2A 3A 4A 5A 6A 7A 8A 9A

C L I N I C I A N E D U C AT O R VOLUME 4
Issue date: February 2011 • Expiration date: February 29, 2012 Participation in this activity includes reviewing the clinician educator Immune response Pathologic inflammatory
CVD Collaboration

© 2010 American College of Rheumatology. Used with permission.

OVERVIEW and completing a posttest and evaluation. For additional information, 4 Months develops response
and to obtain 0.5 CME credits for participating in this activity, please visit
10 years earlier
This pocket educator is designed to aid primary care providers (PCPs) in recognizing the RA symptom onset Primary Care Rheumatologist
Joint destruction
early signs of rheumatoid arthritis (RA) and determining when to refer a patient to a http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
t destruc 6–9�� Serious Rheumatologists: PCP: • Provisional diagnosis • Confirm diagnosis
�Osteoporosis in ti
Rheumatoid Arthritis: Primary care Initiative rheumatologist. Side A discusses the role of the PCP in the early diagnosis of RA and infection rate • Await early referral • Suspect diagnosis • Immediate referral to rheumatologist • Initiate early, aggressive DMARD

o
Jo
ACCREDITATION AND DESIGNATION • Confirm diagnosis • “Immediate” referral Lymphomas
describes how the PCP can work in tandem with the patient’s rheumatologist to effectively • Monitor for toxicities and disease therapy

n
for improved Diagnosis and outcomes This activity has been planned and implemented in accordance with the Essential Areas • Initiate DMARD/ • Baseline labs
progression • Monitor for toxicities and Genes Environment Clinical RA CVD Complications
manage this disease. Side B is designed to help patients understand RA. onset Comorbidities
and Policies of the Accreditation Council for Continuing Medical Education (ACCME). biologics treatment Bony erosions • Address CVD risk and extra- disease progression
Learning Objectives 2 Years Time
Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to 70%–80% articular issues

lity
• Identify patients who have probable early RA and should be referred to a rheumatologist PCP:

Pa
provide continuing medical education for physicians. Jefferson Medical College of Thomas Reprinted from The Lancet 373, Klareskog L et al. Rheumatoid arthritis, 659-672. Copyright 2009, with
• Employ the squeeze test to assist with diagnosis of RA Rheumatologists: • Surveillance permission from Elsevier.

bi
Jefferson University designates this enduring material for a maximum of 0.5 AMA PRA

in
3
• Order appropriate laboratory tests when RA is suspected Long-term

3
• Comorbidity
2��Rate of �Pulmonary LONG-TERM MANAGEMENT OF RA PATIENTS
13 /

a
s
Di
13 /
Category 1 Credit™. Physicians should claim only the credit commensurate with the management Squeeze test Collaboration between primary care

3 13 /
3
Intended Audience malignancy disease management
of RA

13 /
extent of their participation in the activity. CVD: Patients with RA and persistent inflammation may have additional risk for CVD

13 /
3 3
• CVD risk reduction
This tool is intended for PCPs. Long-term disability and rheumatology ensures optimal care
PROVISIONAL DIAGNOSIS OF RA
16 16 13 / 11 /
DISCLOSURE and require more aggressive cholesterol lowering

3
16
Faculty 10–20 Years 80%
Successful management of RA requires long-term team involvement. In
13 / 16 16
Clifton O. Bingham III, MD Jefferson Medical College of Thomas Jefferson University endorses the Standards of the �GI bleeding Patients who have at least 1 joint with definitive clinical synovitis (swelling) • Minimize CVD risk factors (eg, smoking, lipids, blood pressure)
the first stages, the PCP is responsible for identifying possible cases of
16 16
ACCME and the Guidelines for Commercial Support. • Maintain high index of suspicion for CVD
and in whom the synovitis is not better explained by another disease

3
Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical

16
The following individuals have declared no financial interests and/or affiliations: Swelling on the proximal interphalangeal (PIP) joints RA, providing early referral to a rheumatologist and early pain control. The Fever and infections: RA patients on steroids, methotrexate (MTX), leflunomide, or

3/
Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, should be examined for RA.
Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; biologic agents are at increased risk of serious infection
Johns Hopkins University, Baltimore, Maryland rheumatologist confirms the diagnosis and initiates DMARD therapy.
Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; RHEUMATOID ARTHRITIS FACTS RA IS A DISEASE OF THE ENTIRE BODY PRIMARY CARE: EARLY DETECTION Make the Diagnosis • Assess RA patients with fever, suspected infection

4
Joyce P. Carlone, MN, RN, FNP-BC, CCRC • Early referral to a rheumatologist is critical to early initiation of DMARD
Jonathan S. Simmons, ELS IS CRITICAL – Prompt and thorough evaluation of symptoms, antibiotics if warranted
Nurse Practitioner, Division of Rheumatology, Emory University, Atlanta, Georgia
The following individuals have declared financial interests and/or affiliations: RA is a chronic, progressive, systemic inflammatory disease Heart: Cardiovascular disease (CVD) occurs on average 10 years earlier in Does your patient have: therapy and to stop joint damage
Mary Suzanne Cleveland, JD (Patient/Patient Educator) RA patients than in the general population – Biologics may need to be held until infection is resolved
Clifton O. Bingham III, MD • Characterized by: To prevent the progressive destruction of synovial joints and improve long- 3 Swollen or tender joints • To facilitate the evaluation of the patient by the rheumatologist, it is
Senior Analyst, Kansas Health Institute, Topeka, Kansas – Prompt initiation of antibiotics (especially for patients on biologics)
Grant/Research Support: BMS, Genentech, UCB, Roche – Progressive destruction of synovial joints with bony erosions and • Accelerated atherosclerosis term outcomes, RA must be detected and treated early. – Either >1 large or ≥1 small joint of the hands or feet, or advisable to obtain: n Avoid use of trimethoprim/sulfamethoxazole in patients on MTX
Lauren G. Collins, MD Consultant: Genentech, Roche, Centocor Ortho Biotech, Merck, UCB, Flexion, Celgene
Assistant Professor of Family and Community Medicine, Jefferson Medical College of loss of cartilage Lungs: Increased risk of multiple pulmonary comorbidities • Joint damage can be rapid; without treatment, bony erosions may be – Positive squeeze test (pain when gently squeezing across the – Rheumatoid factor (RF) • If patients on immunosuppressive agents and biologics do not respond rapidly to initial
Joyce P. Carlone, MN, RN, FNP-BC, CCRC
Thomas Jefferson University, Philadelphia, Pennsylvania Consultant, Product/Speakers Bureau, Other: UCB – Symptoms usually begin in the small joints of the fingers, wrists, and • Pleuritis may occur detectable by magnetic resonance imaging (MRI) within 4 months of metacarpophalangeal/metatarsophalangeal joints) treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc)
n 30%–70% of RA patients are positive, although positive RF can • Consider septic arthritis when there is
Steering Committee David S. Kountz, MD, MBA, FACP feet • Interstitial lung diseases disease onset 3 Symptoms lasting ≥6 weeks
Michael E. Weinblatt, MD–Co-Chair Consultant: NiCox, Novartis
be caused by many conditions – Isolated monoarthritis when all other joints stable
– Swollen, tender joints are painful and difficult to move Gastrointestinal (GI): RA patients have a high incidence of GI bleeding, • Rate of x-ray progression is more rapid in the first year than in the
John R. and Eileen K. Riedman Professor of Medicine, Harvard Medical School, Michael E. Weinblatt, MD If patient has swollen joints or a positive squeeze test as above for – Anti-CCP antibody – Swelling and tenderness in a patient with total joint replacement
Co-Director, Clinical Rheumatology, Division of Rheumatology, Immunology, and Allergy, – Loss of physical function and quality of life which may be attributable to use of nonsteroidal anti-inflammatory drugs second and third n RA patients may not mount a febrile response and the white blood cell count
Grant/Research Support: Abbott n 40%–60% of RA patients are positive (may be years before
SIDE A is for clinicians Brigham and Women’s Hospital, Boston, Massachusetts (NSAIDs) and steroids during therapy • Without optimal treatment, most patients develop bony erosions ≥6 weeks, refer to a rheumatologist for provisional RA. may not be elevated in this setting
Consultant: Abbott, Centocor Ortho Biotech, Pfizer/Wyeth – Decreased work productivity and increased disability and job loss clinical manifestation)
FREE CME Lauren G. Collins, MD–Co-Chair Content Disclaimer • 1.3 million adult Americans have been diagnosed with RA Nervous system: The deformity and damage to joints in RA may lead to within 2 years, and ~80% of these patients develop long-term disability If the patient does not meet these criteria but has at least 1 swollen • Acute dyspnea and cough in a patient on MTX may represent pneumonitis
See panel 2A Clifton O. Bingham III, MD n May be detectable earlier than RF VACCINATIONS AND DMARD THERAPY
The information presented in this enduring material is for continuing medical education
• Peak age of onset: 30 to 60 years entrapment of nerves • Successful long-term management requires a partnership between or tender joint and a positive RF or anti-CCP test, he or she should
Joyce P. Carlone, MN, RN, FNP-BC, CCRC purposes only and is not meant to substitute for the independent medical judgment of a the PCP and the rheumatologist, the patient, and other health care n Extremely high specificity for RA
Mary Suzanne Cleveland, JD (Patient/Patient Educator) physician regarding diagnosis and treatment of a specific patient’s medical condition. • 2 to 4 times more common in women than men • Patient may present with carpal tunnel syndrome be referred to a rheumatologist. • Recommended before therapy begins
team members – C-reactive protein, erythrocyte sedimentation rate – Influenza and pneumococcal vaccinations
Jeanne G. Cole, MS The views or opinions expressed in the resources provided do not necessarily reflect those • RA patients 7 times as likely to have greater-than-moderate disability Osteoporosis: Generalized bone loss may result from immobility, the A rheumatologist will make a definitive diagnosis of RA based on the – Hepatitis B immunization if appropriate
Director, Office of CME, Jefferson Medical College of Thomas Jefferson University, of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson Benefits of early detection: – Complete blood count (CBC), liver function tests (LFTs)
than age- or sex-matched individuals inflammatory process, and/or treatments such as steroids following criteria: • Safe
Philadelphia, Pennsylvania Health System or staff. • Decreased RA severity, disability, and mortality with effective treat- – Optional x-rays of the hands, wrists, and feet
SIDE B is for patients Karen H. Costenbader, MD, MPH • If undertreated, life expectancy is reduced by 5 to 15 years • Periarticular demineralization may result from mediators of inflammation 1. Clinical signs and symptoms – Influenza (injection), tetanus, pneumococcus, meningococcus, hepatitis A,
This program is supported by educational grants from Abbott, Centocor Ortho Biotech Inc., and Pfizer. ments, such as disease-modifying antirheumatic drugs (DMARDs) • Monitor for alarm signs (infection, dyspnea, neck pain, rheumatoid eye hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV)
Associate Physician, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s – RA accounts for 22% of all deaths from arthritis and other Infections: RA patients have a 6- to 9-fold increase in the rate of serious 2. Pattern and numbers of joints involved
• Lower rates of RA complications disease, painful red eye) • Avoid
Hospital, Assistant Professor of Medicine, Harvard Medical School, Boston, Massachusetts rheumatic conditions infections, including tuberculosis (TB) 3. Laboratory measures (RF and anti-CCP antibody) – Live virus vaccines such as intranasal influenza, mumps/measles/rubella (MMR),
Paul P. Doghramji, MD, FAAFP • Lower rates of lower-extremity orthopedic surgical procedures • Early treatment by the PCP is intended to relieve pain and enhance
Malignancy: RA doubles the risk of some malignancies, particularly 4. Radiographic findings yellow fever, and typhoid should be avoided in patients on immunomodulators
Medical Director for Health Services at Ursinus College, Family Physician, Collegeville It is never too late to stop further damage. • Decreased cardiac risks with control of inflammation mobility
Family Practice, Collegeville, Pennsylvania You can download a free barcode lymphoma 5. Ruling out other causes of inflammatory arthritis – Wait at least 2 weeks after giving these vaccines before initiating immunomodulators
reader app for your smartphone by – NSAIDs, short course of low-dose prednisone; rarely, opioids for – Zoster vaccine, should be avoided in patients on biologic agents, but can be
Daniel Duch, PhD searching for QR CODE SCANNER QR Code
Hochberg MC, Silman AJ, Smolen JS, et al. eds. Rheumatology. 3rd ed. New York, NY: Mosby; 2003. McQueen FM, Stewart N, Crabbe J, et al. Magnetic resonance imaging of the wrist in early rheumatoid arthritis severe pain
Deane K. Managing comorbidities in RA. J Musculoskel Med. 2006;23(suppl):S24-S31. given to patients taking MTX and prednisone <20 mg/day
Medical Director, Curatio CME Institute, Exton, Pennsylvania in the iPhone App Store, Android American College of Rheumatology. Fact sheet. Available at: http://www.rheumatology.org/practice/clinical/patients/
Böttcher J, Pfeil A. Diagnosis of periarticular osteoporosis in rheumatoid arthritis using digital X-ray radiogrammetry.
reveals a high prevalence of erosions at four months after symptom onset. Ann Rheum Dis. 1998;57:350-356.
Co-sponsored by David S. Kountz, MD, MBA, FACP Market, or Blackberry App World.
diseases_and_conditions/ra.asp. Accessed October 1, 2010.
Arthritis Res Ther. 2008;10:103. Bykerk VP, Keystone EC. RA in primary care: 20 clinical pearls. J Musculoskelet Med. 2004;21:133-146. A patient who is RF and anti-CCP negative may still have RA. Deane K. J Musculoskel Med. 2006;23(suppl Nov):S24-S31. Ravikumar R, et al. Curr Rheumatol Rep.
MacLean CH, Louie R, Leake B, et al. Quality of care for patients with rheumatoid arthritis. JAMA. 2000;284:984-992. 2007;9:407-415; CDC. MMWR. 2004;53:Q1-Q4; Avery RK. Rheum Dis Clin North Am. 1999;25:567-584;
Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical
Chalmers A, et al. J Rheumatol. 1994;21:1203-1206; Harpaz R, et al. MMWR Recomm Rep. 2008;57
Center, Associate Professor of Medicine, Robert Wood Johnson Medical School, New Aletaha D, Neogi T, Silman AJ. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/ Bridges SL. Spotting aggressive RA early: the physical examination, testing, and imaging. J Musculoskelet Med. (RR-5):1-30; ACR. Herpes zoster (shingles) vaccine guidelines for immunocompromised patients. Available at:
Brunswick, New Jersey European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010 Sept; 62:2569-2581. 2006;23(suppl Nov):S10-S14. http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp. Accessed October 1, 2010.
 2A 3A 4A 5A 6A 7A 8A 9A
C L I N I C I A N E D U C AT O R VOLUME 4
Issue date: February 2011 • Expiration date: February 29, 2012 Participation in this activity includes reviewing the clinician educator Immune response Pathologic inflammatory
CVD Collaboration

