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DMARDs should be started within three months of diagnosis of Rheumatoid Arthritis-John Axford.

Prof. John Axford from UK was the first speaker in this session on Day-2 of the 23rd International Rheumatology Conference organized by Pakistan Society of Rheumatology at Karachi from 14-17 March 2019. The topic of his presentation was "Curing Rheumatoid Arthritis- Can it be Difficult?" He pointed out that there are many ways to cure it than many inflammatory disorders. The main difficulty is etiology and early diagnosis. Rheumatoid Arthritis may look differently in initial presentation. Often patients are referred to wrong clinicians and patients do not want to listen about RA. They are in a denial phase and the patients do not believe about the diagnosis. Yet another problem is being aware of other co-morbidities. History and clinical examinations are of paramount importance in diagnosis.

Continuing Prof. John Axford said that most common anti rheumatic diseases are multisystem with immunological abnormalities. He then talked about systematic joint inflammation. One of his patients had a history of three months pain and stiffness. She had trouble with rings as her fingers were red, swollen. One needs to dissect out such issues. He then showed some interesting slides of poly arthritis, systemic disease in a patient.

Causes of poly arthritis include osteoarthritis, rheumatoid arthritis, reactive viral. One must think and do the investigations needed before starting to treat the patient. The investigations may include FBC, in acute phase reaction RA Factor, CCP antibodies, imaging which include X-ray to see erosions, MRI and Ultrasound. CT, Scintigraphy should be done. X-Ray in RA is a history lesson. Prayers by physician is no longer important enough. Patient education, counselling, physical therapy, nutrition, diet therapy, bone protection, analgesia, use of Tramadol, NSAIDs, IM/oral corticosteroids are all important.

Disabling joint damage, Prof. John Axford further stated, begins early with the disease. Long duration of active disease has less response to therapy. DMARDs should be started within three months of diagnosis. Investigations should be carried out to see how the patient is responding to treatment. It is important to catch up with the disease. Keep the patient with you, do not leave him behind and maintain good communication. Use of DMARDs and Prednisolone is my preferred options. Remember disease modifying drugs do not work immediately but it does affect the disease process though they may not show immediate therapeutic effect. Prof. Sir Greg Winter was the pioneer of monoclonal antibodies therapy. He then discussed the biological treatment strategies. Ensure that every patients makes the most of every treatment which is initiated. Find out whether it is TB or not TB. One can use anti-TB drugs for just one month.

Speaking about pregnancy and rheumatoid arthritis, Prof. John Axford said that find out if the patient wish to have a family and then advise accordingly. DMDARDs can be used even during postpartum events. Almost 50-80% patients with RA improve during pregnancy but 90% flare up later. Use of Methotrexate should be avoided during pregnancy. He then referred to extra articular complications, hematological and skin related problems like RA skin ulcer, Rheumatoid Dermatitis, Lung Fibrosis in RA, then there are some psychological issues. The patients can have pain and irritation in the eyes, in case of osteoporosis DEXA Scan is helpful. Education of these patients is an ongoing process. He then gave details of the RSM and RCP Teaching Initiative with Fatima Memorial Hospital in Lahore in Pakistan and we will be too glad to collaborate with other institutions in Pakistan, he added.

Diagnosis and Management of SLE

Prof. Sargunan Sockalingam from University of Malaysia was the next speaker who gave an update on Diagnosis and Management of SLE. This disorder, he said, has a wide variety of presentations and one needs to understand the methods of evaluation. To recognize the developments in neuroimaging structural and functional MRI is needed.

As regards management principles, what you are looking at, he said, this is important. Exclude the secondary cause, be mindful of neuro psychiatric syndrome in SLE as defined by American College of Rheumatology. Good history and neurological examination is important to diagnose headache. He then talked in detail about disruption of blood brain barrier, autoantibody mediated neuronal injury, vasculopathy and cytotoxicity, pathophysiology of NPSLE mediators like inflammatory cytokines and Antiphospholipid antibodies.

For diagnosis, history, neuro examination, lumbar puncture, laboratory investigations, PFT, FMRI, and SPECT are important for patients who present with psychiatric manifestations. He also referred to the EULAR recommendations for management of SLE. Glucocorticoids, he opined, remains the primary therapeutics in this disorder. These drugs are very effective, one can taper the dose with which no one disagrees. Hydroxychloroquin is the next good drug. As regards metabolic effects, there is improvement of dyslipidemias. He also referred to the role of anticoagulation, antiplatelet.

