Rheumatoid arthritis

Aims of treatment for RA

Symptomatic relief

prevention of damage

Treat early, aggressively and appropriately

Combo treatment

Methotrexate and biologic agent

Genetic prognostic markers

HLA-DRBI genotype ass. with more severe RA

Lab prognostic markers

High ESR or CRP levels at outset

Positive RF + ACPA

Clinical assessment prognostic markers - SPEARM

Many active joints

poorer functional score (HAQ)

Radiological lesions (erosions)

adverse socio-economic circumstances

lower educational level

smoking

Medical management aim

Least amount of meds that achieve patients T goals

Tapering and cessation of drugs

Medication options

Analgesia

NSAIDS

Glucocorticoids

csDMARDS

bDMARDS A

Analgesic options

Paracetmol

NSAID options

non selective - ibuprofen

selective COX-2 inhibitor - celecoxibG

Glucocorticoid plan

Taper as rapid as clinically feasible

Glucocorticoid S.E

Osteoporosis

Diabetes

weigh gain

cataracts

pancreatitis

csDMARDs

Methotrexate

bDMARDs

TNFi

Bc depletion

IL6- (-)

JAK (-)

TNF inhibitor

Adalimumab, etanercept, certolizumab, golimumab, infliximab

T cell co stimulator blockade

Abatacept

IL6 inhibitor

Tocilizumab

IL-1 inhibitor

Anakinra

JAK inhibitor

Baracitinib, tofacitinib, upadacitinib

B cell depleters

Rituximab

Risk of GI Bleed

NSAIDs

Cox-2 Inhibitors developed to Decrease GI As but still pose a risk and may increase CV risk