© 2010 American College of Rheumatology. Used with permission.

OVERVIEW and completing a posttest and evaluation. For additional information, 4 Months develops response
and to obtain 0.5 CME credits for participating in this activity, please visit
10 years earlier
This pocket educator is designed to aid primary care providers (PCPs) in recognizing the RA symptom onset Primary Care Rheumatologist
Joint destruction
early signs of rheumatoid arthritis (RA) and determining when to refer a patient to a http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
t destruc 6–9�� Serious Rheumatologists: PCP: • Provisional diagnosis • Confirm diagnosis
�Osteoporosis in ti
Rheumatoid Arthritis: Primary care Initiative rheumatologist. Side A discusses the role of the PCP in the early diagnosis of RA and infection rate • Await early referral • Suspect diagnosis • Immediate referral to rheumatologist • Initiate early, aggressive DMARD

o
Jo
ACCREDITATION AND DESIGNATION • Confirm diagnosis • “Immediate” referral Lymphomas
describes how the PCP can work in tandem with the patient’s rheumatologist to effectively • Monitor for toxicities and disease therapy

n
for improved Diagnosis and outcomes This activity has been planned and implemented in accordance with the Essential Areas • Initiate DMARD/ • Baseline labs
progression • Monitor for toxicities and Genes Environment Clinical RA CVD Complications
manage this disease. Side B is designed to help patients understand RA. onset Comorbidities
and Policies of the Accreditation Council for Continuing Medical Education (ACCME). biologics treatment Bony erosions • Address CVD risk and extra- disease progression
Learning Objectives 2 Years Time
Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to 70%–80% articular issues

lity
• Identify patients who have probable early RA and should be referred to a rheumatologist PCP:

Pa
provide continuing medical education for physicians. Jefferson Medical College of Thomas Reprinted from The Lancet 373, Klareskog L et al. Rheumatoid arthritis, 659-672. Copyright 2009, with
• Employ the squeeze test to assist with diagnosis of RA Rheumatologists: • Surveillance permission from Elsevier.

bi
Jefferson University designates this enduring material for a maximum of 0.5 AMA PRA

in
3
• Order appropriate laboratory tests when RA is suspected Long-term

3
• Comorbidity
2��Rate of �Pulmonary LONG-TERM MANAGEMENT OF RA PATIENTS
13 /

a
s
Di
13 /
Category 1 Credit™. Physicians should claim only the credit commensurate with the management Squeeze test Collaboration between primary care

3 13 /
3
Intended Audience malignancy disease management
of RA

13 /
extent of their participation in the activity. CVD: Patients with RA and persistent inflammation may have additional risk for CVD

13 /
3 3
• CVD risk reduction
This tool is intended for PCPs. Long-term disability and rheumatology ensures optimal care
PROVISIONAL DIAGNOSIS OF RA
16 16 13 / 11 /
DISCLOSURE and require more aggressive cholesterol lowering

3
16
Faculty 10–20 Years 80%
Successful management of RA requires long-term team involvement. In
13 / 16 16
Clifton O. Bingham III, MD Jefferson Medical College of Thomas Jefferson University endorses the Standards of the �GI bleeding Patients who have at least 1 joint with definitive clinical synovitis (swelling) • Minimize CVD risk factors (eg, smoking, lipids, blood pressure)
the first stages, the PCP is responsible for identifying possible cases of
16 16
ACCME and the Guidelines for Commercial Support. • Maintain high index of suspicion for CVD
and in whom the synovitis is not better explained by another disease

3
Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical

16
The following individuals have declared no financial interests and/or affiliations: Swelling on the proximal interphalangeal (PIP) joints RA, providing early referral to a rheumatologist and early pain control. The Fever and infections: RA patients on steroids, methotrexate (MTX), leflunomide, or

3/
Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, should be examined for RA.
Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; biologic agents are at increased risk of serious infection
Johns Hopkins University, Baltimore, Maryland rheumatologist confirms the diagnosis and initiates DMARD therapy.
Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; RHEUMATOID ARTHRITIS FACTS RA IS A DISEASE OF THE ENTIRE BODY PRIMARY CARE: EARLY DETECTION Make the Diagnosis • Assess RA patients with fever, suspected infection