ASPIRE showed use in combination have good results. He also discussed the safety and efficacy of cyclophosphamide therapy, besides Methotrexate and Azathioprine in immunosuppressive therapy. Plasmapharesis are the new therapy. Use of psychotropic medications, anti-convulsants and few other non-pharmacological approaches to treatment were also discussed in detail. Adjunct therapy is also used for systematic treatment. Gene therapy, Stem Cell transplants are the future perspectives, he remarked.

Asymptomatic Hyperuricaemia

Treat or not to treat asymptomatic Hyperuricaemia was the topic of presentation by Prof. Terence Gibson from UK who is a frequent traveler to Pakistan and who has always made tremendous contributions to scientific programme of the Rheumatology Conferences. He pointed out that high uric acid can be responsible for cardiovascular disease, kidney disease. Being much more interested, treatment of Hyperuricaemia is also being pushed by the pharmaceutical industry. It can be Hyperuricaemia without any clinical implications but remember it is never without clinical implications. It is a signal that something is wrong.

Many studies have showed that it causes CVS and chronic kidney disease. He also talked about the role of diet in Hyperuricaemia. Use of Fructose is now being recommended but there is no evidence that purine food has any major effect. There is a strong association with obesity. Restriction on alcohol use will result in fall in uric acid. Reduced body weight will reduce TGs. Speaking about the role of Insulin, he said, that insulin resistance is linked to adiposity. Increase in insulin impairs Urate renal clearance. Uric acid has effects on blood vessels. Allopurinol may reduce CVS outcomes in diabetics. Comparison of Febuxostat vs. Allopurinol shows the CVS incidence of 3.43 vs. 3.36 in allopurinol. SVA reduce more with Febuxostat but all-cause mortality and CVS deaths are more with Febuxostat as shown in a study by White in 298 patients.

Continuing Prof. Terrence Gibson remarked that Allopurinol remains the first choice for serum uric acid (SUA). Reduction in SUA is not cardio protective. FDA has asked to use Febuxostat with caution in heart disease patients. Serum Uric Acid reduction retard kidney disease but it is still controversial. Some community studies confirm association of SUA with kidney disease. There are objections to claim of Reno protection of Allopurinol because there is no randomized studies or systemic reviews.

He then spoke about the guidelines for treating Gout and pointed out that all Guidelines by various organizations recommend treatment of Hyperuricaemia in the presence of Gout. Hyperuricaemia and Gout are members of poor health. They have multiple associations. SUA is an independent risk factor of candidiasis. He concluded his presentation by stating that Allopurinol remains the first choice for lowering Serum Uric Acid. There are some concerns about CVS risk with Febuxostat. Too low SUA may also be harmful and that is why there is a need to revise all the Guidelines, he added.

Psoriatic Arthritis (PSA)

Dr. Muhammad Haroon spoke about Psoriatic Arthritis. He discussed in detail its pathogenesis, cardiovascular co-morbidity and management guidelines. It was pointed out that it is progressive inflammatory joint disease. It is not mild disease. Its prevalence in dermatology clinics is about 30%. Diagnosis is always delayed in PSA so much so that only 15% patients get diagnosis in one to two years. In a study 29% of patients were diagnosed after two years or longer. This is an autoimmune disease driven by T cells. PSA has bushy vessels as compared to stringent vessels in RA. He also discussed the related cardiovascular co-morbidity. It is a complex disease. Systemic inflammation are seen on PET-CT scan. In metabolic syndrome a holistic approach is needed. In one of the studies, he quoted, 44% patients had metabolic syndrome. Obesity needs to be treated which will lead to improvement in PSA.

Speaking about the management guidelines, Dr. Haroon said that each patient should be treated individually. Think about diagnosis of disease and think about patient compliance. Ensure tight control of inflammation, look at skin, nails, and peripheral arthritis. Therapeutic landscape for PSA is expanding. He also referred to the concomitant use of Methotrexate with Biologics and pointed out that FDA has approved Tofacitinib in PSA.

During the discussion, it was highlighted as to how the clinicians should make treatment decisions with the use of DMARDs in PSA. A personal experience on six patients who were started with biologics and Methotrexate showed significant effect. Prof. Rukhsana Zuberi remarked that obesity is a monster.
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Publication:Pulse International
Date:May 31, 2019
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