Early diagnosis and treatment of rheumatoid arthritis will prevent structural damage-Prof. Kamran Hameed


 Rheumatology Conference proceedings-II

Early diagnosis and treatment of rheumatoid arthritis
will prevent structural damage-Prof. Kamran Hameed

RA reduces the life span by 3-12 years. Treat to
Target approach improves prognosis-Beena Hameed

KARACHI: Rheumatoid arthritis cusses joint damage besides lot of disability. This was stated by Prof. Kamran Hameed while speaking on Health Assessment in rheumatoid arthritis during the Pakistan Society of Rheumatology conference held here last month. He discussed in detail inflammation, disease progression and highlighted the importance of establishing correct diagnosis. He then talked about disease activity, extra articular manifestations, functional capacity, disability, co-morbidities, efficacy and toxicity of drugs besides rehabilitation needs of the patients. It is multimodality and everything cannot be defined as rheumatoid arthritis. He also talked about its acute, chronic ad systemic manifestations. Various other diseases may also mimic like rheumatoid arthritis. Early diagnosis, Prof. Kamran Hameed said is crucial. Early treatment will prevent the structural damage.

Baseline evaluation like physical examination degree of joint pain, duration of morning stiffness and radiography, Prof. Kamran Hameed opined must be done as number of joints can be involved. Serology and duration of disease should be noted. Response will depend on the number of joints involved and duration of the disease. Functional limitations, extra articular disease and bone erosions are associated with poor prognosis. Various disease activity scores are available and one should chose the one with which one is comfortable and then sticks with that. Take into account the damage assessment. He also referred to early initiation of DMAARD therapy, functional assessment and the disease impact besides giving details of the British Columbia Health Assessment questionnaire. He also pointed towards the hidden as well as ignored enemies. These hidden enemies are the co-morbid. Almost 80% of patients will develop co-morbid and it has greater impact on morbidity and mortality. Addition of each co-morbidity reduces the remission by 28%. It is important to take care of hypertension and diabetes, asthma, chronic obstructive pulmonary disease and cancer. Speaking about ten years risk of cardiovascular disease in RA, Prof. Kamran Hameed said that with the increase in age, rheumatoid arthritis patients will have more cardiovascular diseases. Monitoring of RA patients for cardiovascular diseases is most often suboptimal. It extends to other co morbidities hence other specialists should also be consulted. The situation regarding primary care physicians needs to be improved. He then spoke about EULAR cardiovascular risk assessment in rheumatoid arthritis. Disease activity, he further stated, needs to be controlled to reduce the risk. Heart risk calculator can be used which is quite useful. He concluded his presentation by stating that validate the diagnosis, assess the disease activity, and chose the tools one is comfortable with and then stick with that, take care of the co morbidities and do not forget the human touch which is extremely important while managing these patients.

Dr. Beena Hameed from UAE made a presentation on improving the outcome in rheumatoid arthritis. She discussed in detail how to detect, prevent rheumatoid related complications. Speaking about global burden of RA, Dr. Beena Hameed said that by 2025 there will be a significant increase in rheumatoid arthritis the world over. There will be increase in morbidities and co morbidities. Poor outcome is related to poor functional status, multiple joint involvement, low education, smoking and high RA factor. Cardiovascular diseases, depression, infection, disability, malignancy are mostly related to RA. Disability increases with age. She laid emphasis on early diagnosis and treatment to prevent joint damage. After treatment for six months, there is decrease in the disability as compared to those who are treated later. Long term impact of early treatment is very good. She also talked about treatment to target approach. There is an opportunity for therapeutic window in very early phase.

Prof. Kamran Hameed, Prof. Terrence Gibson, Dr. Mahfooz Alam and others making
presentation at the recently held Rheumatology Conference.