4
Joyce P. Carlone, MN, RN, FNP-BC, CCRC • Early referral to a rheumatologist is critical to early initiation of DMARD
Jonathan S. Simmons, ELS IS CRITICAL – Prompt and thorough evaluation of symptoms, antibiotics if warranted
Nurse Practitioner, Division of Rheumatology, Emory University, Atlanta, Georgia
The following individuals have declared financial interests and/or affiliations: RA is a chronic, progressive, systemic inflammatory disease Heart: Cardiovascular disease (CVD) occurs on average 10 years earlier in Does your patient have: therapy and to stop joint damage
Mary Suzanne Cleveland, JD (Patient/Patient Educator) RA patients than in the general population – Biologics may need to be held until infection is resolved
Clifton O. Bingham III, MD • Characterized by: To prevent the progressive destruction of synovial joints and improve long- 3 Swollen or tender joints • To facilitate the evaluation of the patient by the rheumatologist, it is
Senior Analyst, Kansas Health Institute, Topeka, Kansas – Prompt initiation of antibiotics (especially for patients on biologics)
Grant/Research Support: BMS, Genentech, UCB, Roche – Progressive destruction of synovial joints with bony erosions and • Accelerated atherosclerosis term outcomes, RA must be detected and treated early. – Either >1 large or ≥1 small joint of the hands or feet, or advisable to obtain: n Avoid use of trimethoprim/sulfamethoxazole in patients on MTX
Lauren G. Collins, MD Consultant: Genentech, Roche, Centocor Ortho Biotech, Merck, UCB, Flexion, Celgene
Assistant Professor of Family and Community Medicine, Jefferson Medical College of loss of cartilage Lungs: Increased risk of multiple pulmonary comorbidities • Joint damage can be rapid; without treatment, bony erosions may be – Positive squeeze test (pain when gently squeezing across the – Rheumatoid factor (RF) • If patients on immunosuppressive agents and biologics do not respond rapidly to initial
Joyce P. Carlone, MN, RN, FNP-BC, CCRC
Thomas Jefferson University, Philadelphia, Pennsylvania Consultant, Product/Speakers Bureau, Other: UCB – Symptoms usually begin in the small joints of the fingers, wrists, and • Pleuritis may occur detectable by magnetic resonance imaging (MRI) within 4 months of metacarpophalangeal/metatarsophalangeal joints) treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc)
n 30%–70% of RA patients are positive, although positive RF can • Consider septic arthritis when there is
Steering Committee David S. Kountz, MD, MBA, FACP feet • Interstitial lung diseases disease onset 3 Symptoms lasting ≥6 weeks
Michael E. Weinblatt, MD–Co-Chair Consultant: NiCox, Novartis
be caused by many conditions – Isolated monoarthritis when all other joints stable
– Swollen, tender joints are painful and difficult to move Gastrointestinal (GI): RA patients have a high incidence of GI bleeding, • Rate of x-ray progression is more rapid in the first year than in the
John R. and Eileen K. Riedman Professor of Medicine, Harvard Medical School, Michael E. Weinblatt, MD If patient has swollen joints or a positive squeeze test as above for – Anti-CCP antibody – Swelling and tenderness in a patient with total joint replacement
Co-Director, Clinical Rheumatology, Division of Rheumatology, Immunology, and Allergy, – Loss of physical function and quality of life which may be attributable to use of nonsteroidal anti-inflammatory drugs second and third n RA patients may not mount a febrile response and the white blood cell count
Grant/Research Support: Abbott n 40%–60% of RA patients are positive (may be years before
SIDE A is for clinicians Brigham and Women’s Hospital, Boston, Massachusetts (NSAIDs) and steroids during therapy • Without optimal treatment, most patients develop bony erosions ≥6 weeks, refer to a rheumatologist for provisional RA. may not be elevated in this setting
Consultant: Abbott, Centocor Ortho Biotech, Pfizer/Wyeth – Decreased work productivity and increased disability and job loss clinical manifestation)
FREE CME Lauren G. Collins, MD–Co-Chair Content Disclaimer • 1.3 million adult Americans have been diagnosed with RA Nervous system: The deformity and damage to joints in RA may lead to within 2 years, and ~80% of these patients develop long-term disability If the patient does not meet these criteria but has at least 1 swollen • Acute dyspnea and cough in a patient on MTX may represent pneumonitis
See panel 2A Clifton O. Bingham III, MD n May be detectable earlier than RF VACCINATIONS AND DMARD THERAPY
The information presented in this enduring material is for continuing medical education
• Peak age of onset: 30 to 60 years entrapment of nerves • Successful long-term management requires a partnership between or tender joint and a positive RF or anti-CCP test, he or she should
Joyce P. Carlone, MN, RN, FNP-BC, CCRC purposes only and is not meant to substitute for the independent medical judgment of a the PCP and the rheumatologist, the patient, and other health care n Extremely high specificity for RA
Mary Suzanne Cleveland, JD (Patient/Patient Educator) physician regarding diagnosis and treatment of a specific patient’s medical condition. • 2 to 4 times more common in women than men • Patient may present with carpal tunnel syndrome be referred to a rheumatologist. • Recommended before therapy begins
team members – C-reactive protein, erythrocyte sedimentation rate – Influenza and pneumococcal vaccinations
Jeanne G. Cole, MS The views or opinions expressed in the resources provided do not necessarily reflect those • RA patients 7 times as likely to have greater-than-moderate disability Osteoporosis: Generalized bone loss may result from immobility, the A rheumatologist will make a definitive diagnosis of RA based on the – Hepatitis B immunization if appropriate
Director, Office of CME, Jefferson Medical College of Thomas Jefferson University, of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson Benefits of early detection: – Complete blood count (CBC), liver function tests (LFTs)
than age- or sex-matched individuals inflammatory process, and/or treatments such as steroids following criteria: • Safe
Philadelphia, Pennsylvania Health System or staff. • Decreased RA severity, disability, and mortality with effective treat- – Optional x-rays of the hands, wrists, and feet
SIDE B is for patients Karen H. Costenbader, MD, MPH • If undertreated, life expectancy is reduced by 5 to 15 years • Periarticular demineralization may result from mediators of inflammation 1. Clinical signs and symptoms – Influenza (injection), tetanus, pneumococcus, meningococcus, hepatitis A,
This program is supported by educational grants from Abbott, Centocor Ortho Biotech Inc., and Pfizer. ments, such as disease-modifying antirheumatic drugs (DMARDs) • Monitor for alarm signs (infection, dyspnea, neck pain, rheumatoid eye hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV)
Associate Physician, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s – RA accounts for 22% of all deaths from arthritis and other Infections: RA patients have a 6- to 9-fold increase in the rate of serious 2. Pattern and numbers of joints involved
• Lower rates of RA complications disease, painful red eye) • Avoid
Hospital, Assistant Professor of Medicine, Harvard Medical School, Boston, Massachusetts rheumatic conditions infections, including tuberculosis (TB) 3. Laboratory measures (RF and anti-CCP antibody) – Live virus vaccines such as intranasal influenza, mumps/measles/rubella (MMR),
Paul P. Doghramji, MD, FAAFP • Lower rates of lower-extremity orthopedic surgical procedures • Early treatment by the PCP is intended to relieve pain and enhance
Malignancy: RA doubles the risk of some malignancies, particularly 4. Radiographic findings yellow fever, and typhoid should be avoided in patients on immunomodulators
Medical Director for Health Services at Ursinus College, Family Physician, Collegeville It is never too late to stop further damage. • Decreased cardiac risks with control of inflammation mobility
Family Practice, Collegeville, Pennsylvania You can download a free barcode lymphoma 5. Ruling out other causes of inflammatory arthritis – Wait at least 2 weeks after giving these vaccines before initiating immunomodulators
reader app for your smartphone by – NSAIDs, short course of low-dose prednisone; rarely, opioids for – Zoster vaccine, should be avoided in patients on biologic agents, but can be
Daniel Duch, PhD searching for QR CODE SCANNER QR Code
Hochberg MC, Silman AJ, Smolen JS, et al. eds. Rheumatology. 3rd ed. New York, NY: Mosby; 2003. McQueen FM, Stewart N, Crabbe J, et al. Magnetic resonance imaging of the wrist in early rheumatoid arthritis severe pain
Deane K. Managing comorbidities in RA. J Musculoskel Med. 2006;23(suppl):S24-S31. given to patients taking MTX and prednisone <20 mg/day
Medical Director, Curatio CME Institute, Exton, Pennsylvania in the iPhone App Store, Android American College of Rheumatology. Fact sheet. Available at: http://www.rheumatology.org/practice/clinical/patients/
Böttcher J, Pfeil A. Diagnosis of periarticular osteoporosis in rheumatoid arthritis using digital X-ray radiogrammetry.
reveals a high prevalence of erosions at four months after symptom onset. Ann Rheum Dis. 1998;57:350-356.
Co-sponsored by David S. Kountz, MD, MBA, FACP Market, or Blackberry App World.
diseases_and_conditions/ra.asp. Accessed October 1, 2010.
Arthritis Res Ther. 2008;10:103. Bykerk VP, Keystone EC. RA in primary care: 20 clinical pearls. J Musculoskelet Med. 2004;21:133-146. A patient who is RF and anti-CCP negative may still have RA. Deane K. J Musculoskel Med. 2006;23(suppl Nov):S24-S31. Ravikumar R, et al. Curr Rheumatol Rep.
MacLean CH, Louie R, Leake B, et al. Quality of care for patients with rheumatoid arthritis. JAMA. 2000;284:984-992. 2007;9:407-415; CDC. MMWR. 2004;53:Q1-Q4; Avery RK. Rheum Dis Clin North Am. 1999;25:567-584;
Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical
Chalmers A, et al. J Rheumatol. 1994;21:1203-1206; Harpaz R, et al. MMWR Recomm Rep. 2008;57
Center, Associate Professor of Medicine, Robert Wood Johnson Medical School, New Aletaha D, Neogi T, Silman AJ. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/ Bridges SL. Spotting aggressive RA early: the physical examination, testing, and imaging. J Musculoskelet Med. (RR-5):1-30; ACR. Herpes zoster (shingles) vaccine guidelines for immunocompromised patients. Available at:
Brunswick, New Jersey European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010 Sept; 62:2569-2581. 2006;23(suppl Nov):S10-S14. http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp. Accessed October 1, 2010.
 2A 3A 4A 5A 6A 7A 8A 9A
C L I N I C I A N E D U C AT O R VOLUME 4
Issue date: February 2011 • Expiration date: February 29, 2012 Participation in this activity includes reviewing the clinician educator Immune response Pathologic inflammatory
CVD Collaboration

© 2010 American College of Rheumatology. Used with permission.

OVERVIEW and completing a posttest and evaluation. For additional information, 4 Months develops response
and to obtain 0.5 CME credits for participating in this activity, please visit
10 years earlier
This pocket educator is designed to aid primary care providers (PCPs) in recognizing the RA symptom onset Primary Care Rheumatologist
Joint destruction
early signs of rheumatoid arthritis (RA) and determining when to refer a patient to a http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
t destruc 6–9�� Serious Rheumatologists: PCP: • Provisional diagnosis • Confirm diagnosis
�Osteoporosis in ti
Rheumatoid Arthritis: Primary care Initiative rheumatologist. Side A discusses the role of the PCP in the early diagnosis of RA and infection rate • Await early referral • Suspect diagnosis • Immediate referral to rheumatologist • Initiate early, aggressive DMARD

o
Jo
ACCREDITATION AND DESIGNATION • Confirm diagnosis • “Immediate” referral Lymphomas
describes how the PCP can work in tandem with the patient’s rheumatologist to effectively • Monitor for toxicities and disease therapy

n
for improved Diagnosis and outcomes This activity has been planned and implemented in accordance with the Essential Areas • Initiate DMARD/ • Baseline labs
progression • Monitor for toxicities and Genes Environment Clinical RA CVD Complications
manage this disease. Side B is designed to help patients understand RA. onset Comorbidities
and Policies of the Accreditation Council for Continuing Medical Education (ACCME). biologics treatment Bony erosions • Address CVD risk and extra- disease progression
Learning Objectives 2 Years Time
Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to 70%–80% articular issues

lity
• Identify patients who have probable early RA and should be referred to a rheumatologist PCP:

Pa
provide continuing medical education for physicians. Jefferson Medical College of Thomas Reprinted from The Lancet 373, Klareskog L et al. Rheumatoid arthritis, 659-672. Copyright 2009, with
• Employ the squeeze test to assist with diagnosis of RA Rheumatologists: • Surveillance permission from Elsevier.

bi
Jefferson University designates this enduring material for a maximum of 0.5 AMA PRA

in
3
• Order appropriate laboratory tests when RA is suspected Long-term

3
• Comorbidity
2��Rate of �Pulmonary LONG-TERM MANAGEMENT OF RA PATIENTS
13 /

a
s
Di
13 /
Category 1 Credit™. Physicians should claim only the credit commensurate with the management Squeeze test Collaboration between primary care

3 13 /
3
Intended Audience malignancy disease management
of RA

13 /
extent of their participation in the activity. CVD: Patients with RA and persistent inflammation may have additional risk for CVD

13 /
3 3
• CVD risk reduction
This tool is intended for PCPs. Long-term disability and rheumatology ensures optimal care
PROVISIONAL DIAGNOSIS OF RA
16 16 13 / 11 /
DISCLOSURE and require more aggressive cholesterol lowering

3
16
Faculty 10–20 Years 80%
Successful management of RA requires long-term team involvement. In
13 / 16 16
Clifton O. Bingham III, MD Jefferson Medical College of Thomas Jefferson University endorses the Standards of the �GI bleeding Patients who have at least 1 joint with definitive clinical synovitis (swelling) • Minimize CVD risk factors (eg, smoking, lipids, blood pressure)
the first stages, the PCP is responsible for identifying possible cases of
16 16
ACCME and the Guidelines for Commercial Support. • Maintain high index of suspicion for CVD
and in whom the synovitis is not better explained by another disease

3
Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical

16
The following individuals have declared no financial interests and/or affiliations: Swelling on the proximal interphalangeal (PIP) joints RA, providing early referral to a rheumatologist and early pain control. The Fever and infections: RA patients on steroids, methotrexate (MTX), leflunomide, or

3/
Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, should be examined for RA.
Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; biologic agents are at increased risk of serious infection
Johns Hopkins University, Baltimore, Maryland rheumatologist confirms the diagnosis and initiates DMARD therapy.
Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; RHEUMATOID ARTHRITIS FACTS RA IS A DISEASE OF THE ENTIRE BODY PRIMARY CARE: EARLY DETECTION Make the Diagnosis • Assess RA patients with fever, suspected infection

