disease, prolonged morning stiffness, fatigue, and active synovitis seen on joint examination indicate active disease and the need to consider changing the treatment program.  The joint examination may not adequately reflect disease activity and structural damage. Therefore, periodic measurements of ESR or CRP and functional status and radiographic examinations of involved joints should be performed. Functional status assessment may be performed with questionnaires such as the Arthritis Impact Measurement Scales or the Health Assessment Questionnaire .
 
Monitoring rheumatoid arthritis activity; Each visit: evaluate for subjective and objective evidence of active disease;
1) Degree of joint pain
2) Duration of am stiffness
3) Severity of fatigue
4) Presence of actively inflamed joints on examination
5) Limitation of function
6) Periodically: evaluate for disease activity or progression
7) Evidence of disease progression on physical examination (loss of motion, instability, malalignment, and/or deformity)
8) Erythrocyte sedimentation rate or C-reactive protein elevation
9) Progression of radiographic damage of involved joints

Other parameters for assessing response to treatment (outcomes)
10) Physician global assessment of disease activity
11) Patient global assessment of disease activity
12) Tender and swollen joint count
13) Pain assessment
14) Functional status assessment
 
If the patient's disease is active or progressing, other options, including consultation with a rheumatologist, should be considered. If disease activity is confined to 1 or a few joints, local glucocorticoid injection may help. Change in the drug regimen may be considered, especially increasing DMARD dosage, changing the DMARD, or adding a DMARD.
 
 Patients with severe symptoms may need to start taking or to increase the dosage of systemic glucocorticoids. Active joint disease may be aggravated by physical activity; consultation with a physical therapist, occupational therapist, and/or vocational counselor should be considered. Periods of rest, time off from work, changes in occupation, or stopping work may be necessary. For symptoms that are mechanical, surgical options need to be explored.
 
Refractory rheumatoid arthritis; RA may run a resistant course, with progressive disability and joint damage. Rheumatology referral is strongly recommended for patients with refractory disease. Medications which are not yet FDA-approved for treating RA (such as cyclosporine) may be useful. Some patients may be candidates for treatment with investigational pharmacologic or biologic agents.  Patients with refractory RA frequently require treatment with systemic glucocorticoids and/or analgesics. With a chronic disease like RA, every effort should be made to avoid creating dependency upon narcotic analgesics, although some use may be justified. The longitudinal management of the patient with RA depends on mutual trust and confidence between the patient and his/her health care providers, who are expected to be supportive, empathetic, and knowledgeable.
 
The responsibilities of primary and specialty care physicians: Depending on the health care setting, the majority of the care of the patient with RA may be provided by a single physician (primary care physician, rheumatologist, or rheumatologist who also provides primary care), or the responsibility may be shared.  The role of the primary care physician is to recognize and diagnose RA at its onset and to ensure that the patient receives timely treatment before permanent joint damage has occurred. The rheumatologist should provide support and consultation to the patient and his or her primary care physician in the diagnosis and treatment of RA.
 
Since the level of training and experience in diagnosing and caring for RA varies among primary care physicians, the responsibility for accurate diagnosis and monitoring of RA activity and/or drug toxicity may appropriately be assigned to a rheumatologist. If the care of a patient with RA is to be shared, an explicit plan for monitoring RA disease activity and/or drug toxicity needs to be formulated. The patient's preference may be the most important factor in deciding which physician(s) assume responsibility for care.  General health maintenance: A general health maintenance strategy should be developed and responsibility coordinated among the patient's health care providers. Routine prevention measures should be recommended and risk factors modified.
 
The lifespan of a patient with RA may be shortened by infection, pulmonary disease, renal disease, or GI bleeding . Patients at risk for GI bleeding may benefit from avoidance of gastric irritants and the use of gastroprotective drug therapy. For patients at risk for osteoporosis (by history, inactivity, and/or glucocorticoid treatment), evaluation with bone densitometry at baseline and treatment with calcium supplementation, vitamin D (400 units daily), bisphosphonates, or calcitonin should be considered. Estrogen replacement therapy should be discussed with postmenopausal women.
 