Talking about the complications of osteoporosis Dr. Beena Hameed referred to the ACR guidelines on prevention and treatment of glucocorticoids induced osteoporosis. Risk assessment should be done within six months of therapy and then after every twelve months. Adults need BMD scan within six month and then every two to three years. Use of calcium supplements, Vitamin-D and life style modifications are very helpful. Depression worsens in rheumatoid arthritis and it is also associated with pain and disability. Clinical remission reduces symptoms. She also talked about factors contributing to cardiovascular diseases in rheumatoid arthritis. Cardiovascular morbidity and mortality in rheumatoid arthritis, she said, is higher. Long term outcome after MI in rheumatoid arthritis is poor. Mortality from heart failure is increasing in rheumatoid arthritis and in patients suffering from congestive heart failure, rheumatoid arthritis becomes worse. As regards infections, the best predictors are rheumatoid arthritis severity, disease activity, age, steroid therapy, co morbid diseases and the joint involvement. Infections increases with the use of biological. It is important to screen the patient for tuberculosis. ACR guidelines on vaccination offer very useful information. During treatment of RA there is a risk of malignancy like risk of lymphoma as well as risk of developing solid tumors. Her conclusions were that RA reduces the life span by 3-12 years. Early diagnosis, treat to target approach improves prognosis.

Dr. Sarfraz Hasni from USA spoke about SLE pathogenesis. He pointed out that it has multiple pathways and also discussed the current mode of SLE pathways. Speaking about the role of genetics he said that there is 20% increased risk in first degree relatives and 30-50% risk in monozygotic twins. He also talked about sex hormones and SLE pathogenesis.

Dr. Muhammad Saeed from Pakistan was the next speaker. The first case he presented was of lupus nephritis. It was a thirty five years old woman. He then referred to LN 2018 classification and said that there are more histopathologial components. He also talked about antibodies in lupus nephritis and indications for first real biopsy in SLE besides signs of renal involvement. Treatment goal is for six to twelve months. There are some practical issues involved like complete renal response, bad partial renal response. He then spoke about induction therapy for lupus nephritis. He was of the view that patients planning for pregnancy should not use MMF which is absolutely contra indicated at least during the first three months. He also talked about gradual drug withdrawal. We have to use Statins, ACE Inhibitors in these patients besides Aspirin, Calcium and Vitamin-D supplements. Immunization with vaccines also needs to be looked into. Two to four months follow up is OK, the first visit should be within two months after the diagnosis has been made. On each visit body weight, blood pressure measurement, complete blood count, serum creatinine is essential. He emphasized the importance of early detection, spending some time with the patient to educate them on long term use of drugs. Be careful of infections and minimize the use of corticosteroids, he added.

Dr. Betina Rogalski from Germany was the next speaker in this session whose topic for presentation was Juvenile dermatomyositis. She pointed out that it is a rare but most common inflammatory myositis. It affects one in 1,000,000 childdren. It is a multisystem disease and the average onset is at the age of about seven years. Its cause is not known. One hypothesis is that it is a viral triggering but nothing has been proven as yet. The patient suffers from slight fever, is easily fatigued, and has less energy. The patent might have skin rash, pulpy eyes which in fact is periorbital edema. Patients complain of muscle weakness and have difficulty in climbing stairs, difficulty in getting up from chair, have stiffness of joints. Shortening of muscles and contractures of joints must be avoided by daily stretching. Skin ulcers are most common in thee patients. Age less than five yeas is a risk factor. Delay in diagnosis and treatment can be painful. In retinal GI vasculitis muscle biopsy is recommended but now MRI is preferred because it is non-invasive.

For treatment Prednisolone is the first choice. It is important that one should use long acting inflammatory medications. In DMARDs steroid sparing medications, methotrexate is the drug of first choice. Injections are preferable since it is difficult to swallow tablets. Azathioprine can be used in vasculitis. Skin protection, she stated is important hence it is advised to avoid sun exposure. Physiotherapy is very important in improving strength and flexibility. It also prevents muscle wasting. To begin with one should focus on stretching. Mortality is less than 3% but 30-40% of patients have functional disability. Some patients have persistent chances of skin disease. She conluded her presentation by stating that Juvenile dermatomyositis is a difficult complex disease which affects every organ of the body. Getting disease under control is a challenge. It requires long term treatment with monitoring.