4
Joyce P. Carlone, MN, RN, FNP-BC, CCRC • Early referral to a rheumatologist is critical to early initiation of DMARD
Jonathan S. Simmons, ELS IS CRITICAL – Prompt and thorough evaluation of symptoms, antibiotics if warranted
Nurse Practitioner, Division of Rheumatology, Emory University, Atlanta, Georgia
The following individuals have declared financial interests and/or affiliations: RA is a chronic, progressive, systemic inflammatory disease Heart: Cardiovascular disease (CVD) occurs on average 10 years earlier in Does your patient have: therapy and to stop joint damage
Mary Suzanne Cleveland, JD (Patient/Patient Educator) RA patients than in the general population – Biologics may need to be held until infection is resolved
Clifton O. Bingham III, MD • Characterized by: To prevent the progressive destruction of synovial joints and improve long- 3 Swollen or tender joints • To facilitate the evaluation of the patient by the rheumatologist, it is
Senior Analyst, Kansas Health Institute, Topeka, Kansas – Prompt initiation of antibiotics (especially for patients on biologics)
Grant/Research Support: BMS, Genentech, UCB, Roche – Progressive destruction of synovial joints with bony erosions and • Accelerated atherosclerosis term outcomes, RA must be detected and treated early. – Either >1 large or ≥1 small joint of the hands or feet, or advisable to obtain: n Avoid use of trimethoprim/sulfamethoxazole in patients on MTX
Lauren G. Collins, MD Consultant: Genentech, Roche, Centocor Ortho Biotech, Merck, UCB, Flexion, Celgene
Assistant Professor of Family and Community Medicine, Jefferson Medical College of loss of cartilage Lungs: Increased risk of multiple pulmonary comorbidities • Joint damage can be rapid; without treatment, bony erosions may be – Positive squeeze test (pain when gently squeezing across the – Rheumatoid factor (RF) • If patients on immunosuppressive agents and biologics do not respond rapidly to initial
Joyce P. Carlone, MN, RN, FNP-BC, CCRC
Thomas Jefferson University, Philadelphia, Pennsylvania Consultant, Product/Speakers Bureau, Other: UCB – Symptoms usually begin in the small joints of the fingers, wrists, and • Pleuritis may occur detectable by magnetic resonance imaging (MRI) within 4 months of metacarpophalangeal/metatarsophalangeal joints) treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc)
n 30%–70% of RA patients are positive, although positive RF can • Consider septic arthritis when there is
Steering Committee David S. Kountz, MD, MBA, FACP feet • Interstitial lung diseases disease onset 3 Symptoms lasting ≥6 weeks
Michael E. Weinblatt, MD–Co-Chair Consultant: NiCox, Novartis
be caused by many conditions – Isolated monoarthritis when all other joints stable
– Swollen, tender joints are painful and difficult to move Gastrointestinal (GI): RA patients have a high incidence of GI bleeding, • Rate of x-ray progression is more rapid in the first year than in the
John R. and Eileen K. Riedman Professor of Medicine, Harvard Medical School, Michael E. Weinblatt, MD If patient has swollen joints or a positive squeeze test as above for – Anti-CCP antibody – Swelling and tenderness in a patient with total joint replacement
Co-Director, Clinical Rheumatology, Division of Rheumatology, Immunology, and Allergy, – Loss of physical function and quality of life which may be attributable to use of nonsteroidal anti-inflammatory drugs second and third n RA patients may not mount a febrile response and the white blood cell count
Grant/Research Support: Abbott n 40%–60% of RA patients are positive (may be years before
SIDE A is for clinicians Brigham and Women’s Hospital, Boston, Massachusetts (NSAIDs) and steroids during therapy • Without optimal treatment, most patients develop bony erosions ≥6 weeks, refer to a rheumatologist for provisional RA. may not be elevated in this setting
Consultant: Abbott, Centocor Ortho Biotech, Pfizer/Wyeth – Decreased work productivity and increased disability and job loss clinical manifestation)
FREE CME Lauren G. Collins, MD–Co-Chair Content Disclaimer • 1.3 million adult Americans have been diagnosed with RA Nervous system: The deformity and damage to joints in RA may lead to within 2 years, and ~80% of these patients develop long-term disability If the patient does not meet these criteria but has at least 1 swollen • Acute dyspnea and cough in a patient on MTX may represent pneumonitis
See panel 2A Clifton O. Bingham III, MD n May be detectable earlier than RF VACCINATIONS AND DMARD THERAPY
The information presented in this enduring material is for continuing medical education
• Peak age of onset: 30 to 60 years entrapment of nerves • Successful long-term management requires a partnership between or tender joint and a positive RF or anti-CCP test, he or she should
Joyce P. Carlone, MN, RN, FNP-BC, CCRC purposes only and is not meant to substitute for the independent medical judgment of a the PCP and the rheumatologist, the patient, and other health care n Extremely high specificity for RA
Mary Suzanne Cleveland, JD (Patient/Patient Educator) physician regarding diagnosis and treatment of a specific patient’s medical condition. • 2 to 4 times more common in women than men • Patient may present with carpal tunnel syndrome be referred to a rheumatologist. • Recommended before therapy begins
team members – C-reactive protein, erythrocyte sedimentation rate – Influenza and pneumococcal vaccinations
Jeanne G. Cole, MS The views or opinions expressed in the resources provided do not necessarily reflect those • RA patients 7 times as likely to have greater-than-moderate disability Osteoporosis: Generalized bone loss may result from immobility, the A rheumatologist will make a definitive diagnosis of RA based on the – Hepatitis B immunization if appropriate
Director, Office of CME, Jefferson Medical College of Thomas Jefferson University, of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson Benefits of early detection: – Complete blood count (CBC), liver function tests (LFTs)
than age- or sex-matched individuals inflammatory process, and/or treatments such as steroids following criteria: • Safe
Philadelphia, Pennsylvania Health System or staff. • Decreased RA severity, disability, and mortality with effective treat- – Optional x-rays of the hands, wrists, and feet
SIDE B is for patients Karen H. Costenbader, MD, MPH • If undertreated, life expectancy is reduced by 5 to 15 years • Periarticular demineralization may result from mediators of inflammation 1. Clinical signs and symptoms – Influenza (injection), tetanus, pneumococcus, meningococcus, hepatitis A,
This program is supported by educational grants from Abbott, Centocor Ortho Biotech Inc., and Pfizer. ments, such as disease-modifying antirheumatic drugs (DMARDs) • Monitor for alarm signs (infection, dyspnea, neck pain, rheumatoid eye hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV)
Associate Physician, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s – RA accounts for 22% of all deaths from arthritis and other Infections: RA patients have a 6- to 9-fold increase in the rate of serious 2. Pattern and numbers of joints involved
• Lower rates of RA complications disease, painful red eye) • Avoid
Hospital, Assistant Professor of Medicine, Harvard Medical School, Boston, Massachusetts rheumatic conditions infections, including tuberculosis (TB) 3. Laboratory measures (RF and anti-CCP antibody) – Live virus vaccines such as intranasal influenza, mumps/measles/rubella (MMR),
Paul P. Doghramji, MD, FAAFP • Lower rates of lower-extremity orthopedic surgical procedures • Early treatment by the PCP is intended to relieve pain and enhance
Malignancy: RA doubles the risk of some malignancies, particularly 4. Radiographic findings yellow fever, and typhoid should be avoided in patients on immunomodulators
Medical Director for Health Services at Ursinus College, Family Physician, Collegeville It is never too late to stop further damage. • Decreased cardiac risks with control of inflammation mobility
Family Practice, Collegeville, Pennsylvania You can download a free barcode lymphoma 5. Ruling out other causes of inflammatory arthritis – Wait at least 2 weeks after giving these vaccines before initiating immunomodulators
reader app for your smartphone by – NSAIDs, short course of low-dose prednisone; rarely, opioids for – Zoster vaccine, should be avoided in patients on biologic agents, but can be
Daniel Duch, PhD searching for QR CODE SCANNER QR Code
Hochberg MC, Silman AJ, Smolen JS, et al. eds. Rheumatology. 3rd ed. New York, NY: Mosby; 2003. McQueen FM, Stewart N, Crabbe J, et al. Magnetic resonance imaging of the wrist in early rheumatoid arthritis severe pain
Deane K. Managing comorbidities in RA. J Musculoskel Med. 2006;23(suppl):S24-S31. given to patients taking MTX and prednisone <20 mg/day
Medical Director, Curatio CME Institute, Exton, Pennsylvania in the iPhone App Store, Android American College of Rheumatology. Fact sheet. Available at: http://www.rheumatology.org/practice/clinical/patients/
Böttcher J, Pfeil A. Diagnosis of periarticular osteoporosis in rheumatoid arthritis using digital X-ray radiogrammetry.
reveals a high prevalence of erosions at four months after symptom onset. Ann Rheum Dis. 1998;57:350-356.
Co-sponsored by David S. Kountz, MD, MBA, FACP Market, or Blackberry App World.
diseases_and_conditions/ra.asp. Accessed October 1, 2010.
Arthritis Res Ther. 2008;10:103. Bykerk VP, Keystone EC. RA in primary care: 20 clinical pearls. J Musculoskelet Med. 2004;21:133-146. A patient who is RF and anti-CCP negative may still have RA. Deane K. J Musculoskel Med. 2006;23(suppl Nov):S24-S31. Ravikumar R, et al. Curr Rheumatol Rep.
MacLean CH, Louie R, Leake B, et al. Quality of care for patients with rheumatoid arthritis. JAMA. 2000;284:984-992. 2007;9:407-415; CDC. MMWR. 2004;53:Q1-Q4; Avery RK. Rheum Dis Clin North Am. 1999;25:567-584;
Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical
Chalmers A, et al. J Rheumatol. 1994;21:1203-1206; Harpaz R, et al. MMWR Recomm Rep. 2008;57
Center, Associate Professor of Medicine, Robert Wood Johnson Medical School, New Aletaha D, Neogi T, Silman AJ. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/ Bridges SL. Spotting aggressive RA early: the physical examination, testing, and imaging. J Musculoskelet Med. (RR-5):1-30; ACR. Herpes zoster (shingles) vaccine guidelines for immunocompromised patients. Available at:
Brunswick, New Jersey European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010 Sept; 62:2569-2581. 2006;23(suppl Nov):S10-S14. http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp. Accessed October 1, 2010.
 2A 3A 4A 5A 6A 7A 8A 9A
C L I N I C I A N E D U C AT O R VOLUME 4
Issue date: February 2011 • Expiration date: February 29, 2012 Participation in this activity includes reviewing the clinician educator Immune response Pathologic inflammatory
CVD Collaboration

© 2010 American College of Rheumatology. Used with permission.

OVERVIEW and completing a posttest and evaluation. For additional information, 4 Months develops response
and to obtain 0.5 CME credits for participating in this activity, please visit
10 years earlier
This pocket educator is designed to aid primary care providers (PCPs) in recognizing the RA symptom onset Primary Care Rheumatologist
Joint destruction
early signs of rheumatoid arthritis (RA) and determining when to refer a patient to a http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
t destruc 6–9�� Serious Rheumatologists: PCP: • Provisional diagnosis • Confirm diagnosis
�Osteoporosis in ti
Rheumatoid Arthritis: Primary care Initiative rheumatologist. Side A discusses the role of the PCP in the early diagnosis of RA and infection rate • Await early referral • Suspect diagnosis • Immediate referral to rheumatologist • Initiate early, aggressive DMARD

o
Jo
ACCREDITATION AND DESIGNATION • Confirm diagnosis • “Immediate” referral Lymphomas
describes how the PCP can work in tandem with the patient’s rheumatologist to effectively • Monitor for toxicities and disease therapy

n
for improved Diagnosis and outcomes This activity has been planned and implemented in accordance with the Essential Areas • Initiate DMARD/ • Baseline labs
progression • Monitor for toxicities and Genes Environment Clinical RA CVD Complications
manage this disease. Side B is designed to help patients understand RA. onset Comorbidities
and Policies of the Accreditation Council for Continuing Medical Education (ACCME). biologics treatment Bony erosions • Address CVD risk and extra- disease progression
Learning Objectives 2 Years Time
Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to 70%–80% articular issues

lity
• Identify patients who have probable early RA and should be referred to a rheumatologist PCP:

Pa
provide continuing medical education for physicians. Jefferson Medical College of Thomas Reprinted from The Lancet 373, Klareskog L et al. Rheumatoid arthritis, 659-672. Copyright 2009, with
• Employ the squeeze test to assist with diagnosis of RA Rheumatologists: • Surveillance permission from Elsevier.

bi
Jefferson University designates this enduring material for a maximum of 0.5 AMA PRA

in
3
• Order appropriate laboratory tests when RA is suspected Long-term

3
• Comorbidity
2��Rate of �Pulmonary LONG-TERM MANAGEMENT OF RA PATIENTS
13 /

a
s
Di
13 /
Category 1 Credit™. Physicians should claim only the credit commensurate with the management Squeeze test Collaboration between primary care

3 13 /
3
Intended Audience malignancy disease management
of RA

13 /
extent of their participation in the activity. CVD: Patients with RA and persistent inflammation may have additional risk for CVD

13 /
3 3
• CVD risk reduction
This tool is intended for PCPs. Long-term disability and rheumatology ensures optimal care
PROVISIONAL DIAGNOSIS OF RA
16 16 13 / 11 /
DISCLOSURE and require more aggressive cholesterol lowering

3
16
Faculty 10–20 Years 80%
Successful management of RA requires long-term team involvement. In
13 / 16 16
Clifton O. Bingham III, MD Jefferson Medical College of Thomas Jefferson University endorses the Standards of the �GI bleeding Patients who have at least 1 joint with definitive clinical synovitis (swelling) • Minimize CVD risk factors (eg, smoking, lipids, blood pressure)
the first stages, the PCP is responsible for identifying possible cases of
16 16
ACCME and the Guidelines for Commercial Support. • Maintain high index of suspicion for CVD
and in whom the synovitis is not better explained by another disease

3
Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical

16
The following individuals have declared no financial interests and/or affiliations: Swelling on the proximal interphalangeal (PIP) joints RA, providing early referral to a rheumatologist and early pain control. The Fever and infections: RA patients on steroids, methotrexate (MTX), leflunomide, or

3/
Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, should be examined for RA.
Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; biologic agents are at increased risk of serious infection
Johns Hopkins University, Baltimore, Maryland rheumatologist confirms the diagnosis and initiates DMARD therapy.
Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; RHEUMATOID ARTHRITIS FACTS RA IS A DISEASE OF THE ENTIRE BODY PRIMARY CARE: EARLY DETECTION Make the Diagnosis • Assess RA patients with fever, suspected infection