RA is a chronic progressive polyarthritis (with varying systemic features) associated with substantial disability and economic losses. Successful treatment to limit joint damage and functional loss requires early diagnosis and timely initiation of disease-modifying agents. The goal of treatment is to arrest the disease and to achieve remission. Although remission rarely occurs, patients may still benefit from pharmacologic, nonpharmacologic, and if necessary, surgical inter ventions. Optimal longitudinal treatment requires comprehensive coordinated care and the expertise of a number of providers. Essential components of management include 1) establishment of the diagnosis of RA (versus other forms of polyarthritis), 2) systematic and regular evaluation of disease activity, 3) patient education/ rehabilitation interventions, and initial treatment with NSAIDs, 4) use of DMARDs, 5) possible use of local or low-dose oral glucocorticoids, 6) minimization of the impact on the individual's function, 7) assessment of the adequacy of the treatment program, and 8) general health maintenance.
 
Guidelines Drugs: 
 
Toxicity may range from mild to serious and from reversible to irreversible. We define rare toxicities as those which occur in 1% of patients using the agent, uncommon in 1-10%, and common in 10%.  Toxicities of drugs used in RA that require monitoring include gastrointestinal (GI) bleeding, hypertension, hyperglycemia, macular damage, renal damage, hepatotoxicity, and myelosuppression. Reduction in the incidence, severity, and unfavorable outcomes of these toxicities can be attempted by 1) pretreatment assessment to identify patients with risk factors for toxicity, 2) careful patient and physician education about safe dosage and the signs and symptoms of toxicity, and 3) appropriate monitoring with physician followup and periodic laboratory studies.
 
Since multiple physicians may be following a patient with RA, an explicit plan should be made among the physicians and the patient to assign responsibility for monitoring at the beginning of treatment. This plan should also detail who will make adjustments in the antirheumatic medications.  Extensive guidelines for monitoring drug treatment in RA of toxicities that require monitoring, baseline evaluation, and monitoring strategy for each drug or class of drugs are provided by the ACR. These monitoring recommendations are for patients who have uncomplicated RA with no history of or active concurrent illness and who are not receiving other medications. Situations in which there is concurrent disease or concurrent medication necessitate clinical judgments regarding dosing and monitoring that go beyond the intent of these guidelines.
 
At the heart of an ideal doctor-patient relationship is mutual trust,but it may be diffficult to achieve without tearing down a few of the walls that traditionally separate the two, people with arthritis should be in the decision-making about therapy. It's their individual differences in pain,the disability,and their side effects they're experiencing that will decide whether a given drug is useful for them. It's not a straight-forward deal like some disease treatment where the treatment is more-or-less "standard". A good doctor-patient relationship goes well beyond prescribing medications. If the've formed a broader kind of relationship,the doctor should be able to supply encouragement and express real empathy and understanding for what the patient is going through. And where the results of treatment are not as immediate as what the patient wants,usually that's offset by the fact that the physician is still trying to help the patient at least come to grips with their own condition.  The whole thing doesn't rest on whether the medication will make them better immediately. How the patient maintain faith or trust is a big part of it.

It's a two-way street,patients have to take an active role in the management of their disease,in joint protection, medications, exercise,and therapy. They need to know as much as they can about their condition and once they have a cleare understanding og what their condition entails,the have to learn about available medications in sufficient detail to ask the right questions. Get as much reliable information as you can,then work with your physician to find out what part of that information applies to you. Incorporate that into your lifestyle.  Exploit your strengths and learn to cope with your weaknesses. Comply with the limitations your condition imposes on you,seeking help when you feel you need it,and not trying to do too many things on your own when things don;t seem to going well. Don't worry about "bothering" the physician,professionals are there to help patients with their problems.
 
There are certain constraints on a physician's availability,which is a major reason for self-education. No matter how well-meaning the doctor and how attentive you maybe,a ten-minute interview,the standard GP's allotment for a patient visit,isn't enough for you to get a handle on all you need to know about your treatment regimen. It helps if you can spell out your expectations ahead of time,so the doctor can address them,and eliminate dissapointments caused by unrealistic expectations. Blindly following a doctor's order's orders may work well in acute-care hospitals,but with a chronic disease,you have to take a more active role. Make sure you understand what the doctor is saying to you,communicate your complaints to your doctor,who is not a mind-reader. Two-way communication is of utmost importance,it may be the most important factor in therapy.
 
