Early diagnosis, referral to rheumatologist, target to treatment approach gives better results in RA-Dr. Beena Hameed


Rheumatology conference proceedings-II

Early diagnosis, referral to rheumatologist,
target to treatment approach gives better
results in RA - Dr. Beena Hameed

Medical Synovectomy is an effective, safe and
inexpensive treatment - Dr. Shawe

LAHORE: Dr. Abid Farooqui chaired the first scientific session during the 19th annual conference of Pakistan Rheumatology Society held here from April 10-12, 2015.  Dr. Beena Hameed from UK was the first speaker who gave an update on rheumatoid arthritis (RA). She laid emphasis on early diagnosis and treatment to target approach. RA, she said has a multifactorial pathogenesis with fluctuating clinical course. It has increased morbidity and mortality and loss of physical fitness. Inflammation leads to disability. There is progressive damage to the joints. It is essential to start disease modulating therapy early which results in less radiological damage and less disability.

EULAR came up with classification for diagnosis of RA in 2010. RA score of more than six has more liability and early RA onset. Imaging also plays a role in early diagnosis of rheumatoid arthritis.MRI scan is also useful while ultrasound detects the active joint much better. New approach calls for early assessment and diagnosis, patient education, use of DMARDS and steroids. She also referred to the safety and efficacy of Anti TNF biologicals and Non-Anti TNF biologicals. After remission, physiotherapy, occupational therapy has to be continued for life long. Intensively treated monitored patients do well as compared to routine group. In these patients radiological damage is also much less. She then talked about the steps to improve clinical outcome. Main aim, she opined, is disease remission.

Dr. Javed Mahmood Malik along with others chairing one of the sessions
during the Rheumatology conference held at Lahore during April 2015.

Speaking about treatment options, Dr. Beena Hameed said that goal remains relief of pain, reduction in inflammation, preserve functions, retaining employment, remission. Low Dose Aspirin therapy will reduce cardiovascular risk which will ensure good bone health. Traditional DMARADs include methotrexate, Sulfasalazine and HDC. Biological DMARDS target pro inflammatory cytokines, TNF Alfa, T cells and B Cells interleukin. She then referred to the strategy for selection of therapy and mentioned about predictive factors for severity, patients characteristics, age of the patient, co-morbidities, patient expectations, drugs benefit risk ratio, disease activity besides clinical remission by DAS28. She also talked about withdrawing traditional DMARDS and biological DMARDS. She concluded her presentation by re-emphasizing the importance of early diagnosis, target to treatment approach, early referral to rheumatologist, multidisciplinary approach and consultation by psychiatrists for depressed patients.

Dr. Deirdre Shawe from London made a presentation on Medical Synovectomy. She first referred to reduction of synovial inflammation with steroid injection and then talked about indication for its use, history, osmic acid injections. Trium90 has radiation risk. It is a good effective weapon in battle against synovitis. It is relatively cheap and within the scope of any rheumatologist. Persistent mono or oligo arthritis was mentioned as one of the indications for Synovectomy. It can be an alternate to DMARDS. Speaking about medical radiation Synovectomy, it was pointed out that it emerged in 1950 as an alternative to surgical Synovectomy which was an open procedure. Intra articlar steroid, it was said, are not good and effective in many patients who seek other alternatives. Aspirin, methotrexate, Thiotepra were tried.  Osmic acid use is restricted to knee joints and at twelve months it is equally effective with surgical Synovectomy. Medical Synovectomy gives 75% results after one year and 38% at five years. It is not indicated in active poly arthritis.  One must perform Synovectomy in ward setting. Practical technique of injecting it was also demonstrated. One must immobilize the patient for forty eight hours and do not allow any weight bearing. The side effects include chemical burns, post injection pain which are seen in minority of patients. There is a risk of cartilage damage according to some reports. It is an effective safe treatment. Radiation Synovectomy wherein gold isotopes are used can result in skin irritation, damage and leakage from a few joints was also seen. One needs correct tissue penetration. Radio isotopes are needed for intra articular injection. Comparing it with other treatments shows that it is little different than surgical Synovectomy. Radiation protection case is a must for radiation Synovectomy. Osmic acid is cheap as compared to other agents. Medical Synovectomy it was further stated is an effective, safe and inexpensive treatment.


Dr. Asim, Prof. Kamran Hameed, Dr.Abid Farooqui, Prof. Nighat Mir along
with few other delegates photographed at the Rheumatology Conference 
dinner at Lahore on April 11, 2015.

Dr. Abid Farooqui remarked that protectors are needed for radiation synovectomy. As regards management of RA, patients with HBV and HCV should be first referred to gastroenterologists before starting treatment. However, routine DMARDS can be started. One should have a careful look at the patient; monitor them closely after the treatment for arthritis. DMARDS rarely need to be stopped. We should include these patients for treatment with close monitoring.

DMARDS Vs Biologicals in RA

This was followed by a lively debate on the use of DMARDS Vs Biologicals in rheumatoid arthritis. Initiating the debate Prof. Kamran Hameed said that there are synthetic DMARDS and Biological DMARDS. We have to find out which is suitable for us and is also effective. Methotrexate, he opined, remains a gold standard. Then one can use gold, penicillin. He pointed out that more biologicals are coming since there is lot of money in it for the Pharma industry. He then referred to Premier, Anebor and TEMPO studies which compared methotrexate with other drugs and highlighted their results. Studies have shown that combination therapy with DMARDS is better than monotherapy. DMARDS are much cheap while biologicals are expensive and involve extra cost of laboratory investigations and monitoring, Cost effective methotrexate is a gold standard and far better. However, each patient, he stated, is different, they have different pockets, and hence one should individualize therapy.  DMARDS and Biologicals both have their own role. Hence it is better to individualize therapy whether one uses DMARDS or Biologicals.

Dr. Javed Mahmood Malik opined that biological therapy is superior to DMARDS. He referred to ATTRACT study wherein inflixcimab was compared with methotrexate. It showed 20% greater response with biologicals. Functions of patients were better with biologicals. They were well tolerated, ensured sustained improvement and clinical results were also better. Biologicals also improved quality of life. Joint damage was stopped with the use of biologicals whereas joint damage and bone erosion increased with DMARDS and disability also increased. Progressive erosion and disease results in disability, joint damage. Hence, biologicals, Dr.Javed Mahmood Malik remarked are better and superior than DDMARDS. There is a clear benefit in combining methotrexate with biological agents and it is good if patient can afford it. Biologicals are certainly better than simple DMARDS. Radiological scores, he pointed out, are also better for biologicals as compared to DMARDS. For remission of signs and symptoms, functional outcome biologicals are certainly better, safe and effective. In short for early remission of signs and symptoms, suppression of joint erosion and long term outcome is certainly better with biologicals. Prof. Nighat Mir asked about the use of prophylaxis with anti TB drugs in such patients before putting them on DMARDS or Biologicals? Dr. Abid Farooqui responding to this question said that it is an important issue and nothing is yet definite. There is no final answer either way. We should be open to all information coming through new developments. Dr. Kamran Chima said that INH prophylaxis has been used in the West as there is no risk of exposure to TB. Situation is different in Pakistan. When the patients come, they are already on steroids. There are 3.5% new TB cases. We need proper investigations back up with lavage and culture. Dr. Faisal Sultan stated that negative test makes things easier but still one has to be careful and be on the lookout. Positive results matters in elderly. It is important that the patient should be referred early. Do not start therapy immediately before sending the patient to us, he added.