4
Joyce P. Carlone, MN, RN, FNP-BC, CCRC • Early referral to a rheumatologist is critical to early initiation of DMARD
Jonathan S. Simmons, ELS IS CRITICAL – Prompt and thorough evaluation of symptoms, antibiotics if warranted
Nurse Practitioner, Division of Rheumatology, Emory University, Atlanta, Georgia
The following individuals have declared financial interests and/or affiliations: RA is a chronic, progressive, systemic inflammatory disease Heart: Cardiovascular disease (CVD) occurs on average 10 years earlier in Does your patient have: therapy and to stop joint damage
Mary Suzanne Cleveland, JD (Patient/Patient Educator) RA patients than in the general population – Biologics may need to be held until infection is resolved
Clifton O. Bingham III, MD • Characterized by: To prevent the progressive destruction of synovial joints and improve long- 3 Swollen or tender joints • To facilitate the evaluation of the patient by the rheumatologist, it is
Senior Analyst, Kansas Health Institute, Topeka, Kansas – Prompt initiation of antibiotics (especially for patients on biologics)
Grant/Research Support: BMS, Genentech, UCB, Roche – Progressive destruction of synovial joints with bony erosions and • Accelerated atherosclerosis term outcomes, RA must be detected and treated early. – Either >1 large or ≥1 small joint of the hands or feet, or advisable to obtain: n Avoid use of trimethoprim/sulfamethoxazole in patients on MTX
Lauren G. Collins, MD Consultant: Genentech, Roche, Centocor Ortho Biotech, Merck, UCB, Flexion, Celgene
Assistant Professor of Family and Community Medicine, Jefferson Medical College of loss of cartilage Lungs: Increased risk of multiple pulmonary comorbidities • Joint damage can be rapid; without treatment, bony erosions may be – Positive squeeze test (pain when gently squeezing across the – Rheumatoid factor (RF) • If patients on immunosuppressive agents and biologics do not respond rapidly to initial
Joyce P. Carlone, MN, RN, FNP-BC, CCRC
Thomas Jefferson University, Philadelphia, Pennsylvania Consultant, Product/Speakers Bureau, Other: UCB – Symptoms usually begin in the small joints of the fingers, wrists, and • Pleuritis may occur detectable by magnetic resonance imaging (MRI) within 4 months of metacarpophalangeal/metatarsophalangeal joints) treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc)
n 30%–70% of RA patients are positive, although positive RF can • Consider septic arthritis when there is
Steering Committee David S. Kountz, MD, MBA, FACP feet • Interstitial lung diseases disease onset 3 Symptoms lasting ≥6 weeks
Michael E. Weinblatt, MD–Co-Chair Consultant: NiCox, Novartis
be caused by many conditions – Isolated monoarthritis when all other joints stable
– Swollen, tender joints are painful and difficult to move Gastrointestinal (GI): RA patients have a high incidence of GI bleeding, • Rate of x-ray progression is more rapid in the first year than in the
John R. and Eileen K. Riedman Professor of Medicine, Harvard Medical School, Michael E. Weinblatt, MD If patient has swollen joints or a positive squeeze test as above for – Anti-CCP antibody – Swelling and tenderness in a patient with total joint replacement
Co-Director, Clinical Rheumatology, Division of Rheumatology, Immunology, and Allergy, – Loss of physical function and quality of life which may be attributable to use of nonsteroidal anti-inflammatory drugs second and third n RA patients may not mount a febrile response and the white blood cell count
Grant/Research Support: Abbott n 40%–60% of RA patients are positive (may be years before
SIDE A is for clinicians Brigham and Women’s Hospital, Boston, Massachusetts (NSAIDs) and steroids during therapy • Without optimal treatment, most patients develop bony erosions ≥6 weeks, refer to a rheumatologist for provisional RA. may not be elevated in this setting
Consultant: Abbott, Centocor Ortho Biotech, Pfizer/Wyeth – Decreased work productivity and increased disability and job loss clinical manifestation)
FREE CME Lauren G. Collins, MD–Co-Chair Content Disclaimer • 1.3 million adult Americans have been diagnosed with RA Nervous system: The deformity and damage to joints in RA may lead to within 2 years, and ~80% of these patients develop long-term disability If the patient does not meet these criteria but has at least 1 swollen • Acute dyspnea and cough in a patient on MTX may represent pneumonitis
See panel 2A Clifton O. Bingham III, MD n May be detectable earlier than RF VACCINATIONS AND DMARD THERAPY
The information presented in this enduring material is for continuing medical education
• Peak age of onset: 30 to 60 years entrapment of nerves • Successful long-term management requires a partnership between or tender joint and a positive RF or anti-CCP test, he or she should
Joyce P. Carlone, MN, RN, FNP-BC, CCRC purposes only and is not meant to substitute for the independent medical judgment of a the PCP and the rheumatologist, the patient, and other health care n Extremely high specificity for RA
Mary Suzanne Cleveland, JD (Patient/Patient Educator) physician regarding diagnosis and treatment of a specific patient’s medical condition. • 2 to 4 times more common in women than men • Patient may present with carpal tunnel syndrome be referred to a rheumatologist. • Recommended before therapy begins
team members – C-reactive protein, erythrocyte sedimentation rate – Influenza and pneumococcal vaccinations
Jeanne G. Cole, MS The views or opinions expressed in the resources provided do not necessarily reflect those • RA patients 7 times as likely to have greater-than-moderate disability Osteoporosis: Generalized bone loss may result from immobility, the A rheumatologist will make a definitive diagnosis of RA based on the – Hepatitis B immunization if appropriate
Director, Office of CME, Jefferson Medical College of Thomas Jefferson University, of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson Benefits of early detection: – Complete blood count (CBC), liver function tests (LFTs)
than age- or sex-matched individuals inflammatory process, and/or treatments such as steroids following criteria: • Safe
Philadelphia, Pennsylvania Health System or staff. • Decreased RA severity, disability, and mortality with effective treat- – Optional x-rays of the hands, wrists, and feet
SIDE B is for patients Karen H. Costenbader, MD, MPH • If undertreated, life expectancy is reduced by 5 to 15 years • Periarticular demineralization may result from mediators of inflammation 1. Clinical signs and symptoms – Influenza (injection), tetanus, pneumococcus, meningococcus, hepatitis A,
This program is supported by educational grants from Abbott, Centocor Ortho Biotech Inc., and Pfizer. ments, such as disease-modifying antirheumatic drugs (DMARDs) • Monitor for alarm signs (infection, dyspnea, neck pain, rheumatoid eye hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV)
Associate Physician, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s – RA accounts for 22% of all deaths from arthritis and other Infections: RA patients have a 6- to 9-fold increase in the rate of serious 2. Pattern and numbers of joints involved
• Lower rates of RA complications disease, painful red eye) • Avoid
Hospital, Assistant Professor of Medicine, Harvard Medical School, Boston, Massachusetts rheumatic conditions infections, including tuberculosis (TB) 3. Laboratory measures (RF and anti-CCP antibody) – Live virus vaccines such as intranasal influenza, mumps/measles/rubella (MMR),
Paul P. Doghramji, MD, FAAFP • Lower rates of lower-extremity orthopedic surgical procedures • Early treatment by the PCP is intended to relieve pain and enhance
Malignancy: RA doubles the risk of some malignancies, particularly 4. Radiographic findings yellow fever, and typhoid should be avoided in patients on immunomodulators
Medical Director for Health Services at Ursinus College, Family Physician, Collegeville It is never too late to stop further damage. • Decreased cardiac risks with control of inflammation mobility
Family Practice, Collegeville, Pennsylvania You can download a free barcode lymphoma 5. Ruling out other causes of inflammatory arthritis – Wait at least 2 weeks after giving these vaccines before initiating immunomodulators
reader app for your smartphone by – NSAIDs, short course of low-dose prednisone; rarely, opioids for – Zoster vaccine, should be avoided in patients on biologic agents, but can be
Daniel Duch, PhD searching for QR CODE SCANNER QR Code
Hochberg MC, Silman AJ, Smolen JS, et al. eds. Rheumatology. 3rd ed. New York, NY: Mosby; 2003. McQueen FM, Stewart N, Crabbe J, et al. Magnetic resonance imaging of the wrist in early rheumatoid arthritis severe pain
Deane K. Managing comorbidities in RA. J Musculoskel Med. 2006;23(suppl):S24-S31. given to patients taking MTX and prednisone <20 mg/day
Medical Director, Curatio CME Institute, Exton, Pennsylvania in the iPhone App Store, Android American College of Rheumatology. Fact sheet. Available at: http://www.rheumatology.org/practice/clinical/patients/
Böttcher J, Pfeil A. Diagnosis of periarticular osteoporosis in rheumatoid arthritis using digital X-ray radiogrammetry.
reveals a high prevalence of erosions at four months after symptom onset. Ann Rheum Dis. 1998;57:350-356.
Co-sponsored by David S. Kountz, MD, MBA, FACP Market, or Blackberry App World.
diseases_and_conditions/ra.asp. Accessed October 1, 2010.
Arthritis Res Ther. 2008;10:103. Bykerk VP, Keystone EC. RA in primary care: 20 clinical pearls. J Musculoskelet Med. 2004;21:133-146. A patient who is RF and anti-CCP negative may still have RA. Deane K. J Musculoskel Med. 2006;23(suppl Nov):S24-S31. Ravikumar R, et al. Curr Rheumatol Rep.
MacLean CH, Louie R, Leake B, et al. Quality of care for patients with rheumatoid arthritis. JAMA. 2000;284:984-992. 2007;9:407-415; CDC. MMWR. 2004;53:Q1-Q4; Avery RK. Rheum Dis Clin North Am. 1999;25:567-584;
Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical
Chalmers A, et al. J Rheumatol. 1994;21:1203-1206; Harpaz R, et al. MMWR Recomm Rep. 2008;57
Center, Associate Professor of Medicine, Robert Wood Johnson Medical School, New Aletaha D, Neogi T, Silman AJ. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/ Bridges SL. Spotting aggressive RA early: the physical examination, testing, and imaging. J Musculoskelet Med. (RR-5):1-30; ACR. Herpes zoster (shingles) vaccine guidelines for immunocompromised patients. Available at:
Brunswick, New Jersey European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010 Sept; 62:2569-2581. 2006;23(suppl Nov):S10-S14. http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp. Accessed October 1, 2010.
 2A 3A 4A 5A 6A 7A 8A 9A
C L I N I C I A N E D U C AT O R VOLUME 4
Issue date: February 2011 • Expiration date: February 29, 2012 Participation in this activity includes reviewing the clinician educator Immune response Pathologic inflammatory
CVD Collaboration

© 2010 American College of Rheumatology. Used with permission.

