Reumatoid artrit, tidig diagnos (och behandling) Jon Thorkell Einarsson MD PhD Internmedicinare och reumatolog Enhetsansvarig läkare Lund

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1 Reumatoid artrit, tidig diagnos (och behandling) Jon Thorkell Einarsson MD PhD Internmedicinare och reumatolog Enhetsansvarig läkare Lund

2 Medel kostnad per patient per år

3 Sjukskrivning efter RA diagnosis Mean monthly days of sick leave and disability pension every 12 th month from month 36 before RA diagnosis to month 36 thereafter for RA patients, years, diagnosed in Sweden.

4 Reumatoid artrit Eriksson, Jonas K., Martin Neovius, Sofia Ernestam, Staffan Lindblad, Julia F. Simard, and Johan Askling. Incidence of Rheumatoid Arthritis in Sweden: A Nationwide Population-Based Assessment of Incidence, Its Determinants, and Treatment Penetration. Arthritis Care & Research 65, no. 6 (June 1, 2013):

5 Kaplan-Meier kurva Patienter som får diagnos och behandling inom 6 månader från symtomstart har 3 gånger större odds att uppnå långvarig remisson

6 1. Historically chronic persistent disease course 2. Treatment targeted at low disease activity 3. Early treatment targeted at sustained low disease activity 4. Induction treatment targeted at sustained remission

The changes in management of RA have been driven by: a) the

outcome b) new diagnostic criteria and the appreciation of early

diseasemodifying antirheumatic drugs (csdmard) with or without

drug, e) development of new biologic DMARDs (bdmards) f) the

7 The changes in management of RA have been driven by: a) the development of reliable tools for assessing disease activity and outcome b) new diagnostic criteria and the appreciation of early diagnosis c) early start of conventional synthetic diseasemodifying antirheumatic drugs (csdmard) with or without glucocorticoids (GC), d) recognition of MTX as powerful anchor drug, e) development of new biologic DMARDs (bdmards) f) the definition of remission as a treatment target g) the application of the treat-to-target recommendations

8 Hur kan vi bli bättre? (evidence based) Tidig diagnos (och behandling) Täta kontroller Målstyrd behandling Smolen, Josef S., Robert Landewé, Johannes Bijlsma, Gerd Burmester, Katerina Chatzidionysiou, Maxime Dougados, Jackie Nam, et al. EULAR Recommendations for the Management of Rheumatoid Arthritis with Synthetic and Biological Disease-Modifying Antirheumatic Drugs: 2016 Update. Annals of the Rheumatic Diseases 76, no. 6 (June 1, 2017):

9 HR to reach DMARDfree sustained remission Nies, J. A. B. van, R. Tsonaka, C. Gaujoux- Viala, B. Fautrel, and A. H. M. van der Helmvan Mil. Evaluating Relationships between Symptom Duration and Persistence of Rheumatoid Arthritis: Does a Window of Opportunity Exist? Results on the Leiden Early Arthritis Clinic and ESPOIR Cohorts. Annals of the Rheumatic Diseases 74, no. 5 (May 1, 2015): doi: /annrheumdis

10 Arthritis & Rheumatology Volume 68, Issue 4, pages , 28 MAR 2016 DOI: /art

12 Steenbergen, Hanna W. van, et al. EULAR Definition of Arthralgia Suspicious for Progression to Rheumatoid Arthritis. Annals of the Rheumatic Diseases 76, no. 3 (March 1, 2017):

13 RA prediction hos pat med ospecifik artrit

14 Table ACR classification criteria Rheumatoid arthritis is defined by the presence of 4 or more criteria. Criteria A, B, C and D must have been present for at least 6 weeks. Table ACR/EULAR classification criteria for RA Target population are patients who have at least 1 joint with definite clinical synovitis and with the synovitis not better explained by another disease. Scores for each of four domains are added. A score of 6 indicates RA ACR classification criteria for RA At least four of the following criteria Morning stiffness >1h Arthritis of 3 joint areas Arthritis of hand joints Symmetrical arthritis Rheumatoid nodules Serum rheumatoid factor Radiographic changes 2010 ACR classification criteria for RA Domain Parameter Score A. Joint involvement 1 large joint large joints small joints small joints 3 >10 joints ( 1 small) 5 A. Serology Negative RF and 0 negative ACPA Low positive RF or 2 low positive ACPA High positive RF or 3 A. Acute phase reactants A. Duration of symptoms high positive ACPA Normal CRP and 0 normal ESR Abnormal CRP or 1 abnormal ESR <6 weeks 0 6 weeks 1

15 Tidig artrit mottagning - TYR Hur fungerar TYR? Hur diagnostisera RA?

16 Smolen, Josef S., Robert Landewé, Johannes Bijlsma, Gerd Burmester, Katerina Chatzidionysiou, Maxime Dougados, Jackie Nam, et al. EULAR Recommendations for the Management of Rheumatoid Arthritis with Synthetic and Biological Disease-Modifying Antirheumatic Drugs: 2016 Update. Annals of the Rheumatic Diseases 76, no. 6 (June 1, 2017):

17 Raza, Karim et al. Delays in Assessment of Patients with Rheumatoid Arthritis: Variations across Europe. Annals of the Rheumatic Diseases 70, no. 10 (October 1, 2011):

18 Villeneuve, Edith et al. A Systematic Literature Review of Strategies Promoting Early Referral and Reducing Delays in the Diagnosis and Management of Inflammatory Arthritis. Annals of the Rheumatic Diseases 72, no. 1 (January 1, 2013):

20 Ledsymtom Vilken struktur? Ej ledutlösta symtom Ledutlösta symtom Ej inflammatoriskt Inflammatoriskt tillstånd 3. Oligo/Poly- artikulärt Monoartikulärt Axialt??