Medicine is often an inexact science,your doctor should know more about you the the facts of your illness. You have the right to know your diagnosis, prognosis, alternate forms of treatment, recommendations  of your doctor and why. If a diagnosis has not been reached,you should have a clear understanding and explanation of why not. Also,if further studies or follow-up is indicated,this should be explained. It is your body the doctor is treating,and your health is in the balance.With the rights come resposibilites;Plan your visits. Ask questions. It's up to you to disclose all information relating to your illness to the physician. The doctor cannot be expected to make an accurate diagnosis and institute proper therapy if some informtion is withheld. ithholding or mistating data requested by the physicin may result in the use of improper,even potentilly dangerous therapies or risky tests.
 
Doctors have rights and resposibilities,too. They have to tell patients not merely of what the doctor feels,they need to know,but what patients want to know. Sometimes the doctor forget you need vital basic information,or feel you don't want a lot of information. Don't be afraid to ask. You can't be timid about your care,it's your health at stake. If you feel your doctor has missed something,ask him. Don't assume everything has been done. Doctors are humans,they can miss doing things. Make your questions accurate clear and specific.
 
Volunteer facts,and be ready to conquer the fears of the unknown ( ignoring facts won't make them go away ). Don't be afraid to ask for clarification or repeat explanations. Take mental notes ( later write some down ),proceed in an organized way. Don't be overwhelmedd or mislead by statistics,and don't ask questions a doctor can reasonably be expected to answer.  Ultimately patients have to remember that their role is at the heart of their own health care. All their concerns,whether about medication, procedures,or surgery,must be addressed. Fear,is taken away by true knowledge. Knowledge is power. It gives patients the power to go forward,to look ahead to a time when their illness won't be controlling them.
 
Know when a drug once efficacious,unravels !
 
Have you ever felt frustrated after you have visited with your doctor or pharmacist? Did you feel that your doctor wasn't clear describing the disease or drug regimen? Have you ever felt that your doctor didn't have enough time to listen to you? Did you ever arrive back home feeling frustrated that you couldn't remember what your doctor told you or it didn't make sense?  Try to think back to the times when your doctor or pharmacist explained how to take your medicine and whether it might have helped if you would have asked more questions. Here is an example:
 
You get to the doctor's office. The doctor asks a few questions, and does a physical exam. The doctor explains the possible cause of your symptoms, may prescribe a medicine, and describes how to take it.  After the doctor's visit, you go to the pharmacy. The pharmacist asks if you have taken the medicine before. The pharmacist tells you how to take the medicine, potential side effects to look out for, and how to prevent or manage the side effects.  You get home and start taking the medicine. You get busy and forget to take your medicine - or even stop taking it. You might develop side effects and feel nauseated, drowsy, or light-headed, and you decide to stop taking the medicine.
 
Upon the next doctor visit, you are asked, "Have you been taking the drug?". Of course you say "Yes" because nobody wants to disappoint their doctor. Your doctor then asks, "Are you taking the medicine every day, three times a day, the way it was prescribed to you?" Once again, the answer is "Yes" to avoid feeling that you have let your doctor down.  Actually, you are hurting yourself because now the doctor can't understand why you are not getting better. Your doctor might decide that the medicine you are taking is not working and may prescribe another medicine. You go back to the pharmacy, are in a hurry, and tell the pharmacist that you know all about the medicine because the doctor has already told you how to take it. You get home, start the medicine, and for some reason you decide to stop taking it.
 
Study after study has shown that most patients are having problems taking their medicine correctly because they simply do not have enough information, misunderstand directions or forget what they have been told. It is normal for most people to forget much of the information after a few days. Unfortunately, this is not apparent to the doctor until one of your follow-up appointments.
 
 Unless patients are completely honest with their doctors, doctors will determine future treatment based on what you have told them. Lack of communication can have tragic consequences. Medication errors made by patients claim hundreds of thousands of lives every year simply because people do not take the prescribed medications properly or they skip them altogether.
 
The next time you receive a prescription from your doctor, make sure you clearly understand what your doctor and pharmacist are telling you. If you don't understand something, you need to ask questions. This is the only way to get the information you need to manage medicines at home and protect your health! Don't be afraid to ask questions at every doctor visit. Be sure you know the answers to the following questions: "What is the medicine for?" You need to know why the doctor prescribed the medicine for YOU. "How will the medicine help me get better?" You want to be able to recognize the signs that the medicine is working and that you are getting better."How do I take the medicine?" If you don't know how to take your medicine, you could make a serious mistake that could cause dangerous problems. If your doctor tells you to take a medicine three times a day, be sure you know whether this means to take all three pills at the same time or one every eight hours.
 