OVERVIEW and completing a posttest and evaluation. For additional information, 4 Months develops response
and to obtain 0.5 CME credits for participating in this activity, please visit
10 years earlier
This pocket educator is designed to aid primary care providers (PCPs) in recognizing the RA symptom onset Primary Care Rheumatologist
Joint destruction
early signs of rheumatoid arthritis (RA) and determining when to refer a patient to a http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
t destruc 6–9�� Serious Rheumatologists: PCP: • Provisional diagnosis • Confirm diagnosis
�Osteoporosis in ti
Rheumatoid Arthritis: Primary care Initiative rheumatologist. Side A discusses the role of the PCP in the early diagnosis of RA and infection rate • Await early referral • Suspect diagnosis • Immediate referral to rheumatologist • Initiate early, aggressive DMARD

o
Jo
ACCREDITATION AND DESIGNATION • Confirm diagnosis • “Immediate” referral Lymphomas
describes how the PCP can work in tandem with the patient’s rheumatologist to effectively • Monitor for toxicities and disease therapy

n
for improved Diagnosis and outcomes This activity has been planned and implemented in accordance with the Essential Areas • Initiate DMARD/ • Baseline labs
progression • Monitor for toxicities and Genes Environment Clinical RA CVD Complications
manage this disease. Side B is designed to help patients understand RA. onset Comorbidities
and Policies of the Accreditation Council for Continuing Medical Education (ACCME). biologics treatment Bony erosions • Address CVD risk and extra- disease progression
Learning Objectives 2 Years Time
Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to 70%–80% articular issues

lity
• Identify patients who have probable early RA and should be referred to a rheumatologist PCP:

Pa
provide continuing medical education for physicians. Jefferson Medical College of Thomas Reprinted from The Lancet 373, Klareskog L et al. Rheumatoid arthritis, 659-672. Copyright 2009, with
• Employ the squeeze test to assist with diagnosis of RA Rheumatologists: • Surveillance permission from Elsevier.

bi
Jefferson University designates this enduring material for a maximum of 0.5 AMA PRA

in
3
• Order appropriate laboratory tests when RA is suspected Long-term

3
• Comorbidity
2��Rate of �Pulmonary LONG-TERM MANAGEMENT OF RA PATIENTS
13 /

a
s
Di
13 /
Category 1 Credit™. Physicians should claim only the credit commensurate with the management Squeeze test Collaboration between primary care

3 13 /
3
Intended Audience malignancy disease management
of RA

13 /
extent of their participation in the activity. CVD: Patients with RA and persistent inflammation may have additional risk for CVD

13 /
3 3
• CVD risk reduction
This tool is intended for PCPs. Long-term disability and rheumatology ensures optimal care
PROVISIONAL DIAGNOSIS OF RA
16 16 13 / 11 /
DISCLOSURE and require more aggressive cholesterol lowering

3
16
Faculty 10–20 Years 80%
Successful management of RA requires long-term team involvement. In
13 / 16 16
Clifton O. Bingham III, MD Jefferson Medical College of Thomas Jefferson University endorses the Standards of the �GI bleeding Patients who have at least 1 joint with definitive clinical synovitis (swelling) • Minimize CVD risk factors (eg, smoking, lipids, blood pressure)
the first stages, the PCP is responsible for identifying possible cases of
16 16
ACCME and the Guidelines for Commercial Support. • Maintain high index of suspicion for CVD
and in whom the synovitis is not better explained by another disease

3
Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical

16
The following individuals have declared no financial interests and/or affiliations: Swelling on the proximal interphalangeal (PIP) joints RA, providing early referral to a rheumatologist and early pain control. The Fever and infections: RA patients on steroids, methotrexate (MTX), leflunomide, or

3/
Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, should be examined for RA.
Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; biologic agents are at increased risk of serious infection
Johns Hopkins University, Baltimore, Maryland rheumatologist confirms the diagnosis and initiates DMARD therapy.
Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; RHEUMATOID ARTHRITIS FACTS RA IS A DISEASE OF THE ENTIRE BODY PRIMARY CARE: EARLY DETECTION Make the Diagnosis • Assess RA patients with fever, suspected infection

4
Joyce P. Carlone, MN, RN, FNP-BC, CCRC • Early referral to a rheumatologist is critical to early initiation of DMARD
Jonathan S. Simmons, ELS IS CRITICAL – Prompt and thorough evaluation of symptoms, antibiotics if warranted
Nurse Practitioner, Division of Rheumatology, Emory University, Atlanta, Georgia
The following individuals have declared financial interests and/or affiliations: RA is a chronic, progressive, systemic inflammatory disease Heart: Cardiovascular disease (CVD) occurs on average 10 years earlier in Does your patient have: therapy and to stop joint damage
Mary Suzanne Cleveland, JD (Patient/Patient Educator) RA patients than in the general population – Biologics may need to be held until infection is resolved
Clifton O. Bingham III, MD • Characterized by: To prevent the progressive destruction of synovial joints and improve long- 3 Swollen or tender joints • To facilitate the evaluation of the patient by the rheumatologist, it is
Senior Analyst, Kansas Health Institute, Topeka, Kansas – Prompt initiation of antibiotics (especially for patients on biologics)
Grant/Research Support: BMS, Genentech, UCB, Roche – Progressive destruction of synovial joints with bony erosions and • Accelerated atherosclerosis term outcomes, RA must be detected and treated early. – Either >1 large or ≥1 small joint of the hands or feet, or advisable to obtain: n Avoid use of trimethoprim/sulfamethoxazole in patients on MTX
Lauren G. Collins, MD Consultant: Genentech, Roche, Centocor Ortho Biotech, Merck, UCB, Flexion, Celgene
Assistant Professor of Family and Community Medicine, Jefferson Medical College of loss of cartilage Lungs: Increased risk of multiple pulmonary comorbidities • Joint damage can be rapid; without treatment, bony erosions may be – Positive squeeze test (pain when gently squeezing across the – Rheumatoid factor (RF) • If patients on immunosuppressive agents and biologics do not respond rapidly to initial
Joyce P. Carlone, MN, RN, FNP-BC, CCRC
Thomas Jefferson University, Philadelphia, Pennsylvania Consultant, Product/Speakers Bureau, Other: UCB – Symptoms usually begin in the small joints of the fingers, wrists, and • Pleuritis may occur detectable by magnetic resonance imaging (MRI) within 4 months of metacarpophalangeal/metatarsophalangeal joints) treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc)
n 30%–70% of RA patients are positive, although positive RF can • Consider septic arthritis when there is
Steering Committee David S. Kountz, MD, MBA, FACP feet • Interstitial lung diseases disease onset 3 Symptoms lasting ≥6 weeks
Michael E. Weinblatt, MD–Co-Chair Consultant: NiCox, Novartis
be caused by many conditions – Isolated monoarthritis when all other joints stable
– Swollen, tender joints are painful and difficult to move Gastrointestinal (GI): RA patients have a high incidence of GI bleeding, • Rate of x-ray progression is more rapid in the first year than in the
John R. and Eileen K. Riedman Professor of Medicine, Harvard Medical School, Michael E. Weinblatt, MD If patient has swollen joints or a positive squeeze test as above for – Anti-CCP antibody – Swelling and tenderness in a patient with total joint replacement
Co-Director, Clinical Rheumatology, Division of Rheumatology, Immunology, and Allergy, – Loss of physical function and quality of life which may be attributable to use of nonsteroidal anti-inflammatory drugs second and third n RA patients may not mount a febrile response and the white blood cell count
Grant/Research Support: Abbott n 40%–60% of RA patients are positive (may be years before
SIDE A is for clinicians Brigham and Women’s Hospital, Boston, Massachusetts (NSAIDs) and steroids during therapy • Without optimal treatment, most patients develop bony erosions ≥6 weeks, refer to a rheumatologist for provisional RA. may not be elevated in this setting
Consultant: Abbott, Centocor Ortho Biotech, Pfizer/Wyeth – Decreased work productivity and increased disability and job loss clinical manifestation)
FREE CME Lauren G. Collins, MD–Co-Chair Content Disclaimer • 1.3 million adult Americans have been diagnosed with RA Nervous system: The deformity and damage to joints in RA may lead to within 2 years, and ~80% of these patients develop long-term disability If the patient does not meet these criteria but has at least 1 swollen • Acute dyspnea and cough in a patient on MTX may represent pneumonitis
See panel 2A Clifton O. Bingham III, MD n May be detectable earlier than RF VACCINATIONS AND DMARD THERAPY
The information presented in this enduring material is for continuing medical education
• Peak age of onset: 30 to 60 years entrapment of nerves • Successful long-term management requires a partnership between or tender joint and a positive RF or anti-CCP test, he or she should
Joyce P. Carlone, MN, RN, FNP-BC, CCRC purposes only and is not meant to substitute for the independent medical judgment of a the PCP and the rheumatologist, the patient, and other health care n Extremely high specificity for RA
Mary Suzanne Cleveland, JD (Patient/Patient Educator) physician regarding diagnosis and treatment of a specific patient’s medical condition. • 2 to 4 times more common in women than men • Patient may present with carpal tunnel syndrome be referred to a rheumatologist. • Recommended before therapy begins
team members – C-reactive protein, erythrocyte sedimentation rate – Influenza and pneumococcal vaccinations
Jeanne G. Cole, MS The views or opinions expressed in the resources provided do not necessarily reflect those • RA patients 7 times as likely to have greater-than-moderate disability Osteoporosis: Generalized bone loss may result from immobility, the A rheumatologist will make a definitive diagnosis of RA based on the – Hepatitis B immunization if appropriate
Director, Office of CME, Jefferson Medical College of Thomas Jefferson University, of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson Benefits of early detection: – Complete blood count (CBC), liver function tests (LFTs)
than age- or sex-matched individuals inflammatory process, and/or treatments such as steroids following criteria: • Safe
Philadelphia, Pennsylvania Health System or staff. • Decreased RA severity, disability, and mortality with effective treat- – Optional x-rays of the hands, wrists, and feet
SIDE B is for patients Karen H. Costenbader, MD, MPH • If undertreated, life expectancy is reduced by 5 to 15 years • Periarticular demineralization may result from mediators of inflammation 1. Clinical signs and symptoms – Influenza (injection), tetanus, pneumococcus, meningococcus, hepatitis A,
This program is supported by educational grants from Abbott, Centocor Ortho Biotech Inc., and Pfizer. ments, such as disease-modifying antirheumatic drugs (DMARDs) • Monitor for alarm signs (infection, dyspnea, neck pain, rheumatoid eye hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV)
Associate Physician, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s – RA accounts for 22% of all deaths from arthritis and other Infections: RA patients have a 6- to 9-fold increase in the rate of serious 2. Pattern and numbers of joints involved
• Lower rates of RA complications disease, painful red eye) • Avoid
Hospital, Assistant Professor of Medicine, Harvard Medical School, Boston, Massachusetts rheumatic conditions infections, including tuberculosis (TB) 3. Laboratory measures (RF and anti-CCP antibody) – Live virus vaccines such as intranasal influenza, mumps/measles/rubella (MMR),
Paul P. Doghramji, MD, FAAFP • Lower rates of lower-extremity orthopedic surgical procedures • Early treatment by the PCP is intended to relieve pain and enhance
Malignancy: RA doubles the risk of some malignancies, particularly 4. Radiographic findings yellow fever, and typhoid should be avoided in patients on immunomodulators
Medical Director for Health Services at Ursinus College, Family Physician, Collegeville It is never too late to stop further damage. • Decreased cardiac risks with control of inflammation mobility
Family Practice, Collegeville, Pennsylvania You can download a free barcode lymphoma 5. Ruling out other causes of inflammatory arthritis – Wait at least 2 weeks after giving these vaccines before initiating immunomodulators
reader app for your smartphone by – NSAIDs, short course of low-dose prednisone; rarely, opioids for – Zoster vaccine, should be avoided in patients on biologic agents, but can be
Daniel Duch, PhD searching for QR CODE SCANNER QR Code
Hochberg MC, Silman AJ, Smolen JS, et al. eds. Rheumatology. 3rd ed. New York, NY: Mosby; 2003. McQueen FM, Stewart N, Crabbe J, et al. Magnetic resonance imaging of the wrist in early rheumatoid arthritis severe pain
Deane K. Managing comorbidities in RA. J Musculoskel Med. 2006;23(suppl):S24-S31. given to patients taking MTX and prednisone <20 mg/day
Medical Director, Curatio CME Institute, Exton, Pennsylvania in the iPhone App Store, Android American College of Rheumatology. Fact sheet. Available at: http://www.rheumatology.org/practice/clinical/patients/
Böttcher J, Pfeil A. Diagnosis of periarticular osteoporosis in rheumatoid arthritis using digital X-ray radiogrammetry.
reveals a high prevalence of erosions at four months after symptom onset. Ann Rheum Dis. 1998;57:350-356.
Co-sponsored by David S. Kountz, MD, MBA, FACP Market, or Blackberry App World.
diseases_and_conditions/ra.asp. Accessed October 1, 2010.
Arthritis Res Ther. 2008;10:103. Bykerk VP, Keystone EC. RA in primary care: 20 clinical pearls. J Musculoskelet Med. 2004;21:133-146. A patient who is RF and anti-CCP negative may still have RA. Deane K. J Musculoskel Med. 2006;23(suppl Nov):S24-S31. Ravikumar R, et al. Curr Rheumatol Rep.
MacLean CH, Louie R, Leake B, et al. Quality of care for patients with rheumatoid arthritis. JAMA. 2000;284:984-992. 2007;9:407-415; CDC. MMWR. 2004;53:Q1-Q4; Avery RK. Rheum Dis Clin North Am. 1999;25:567-584;
Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical
Chalmers A, et al. J Rheumatol. 1994;21:1203-1206; Harpaz R, et al. MMWR Recomm Rep. 2008;57
Center, Associate Professor of Medicine, Robert Wood Johnson Medical School, New Aletaha D, Neogi T, Silman AJ. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/ Bridges SL. Spotting aggressive RA early: the physical examination, testing, and imaging. J Musculoskelet Med. (RR-5):1-30; ACR. Herpes zoster (shingles) vaccine guidelines for immunocompromised patients. Available at:
Brunswick, New Jersey European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010 Sept; 62:2569-2581. 2006;23(suppl Nov):S10-S14. http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp. Accessed October 1, 2010.
 2A 3A 4A 5A 6A 7A 8A 9A
C L I N I C I A N E D U C AT O R VOLUME 4
Issue date: February 2011 • Expiration date: February 29, 2012 Participation in this activity includes reviewing the clinician educator Immune response Pathologic inflammatory
CVD Collaboration

© 2010 American College of Rheumatology. Used with permission.