21 Allmänsymtom Trötthet 100 år gammal Aptitlöshet Viktnedgång Subfebrilitet Virosis liknande symtom Anamnes Rörelseorganen Träningsvärk Dygnsrytm Stelhet, rörelsesmärta-vilovärk Svårt att Öppna förpackningar Knyta handen Gå barfota inomhos ringarna passar inte, försämrad finmotorik tappa saker

22 Inflammatorisk värk Inflammation Icke inflammation, "mekanisk" Karakter Morgonstelhet och smärta Vila Ej bättre, ofta sämre Bättre Smärta och muskelstelhet efter anstränging Rörelse Bättre Sämre

23 Monoartrit Oligoartrit Polyartrit 1 led 2-4 leder 5 leder Asymmetri Symmetri Axialt Perifert

24 Vilka leder drabbas? Reumatoid artrit Artros

25 RA Artros

26 Reumatoid artrit Spondylartriter PsoA, ReA, ankyloserande spondylit Artros Systemiska bindvävssjukdomar SLE, systemisk skleros, Sjögrens syndrom, myositis Vaskuliter Annat Gikt, pseudogikt Parvo B19, Hep B+C m flera Polymyalgia reumatica Hypothyr

27 Symmetrisk polyartrit mer en 6veckor Seropositiv (RF+ eller accp+) RA Seronegativ (RF- och accp-) Seronegativ RA Spondylartrit Psoriasis artrit Polyartrit, varför PsA men inte RA? DIP leder / Tumbas Korv fingrar Hereditet Inflammatorisk ryggvärk Psoriasis Nagelförändringar IBD Entesitis Iritis

29 Reumatologins kardinalsymtom Kapselsvullnad Ömhet Effussion Rörelsesmärta Rodnad Värmeökning (hög specificitet, men saknas ofta)

30 RA tidigt skede

32 Table ACR/EULAR classification criteria for RA Target population are patients who have at least 1 joint with definite clinical synovitis and with the synovitis not better explained by another disease. Scores for each of four domains are added. A score of 6 indicates RA ACR classification criteria for RA Domain Parameter Score A. Joint involvement 1 large joint large joints small joints small joints 3 >10 joints ( 1 small) 5 A. Serology Negative RF and 0 negative ACPA Low positive RF or 2 low positive ACPA High positive RF or 3 A. Acute phase reactants A. Duration of symptoms high positive ACPA Normal CRP and 0 normal ESR Abnormal CRP or 1 abnormal ESR <6 weeks 0 6 weeks 1

34 Nyckelperson med flera kontakter både fysiska och via telefon Förutom fokus på Levnadsvanor -Rökning -Vigt / kost -Alcohol -Fysiskt aktivitet Kardio-risk Graviditet Vaccinering Komorbiditet Tandstatus

35 Acceptera inte svullna leder Steg1 Steg2 Steg3 Steg 4 Steg 5 Step 6 Step 7 Methotrexate 20mg/v (4-6-8) Methotrexate öka till 25 alt 30 mg/v Triple behandling Optimise triple behandling Biologiskt behandling Optimise biologic Switch Folic acid 5mg/v Höja folic acid om illamåande Methotrexate 25mg /v Prednisolone 7,5 mg MTX + atnf MTX + atnf Repeat 5+6 om behövs. Prednisolon 15 mg/d v1 Sulfasalazine 1000x2 (4v upptrappning) Justera dos / interval -10 mg v2 Hydroxyklorokin 400mg x1-7,5 mg v3-5 mg v ,5 mg v11-12 Spruta ev svullna leder med IA steroider

36 Biologiska läkemedel RA RA+SPA SPA Övr ail-6 RoActemra /Kevzara (Jättecellsarterit) Pat producerar inte akut fas reaktanter (CRP/SR) acd80/86 (APC T cell) Orencia ajak1/3 Xeljanz* Olumiant* acd20 Rituximab (flera autoimmuna sjukdomar) atnf Remicade / Remsima Enbrel /Benepali Simponi Cimzia Humira ail-12/23 Stelara ail-17 Cosentyx apde4 Otezla* ab-celler Benlysta *Targeted synthetic (tabletter)

37 Friskare patienter Bättre livskvalitet Högre arbetsförmåga Kräver MINDRE vård Färre på biologiska läkemedel

38 Ledvärk i små leder <12 mån Morgonsymtom Pos squeeze test Svårt att knyta A-CCP / RF Pos Misstänke om synovit (ej klar gikt) -First-degree hereditet *Häller för många remisser en för få. En vänd remiss är ett form av bedömning. Ring gärna reumakonsulten vid behov

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