 "What do I do if I miss a dose?" This depends on actual medicine you are taking. It is always best to call your doctor or pharmacist and ask them what to do if you miss doses. "What are the side effects of the medicine?" Your doctor or pharmacist should inform you of all the potential side effects of the medicines you are taking. It is important to recognize the differences between the side effects of a drug and the symptoms of your medical problem. If you are aware of them, you can help avoid many of the side effects. "What can I do to avoid the side effects?" There are certain side effects that can be avoided if you take medicines correctly. For example, some medicines are best to take on an empty stomach because more of the drug gets absorbed into the body, but this may cause some people to get nauseated. Other medicines must always be taken with food.
 
"What can I do to manage the side effects?" Every medication can cause some side effects. But not every person who takes the drug will experience every side effect. You should be aware of the possible side effects before you start taking the medicine so you know how to manage them.  For example, some people need medicine to lower their blood pressure. This medication could cause dizziness. When a person stands up too fast, they may get dizzy or lightheaded and could fall down and hurt themselves. To decrease the risk of falling, it may help to stand up slowly, and hold on to something that will help them keep their balance. Always ask your doctor or pharmacist how you can manage minor side effects from the medicine so you can keep taking it.
 
"Are there any drug-drug interactions?" There are medicines that should not be taken together because they can worsen your health. For example, Viagra should never be taken while also taking medicines that contain nitrates of any kind at any time. This includes nitroglycerin. A serious drug interaction could occur and even lead to sudden death. It is important to tell all your doctors and pharmacists of all the medicines you take. It could save your life! "Are there any foods that I should not eat while I am on this medicine? "There are some medicines that should not be taken with certain foods. For example, some medicines that lower high cholesterol should not be taken with grapefruit juice. Other medicines interact with different foods.
 
"Will my medicine interact with any herbal products or nonprescription medicines? "There are some herbal products and non-prescription medicines that should be avoided while on certain medicines or if you have certain health conditions. For example, if you have uncontrolled high blood pressure and a stuffy nose, you should not buy decongestant products that contain pseudophedrine because it can make your blood pressure go too high.
 
"How should the medicine be stored? "If medicines are not stored correctly many lose their effectiveness. For example some medicines are very sensitive to heat and must be stored in a refrigerator. Other medicines can be stored at room temperature but must not be kept in placesthat have high heat or humidity.  This is important for warm climate residents  who are traveling by car in the summer. They should not store any medicines in the glove compartment of the car because heat can reach extreme temperatures and destroy the drugs. Always ask your doctor or pharmacist how long and where to store your medicines.
 
If you don't understand what your doctor or pharmacist is trying to tell you ask them to explain it to you. It is always a good idea to keep a daily record so you can tell your doctor at your next visit when you started feeling better, any problems you had remembering to take each dose, minor side effects and how you managed them. The next time you go to the doctor, this record can help your doctor monitor your progress and provide better follow-up care. Never leave your doctor's office or the pharmacy confused or uncertain. Also, be open and honest with your doctor and pharmacist. They don't expect anyone to be perfect. But in order to help you get better or manage your disease, they need to know what problems you are having and any concerns you may have about the treatment. Your medicine can only be effective...if you know how to take it correctly!

A widely accepted composite measure of improvement in RA is the ACR response criteria. ACR20 refers to a composite improvement of 20% in swollen joint count (SJC), tender joint count (TJC) (both joint counts based on an assessment of 28 or more joints), and three or more of the following measures:

a) Patient's global assessment of RA disease activity
b) Physician's assessment of disease activity
c) Patient's assessment of pain due to RA
d) Acute-phase reactant (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP])
e) Disability Stanford Health Assessment Questionnaire (HAQ)
 
Following is an example of a patient who has achieved an ACR20 response after a 4-week treatment period:
 
1) The number of tender joints is reduced from 28 to 22 (>20% improvement).
2) The number of swollen joints is reduced from 30 to 24 (20% improvement).
3) The patient rates how well he/she is doing (ie, global assessment of RA disease activity) using a 100-mm visual analog scale or a Likert scale; disease activity is reduced by 20 out of 100 mm (20% improvement).
4) The physician's assessment of the patient's current disease activity is decreased by 30 mm out of a 100-mm visual analog scale or a Likert scale (>20% improvement).
5) The patient assesses his/her current level of pain using a 100-mm visual analog scale or a Likert scale; his/her level of pain is reduced by 30 mm (>30% improvement).
6) There is no change in ESR rate or CRP level (no improvement).
7) The patient reports a 15% improvement in scores on the HAQ (<20% improvement).
 