OVERVIEW and completing a posttest and evaluation. For additional information, 4 Months develops response
and to obtain 0.5 CME credits for participating in this activity, please visit
10 years earlier
This pocket educator is designed to aid primary care providers (PCPs) in recognizing the RA symptom onset Primary Care Rheumatologist
Joint destruction
early signs of rheumatoid arthritis (RA) and determining when to refer a patient to a http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
t destruc 6–9�� Serious Rheumatologists: PCP: • Provisional diagnosis • Confirm diagnosis
�Osteoporosis in ti
Rheumatoid Arthritis: Primary care Initiative rheumatologist. Side A discusses the role of the PCP in the early diagnosis of RA and infection rate • Await early referral • Suspect diagnosis • Immediate referral to rheumatologist • Initiate early, aggressive DMARD

o
Jo
ACCREDITATION AND DESIGNATION • Confirm diagnosis • “Immediate” referral Lymphomas
describes how the PCP can work in tandem with the patient’s rheumatologist to effectively • Monitor for toxicities and disease therapy

n
for improved Diagnosis and outcomes This activity has been planned and implemented in accordance with the Essential Areas • Initiate DMARD/ • Baseline labs
progression • Monitor for toxicities and Genes Environment Clinical RA CVD Complications
manage this disease. Side B is designed to help patients understand RA. onset Comorbidities
and Policies of the Accreditation Council for Continuing Medical Education (ACCME). biologics treatment Bony erosions • Address CVD risk and extra- disease progression
Learning Objectives 2 Years Time
Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to 70%–80% articular issues

lity
• Identify patients who have probable early RA and should be referred to a rheumatologist PCP:

Pa
provide continuing medical education for physicians. Jefferson Medical College of Thomas Reprinted from The Lancet 373, Klareskog L et al. Rheumatoid arthritis, 659-672. Copyright 2009, with
• Employ the squeeze test to assist with diagnosis of RA Rheumatologists: • Surveillance permission from Elsevier.

bi
Jefferson University designates this enduring material for a maximum of 0.5 AMA PRA

in
3
• Order appropriate laboratory tests when RA is suspected Long-term

3
• Comorbidity
2��Rate of �Pulmonary LONG-TERM MANAGEMENT OF RA PATIENTS
13 /

a
s
Di
13 /
Category 1 Credit™. Physicians should claim only the credit commensurate with the management Squeeze test Collaboration between primary care

3 13 /
3
Intended Audience malignancy disease management
of RA

13 /
extent of their participation in the activity. CVD: Patients with RA and persistent inflammation may have additional risk for CVD

13 /
3 3
• CVD risk reduction
This tool is intended for PCPs. Long-term disability and rheumatology ensures optimal care
PROVISIONAL DIAGNOSIS OF RA
16 16 13 / 11 /
DISCLOSURE and require more aggressive cholesterol lowering

3
16
Faculty 10–20 Years 80%
Successful management of RA requires long-term team involvement. In
13 / 16 16
Clifton O. Bingham III, MD Jefferson Medical College of Thomas Jefferson University endorses the Standards of the �GI bleeding Patients who have at least 1 joint with definitive clinical synovitis (swelling) • Minimize CVD risk factors (eg, smoking, lipids, blood pressure)
the first stages, the PCP is responsible for identifying possible cases of
16 16
ACCME and the Guidelines for Commercial Support. • Maintain high index of suspicion for CVD
and in whom the synovitis is not better explained by another disease

3
Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical

16
The following individuals have declared no financial interests and/or affiliations: Swelling on the proximal interphalangeal (PIP) joints RA, providing early referral to a rheumatologist and early pain control. The Fever and infections: RA patients on steroids, methotrexate (MTX), leflunomide, or

3/
Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, should be examined for RA.
Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; biologic agents are at increased risk of serious infection
Johns Hopkins University, Baltimore, Maryland rheumatologist confirms the diagnosis and initiates DMARD therapy.
Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; RHEUMATOID ARTHRITIS FACTS RA IS A DISEASE OF THE ENTIRE BODY PRIMARY CARE: EARLY DETECTION Make the Diagnosis • Assess RA patients with fever, suspected infection

4
Joyce P. Carlone, MN, RN, FNP-BC, CCRC • Early referral to a rheumatologist is critical to early initiation of DMARD
Jonathan S. Simmons, ELS IS CRITICAL – Prompt and thorough evaluation of symptoms, antibiotics if warranted
Nurse Practitioner, Division of Rheumatology, Emory University, Atlanta, Georgia
The following individuals have declared financial interests and/or affiliations: RA is a chronic, progressive, systemic inflammatory disease Heart: Cardiovascular disease (CVD) occurs on average 10 years earlier in Does your patient have: therapy and to stop joint damage
Mary Suzanne Cleveland, JD (Patient/Patient Educator) RA patients than in the general population – Biologics may need to be held until infection is resolved
Clifton O. Bingham III, MD • Characterized by: To prevent the progressive destruction of synovial joints and improve long- 3 Swollen or tender joints • To facilitate the evaluation of the patient by the rheumatologist, it is
Senior Analyst, Kansas Health Institute, Topeka, Kansas – Prompt initiation of antibiotics (especially for patients on biologics)
Grant/Research Support: BMS, Genentech, UCB, Roche – Progressive destruction of synovial joints with bony erosions and • Accelerated atherosclerosis term outcomes, RA must be detected and treated early. – Either >1 large or ≥1 small joint of the hands or feet, or advisable to obtain: n Avoid use of trimethoprim/sulfamethoxazole in patients on MTX
Lauren G. Collins, MD Consultant: Genentech, Roche, Centocor Ortho Biotech, Merck, UCB, Flexion, Celgene
Assistant Professor of Family and Community Medicine, Jefferson Medical College of loss of cartilage Lungs: Increased risk of multiple pulmonary comorbidities • Joint damage can be rapid; without treatment, bony erosions may be – Positive squeeze test (pain when gently squeezing across the – Rheumatoid factor (RF) • If patients on immunosuppressive agents and biologics do not respond rapidly to initial
Joyce P. Carlone, MN, RN, FNP-BC, CCRC
Thomas Jefferson University, Philadelphia, Pennsylvania Consultant, Product/Speakers Bureau, Other: UCB – Symptoms usually begin in the small joints of the fingers, wrists, and • Pleuritis may occur detectable by magnetic resonance imaging (MRI) within 4 months of metacarpophalangeal/metatarsophalangeal joints) treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc)
n 30%–70% of RA patients are positive, although positive RF can • Consider septic arthritis when there is
Steering Committee David S. Kountz, MD, MBA, FACP feet • Interstitial lung diseases disease onset 3 Symptoms lasting ≥6 weeks
Michael E. Weinblatt, MD–Co-Chair Consultant: NiCox, Novartis
be caused by many conditions – Isolated monoarthritis when all other joints stable
– Swollen, tender joints are painful and difficult to move Gastrointestinal (GI): RA patients have a high incidence of GI bleeding, • Rate of x-ray progression is more rapid in the first year than in the
John R. and Eileen K. Riedman Professor of Medicine, Harvard Medical School, Michael E. Weinblatt, MD If patient has swollen joints or a positive squeeze test as above for – Anti-CCP antibody – Swelling and tenderness in a patient with total joint replacement
Co-Director, Clinical Rheumatology, Division of Rheumatology, Immunology, and Allergy, – Loss of physical function and quality of life which may be attributable to use of nonsteroidal anti-inflammatory drugs second and third n RA patients may not mount a febrile response and the white blood cell count
Grant/Research Support: Abbott n 40%–60% of RA patients are positive (may be years before
SIDE A is for clinicians Brigham and Women’s Hospital, Boston, Massachusetts (NSAIDs) and steroids during therapy • Without optimal treatment, most patients develop bony erosions ≥6 weeks, refer to a rheumatologist for provisional RA. may not be elevated in this setting
Consultant: Abbott, Centocor Ortho Biotech, Pfizer/Wyeth – Decreased work productivity and increased disability and job loss clinical manifestation)
FREE CME Lauren G. Collins, MD–Co-Chair Content Disclaimer • 1.3 million adult Americans have been diagnosed with RA Nervous system: The deformity and damage to joints in RA may lead to within 2 years, and ~80% of these patients develop long-term disability If the patient does not meet these criteria but has at least 1 swollen • Acute dyspnea and cough in a patient on MTX may represent pneumonitis
See panel 2A Clifton O. Bingham III, MD n May be detectable earlier than RF VACCINATIONS AND DMARD THERAPY
The information presented in this enduring material is for continuing medical education
• Peak age of onset: 30 to 60 years entrapment of nerves • Successful long-term management requires a partnership between or tender joint and a positive RF or anti-CCP test, he or she should
Joyce P. Carlone, MN, RN, FNP-BC, CCRC purposes only and is not meant to substitute for the independent medical judgment of a the PCP and the rheumatologist, the patient, and other health care n Extremely high specificity for RA
Mary Suzanne Cleveland, JD (Patient/Patient Educator) physician regarding diagnosis and treatment of a specific patient’s medical condition. • 2 to 4 times more common in women than men • Patient may present with carpal tunnel syndrome be referred to a rheumatologist. • Recommended before therapy begins
team members – C-reactive protein, erythrocyte sedimentation rate – Influenza and pneumococcal vaccinations
Jeanne G. Cole, MS The views or opinions expressed in the resources provided do not necessarily reflect those • RA patients 7 times as likely to have greater-than-moderate disability Osteoporosis: Generalized bone loss may result from immobility, the A rheumatologist will make a definitive diagnosis of RA based on the – Hepatitis B immunization if appropriate
Director, Office of CME, Jefferson Medical College of Thomas Jefferson University, of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson Benefits of early detection: – Complete blood count (CBC), liver function tests (LFTs)
than age- or sex-matched individuals inflammatory process, and/or treatments such as steroids following criteria: • Safe
Philadelphia, Pennsylvania Health System or staff. • Decreased RA severity, disability, and mortality with effective treat- – Optional x-rays of the hands, wrists, and feet
SIDE B is for patients Karen H. Costenbader, MD, MPH • If undertreated, life expectancy is reduced by 5 to 15 years • Periarticular demineralization may result from mediators of inflammation 1. Clinical signs and symptoms – Influenza (injection), tetanus, pneumococcus, meningococcus, hepatitis A,
This program is supported by educational grants from Abbott, Centocor Ortho Biotech Inc., and Pfizer. ments, such as disease-modifying antirheumatic drugs (DMARDs) • Monitor for alarm signs (infection, dyspnea, neck pain, rheumatoid eye hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV)
Associate Physician, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s – RA accounts for 22% of all deaths from arthritis and other Infections: RA patients have a 6- to 9-fold increase in the rate of serious 2. Pattern and numbers of joints involved
• Lower rates of RA complications disease, painful red eye) • Avoid
Hospital, Assistant Professor of Medicine, Harvard Medical School, Boston, Massachusetts rheumatic conditions infections, including tuberculosis (TB) 3. Laboratory measures (RF and anti-CCP antibody) – Live virus vaccines such as intranasal influenza, mumps/measles/rubella (MMR),
Paul P. Doghramji, MD, FAAFP • Lower rates of lower-extremity orthopedic surgical procedures • Early treatment by the PCP is intended to relieve pain and enhance
Malignancy: RA doubles the risk of some malignancies, particularly 4. Radiographic findings yellow fever, and typhoid should be avoided in patients on immunomodulators
Medical Director for Health Services at Ursinus College, Family Physician, Collegeville It is never too late to stop further damage. • Decreased cardiac risks with control of inflammation mobility
Family Practice, Collegeville, Pennsylvania You can download a free barcode lymphoma 5. Ruling out other causes of inflammatory arthritis – Wait at least 2 weeks after giving these vaccines before initiating immunomodulators
reader app for your smartphone by – NSAIDs, short course of low-dose prednisone; rarely, opioids for – Zoster vaccine, should be avoided in patients on biologic agents, but can be
Daniel Duch, PhD searching for QR CODE SCANNER QR Code
Hochberg MC, Silman AJ, Smolen JS, et al. eds. Rheumatology. 3rd ed. New York, NY: Mosby; 2003. McQueen FM, Stewart N, Crabbe J, et al. Magnetic resonance imaging of the wrist in early rheumatoid arthritis severe pain
Deane K. Managing comorbidities in RA. J Musculoskel Med. 2006;23(suppl):S24-S31. given to patients taking MTX and prednisone <20 mg/day
Medical Director, Curatio CME Institute, Exton, Pennsylvania in the iPhone App Store, Android American College of Rheumatology. Fact sheet. Available at: http://www.rheumatology.org/practice/clinical/patients/
Böttcher J, Pfeil A. Diagnosis of periarticular osteoporosis in rheumatoid arthritis using digital X-ray radiogrammetry.
reveals a high prevalence of erosions at four months after symptom onset. Ann Rheum Dis. 1998;57:350-356.
Co-sponsored by David S. Kountz, MD, MBA, FACP Market, or Blackberry App World.
diseases_and_conditions/ra.asp. Accessed October 1, 2010.
Arthritis Res Ther. 2008;10:103. Bykerk VP, Keystone EC. RA in primary care: 20 clinical pearls. J Musculoskelet Med. 2004;21:133-146. A patient who is RF and anti-CCP negative may still have RA. Deane K. J Musculoskel Med. 2006;23(suppl Nov):S24-S31. Ravikumar R, et al. Curr Rheumatol Rep.
MacLean CH, Louie R, Leake B, et al. Quality of care for patients with rheumatoid arthritis. JAMA. 2000;284:984-992. 2007;9:407-415; CDC. MMWR. 2004;53:Q1-Q4; Avery RK. Rheum Dis Clin North Am. 1999;25:567-584;
Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical
Chalmers A, et al. J Rheumatol. 1994;21:1203-1206; Harpaz R, et al. MMWR Recomm Rep. 2008;57
Center, Associate Professor of Medicine, Robert Wood Johnson Medical School, New Aletaha D, Neogi T, Silman AJ. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/ Bridges SL. Spotting aggressive RA early: the physical examination, testing, and imaging. J Musculoskelet Med. (RR-5):1-30; ACR. Herpes zoster (shingles) vaccine guidelines for immunocompromised patients. Available at:
Brunswick, New Jersey European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010 Sept; 62:2569-2581. 2006;23(suppl Nov):S10-S14. http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp. Accessed October 1, 2010.
 2A 3A 4A 5A 6A 7A 8A 9A
C L I N I C I A N E D U C AT O R VOLUME 4
Issue date: February 2011 • Expiration date: February 29, 2012 Participation in this activity includes reviewing the clinician educator Immune response Pathologic inflammatory
CVD Collaboration