This patient satisfied the required =20% improvement in TJC and SJC and improved by =20% in three of the five remaining assessments.
 
ACR50 and ACR70 refer to a standard of 50% and 70% improvement in the preceding measures, respectively. The ACR response criteria provide a relative measure that refers to the individual patient's baseline disease activity, with three of its seven criteria assessed by the patient and four of seven assessed by the physician. Radiographs are a suitable outcome measure in patients with RA. They reflect the history of joint pathology and provide a permanent record necessary for serial evaluation of the disease.
 
Many scoring methods have been described, ranging from a global score for the whole patient to the more sophisticated methods of scoring erosions and joint space narrowing (JSN) in a selected number of joints. These abnormalities give additive information and are the most important features in scoring radiographs in RA.  The Sharp method (modified by van der Heijde) appears to be the most sensitive approach for detecting changes over time and is most appropriate for use in clinical trials where small differences are important. In the modified Sharp method, 40 joints in the hands and feet are evaluated for JSN, which is scored from normal (0) to bony ankylosis or luxation (4). Erosions are evaluated in 44 joints and are scored from discrete (1) to complete collapse (5).
 
RA produces functional impairment that is not simply related to the severity of the disease process. Two thirds of patients are more concerned with potential loss of function than with discomfort.  The HAQ is a widely accepted, validated, rheumatology-specific instrument that is used to assess physical function in patients with RA.2 It is the "gold standard" accepted by the Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT) conference committee and the US Food and Drug Administration.  The HAQ is easily understood, has 20 questions concerned with 8 types of activities (dressing and grooming, arising, eating, walking, hygiene, reaching, gripping, and activities of daily living), and takes patients only 10 to 15 minutes to complete.
 
 The HAQ Disability Index (HAQ DI) scores the worst item within each of the 8 domains and is based on information about the use of aids and devices. HAQ scores have also been shown to be strong predictors of functional status, work disability, cost of treatment, total joint replacement,and death in patients with RA. The results of clinical studies have demonstrated that functional disability, as demonstrated by results of the HAQ, is a stronger predictor of disease progression in patients with RA than any other measurement of the ACR response criteria. The results of these trials indicate that an increase of 1 unit per year in HAQ DI over the first 2 years of disease results in 90% greater disability and 87% greater costs over the next 3 years.
 
The Disease Activity Score (DAS) is a composite index that enables clinicians to assess the level of a patient's disease activity from baseline to follow-up, so that disease progression can be assessed or response to treatment evaluated.
 
The DAS28 is an abbreviated version of the DAS that is used in clinical practice because of its accuracy and relative simplicity. The DAS28 assesses joint tenderness and joint swelling from among 28 joints in the body, including the shoulders, elbows, wrists, MCP joints, PIP joints, and knees. The DAS28 can be calculated using a equation. It includes 4 variables: (1) the number of tender joints among the 28 joints, (2) the number of swollen joints among the 28 joints, (3) the erythrocyte sedimentation rate, and (4) general health status assessed by the patient using a 100-mm visual analog scale. The number of tender joints, with a multiplier of 0.56, is given the most weight in the equation, indicating that the number of tender joints is the greatest determining factor in the DAS28. Using the DAS28, a patient is determined to have high disease activity if his or her DAS28 score is greater than 5.1 or low disease activity if the DAS28 score is less than. The patient is considered to be in remission if the DAS28 score falls below that level.
 
When assessing long-term outcomes in patients with RA, physicians should consider not only joint destruction, and functional and work disability, but also the side effects of drugs used to treat the disease, psychosocial dysfunction, and comorbidities. Any of these outcomes can contribute to reduced quality of life and decreased life expectancy. Overall, outcomes in RA patients are less than optimal, partially because most currently available DMARDs (disease-modifying anti-rheumatic drugs) are usually discontinued within 5 years as a result of loss of clinical efficacy or toxicity.
 
New immunomodulatory agents, particularly biologic DMARDs that block putative proinflammatory cytokines, have been shown to significantly reduce the signs and symptoms of RA and slow progression of joint destruction while having acceptable side effect profiles. Although the long-term safety and efficacy of these agents remain to be confirmed, biologic DMARDs are a valuable addition to the RA armamentarium.