© 2010 American College of Rheumatology. Used with permission.

OVERVIEW and completing a posttest and evaluation. For additional information, 4 Months develops response
and to obtain 0.5 CME credits for participating in this activity, please visit
10 years earlier
This pocket educator is designed to aid primary care providers (PCPs) in recognizing the RA symptom onset Primary Care Rheumatologist
Joint destruction
early signs of rheumatoid arthritis (RA) and determining when to refer a patient to a http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
t destruc 6–9�� Serious Rheumatologists: PCP: • Provisional diagnosis • Confirm diagnosis
�Osteoporosis in ti
Rheumatoid Arthritis: Primary care Initiative rheumatologist. Side A discusses the role of the PCP in the early diagnosis of RA and infection rate • Await early referral • Suspect diagnosis • Immediate referral to rheumatologist • Initiate early, aggressive DMARD

o
Jo
ACCREDITATION AND DESIGNATION • Confirm diagnosis • “Immediate” referral Lymphomas
describes how the PCP can work in tandem with the patient’s rheumatologist to effectively • Monitor for toxicities and disease therapy

n
for improved Diagnosis and outcomes This activity has been planned and implemented in accordance with the Essential Areas • Initiate DMARD/ • Baseline labs
progression • Monitor for toxicities and Genes Environment Clinical RA CVD Complications
manage this disease. Side B is designed to help patients understand RA. onset Comorbidities
and Policies of the Accreditation Council for Continuing Medical Education (ACCME). biologics treatment Bony erosions • Address CVD risk and extra- disease progression
Learning Objectives 2 Years Time
Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to 70%–80% articular issues

lity
• Identify patients who have probable early RA and should be referred to a rheumatologist PCP:

Pa
provide continuing medical education for physicians. Jefferson Medical College of Thomas Reprinted from The Lancet 373, Klareskog L et al. Rheumatoid arthritis, 659-672. Copyright 2009, with
• Employ the squeeze test to assist with diagnosis of RA Rheumatologists: • Surveillance permission from Elsevier.

bi
Jefferson University designates this enduring material for a maximum of 0.5 AMA PRA

in
3
• Order appropriate laboratory tests when RA is suspected Long-term

3
• Comorbidity
2��Rate of �Pulmonary LONG-TERM MANAGEMENT OF RA PATIENTS
13 /

a
s
Di
13 /
Category 1 Credit™. Physicians should claim only the credit commensurate with the management Squeeze test Collaboration between primary care

3 13 /
3
Intended Audience malignancy disease management
of RA

13 /
extent of their participation in the activity. CVD: Patients with RA and persistent inflammation may have additional risk for CVD

13 /
3 3
• CVD risk reduction
This tool is intended for PCPs. Long-term disability and rheumatology ensures optimal care
PROVISIONAL DIAGNOSIS OF RA
16 16 13 / 11 /
DISCLOSURE and require more aggressive cholesterol lowering

3
16
Faculty 10–20 Years 80%
Successful management of RA requires long-term team involvement. In
13 / 16 16
Clifton O. Bingham III, MD Jefferson Medical College of Thomas Jefferson University endorses the Standards of the �GI bleeding Patients who have at least 1 joint with definitive clinical synovitis (swelling) • Minimize CVD risk factors (eg, smoking, lipids, blood pressure)
the first stages, the PCP is responsible for identifying possible cases of
16 16
ACCME and the Guidelines for Commercial Support. • Maintain high index of suspicion for CVD
and in whom the synovitis is not better explained by another disease

3
Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical

16
The following individuals have declared no financial interests and/or affiliations: Swelling on the proximal interphalangeal (PIP) joints RA, providing early referral to a rheumatologist and early pain control. The Fever and infections: RA patients on steroids, methotrexate (MTX), leflunomide, or

3/
Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, should be examined for RA.
Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; biologic agents are at increased risk of serious infection
Johns Hopkins University, Baltimore, Maryland rheumatologist confirms the diagnosis and initiates DMARD therapy.
Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; RHEUMATOID ARTHRITIS FACTS RA IS A DISEASE OF THE ENTIRE BODY PRIMARY CARE: EARLY DETECTION Make the Diagnosis • Assess RA patients with fever, suspected infection

4
Joyce P. Carlone, MN, RN, FNP-BC, CCRC • Early referral to a rheumatologist is critical to early initiation of DMARD
Jonathan S. Simmons, ELS IS CRITICAL – Prompt and thorough evaluation of symptoms, antibiotics if warranted
Nurse Practitioner, Division of Rheumatology, Emory University, Atlanta, Georgia
The following individuals have declared financial interests and/or affiliations: RA is a chronic, progressive, systemic inflammatory disease Heart: Cardiovascular disease (CVD) occurs on average 10 years earlier in Does your patient have: therapy and to stop joint damage
Mary Suzanne Cleveland, JD (Patient/Patient Educator) RA patients than in the general population – Biologics may need to be held until infection is resolved
Clifton O. Bingham III, MD • Characterized by: To prevent the progressive destruction of synovial joints and improve long- 3 Swollen or tender joints • To facilitate the evaluation of the patient by the rheumatologist, it is
Senior Analyst, Kansas Health Institute, Topeka, Kansas – Prompt initiation of antibiotics (especially for patients on biologics)
Grant/Research Support: BMS, Genentech, UCB, Roche – Progressive destruction of synovial joints with bony erosions and • Accelerated atherosclerosis term outcomes, RA must be detected and treated early. – Either >1 large or ≥1 small joint of the hands or feet, or advisable to obtain: n Avoid use of trimethoprim/sulfamethoxazole in patients on MTX
Lauren G. Collins, MD Consultant: Genentech, Roche, Centocor Ortho Biotech, Merck, UCB, Flexion, Celgene
Assistant Professor of Family and Community Medicine, Jefferson Medical College of loss of cartilage Lungs: Increased risk of multiple pulmonary comorbidities • Joint damage can be rapid; without treatment, bony erosions may be – Positive squeeze test (pain when gently squeezing across the – Rheumatoid factor (RF) • If patients on immunosuppressive agents and biologics do not respond rapidly to initial
Joyce P. Carlone, MN, RN, FNP-BC, CCRC
Thomas Jefferson University, Philadelphia, Pennsylvania Consultant, Product/Speakers Bureau, Other: UCB – Symptoms usually begin in the small joints of the fingers, wrists, and • Pleuritis may occur detectable by magnetic resonance imaging (MRI) within 4 months of metacarpophalangeal/metatarsophalangeal joints) treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc)
n 30%–70% of RA patients are positive, although positive RF can • Consider septic arthritis when there is
Steering Committee David S. Kountz, MD, MBA, FACP feet • Interstitial lung diseases disease onset 3 Symptoms lasting ≥6 weeks
Michael E. Weinblatt, MD–Co-Chair Consultant: NiCox, Novartis
be caused by many conditions – Isolated monoarthritis when all other joints stable
– Swollen, tender joints are painful and difficult to move Gastrointestinal (GI): RA patients have a high incidence of GI bleeding, • Rate of x-ray progression is more rapid in the first year than in the
John R. and Eileen K. Riedman Professor of Medicine, Harvard Medical School, Michael E. Weinblatt, MD If patient has swollen joints or a positive squeeze test as above for – Anti-CCP antibody – Swelling and tenderness in a patient with total joint replacement
Co-Director, Clinical Rheumatology, Division of Rheumatology, Immunology, and Allergy, – Loss of physical function and quality of life which may be attributable to use of nonsteroidal anti-inflammatory drugs second and third n RA patients may not mount a febrile response and the white blood cell count
Grant/Research Support: Abbott n 40%–60% of RA patients are positive (may be years before
SIDE A is for clinicians Brigham and Women’s Hospital, Boston, Massachusetts (NSAIDs) and steroids during therapy • Without optimal treatment, most patients develop bony erosions ≥6 weeks, refer to a rheumatologist for provisional RA. may not be elevated in this setting
Consultant: Abbott, Centocor Ortho Biotech, Pfizer/Wyeth – Decreased work productivity and increased disability and job loss clinical manifestation)
FREE CME Lauren G. Collins, MD–Co-Chair Content Disclaimer • 1.3 million adult Americans have been diagnosed with RA Nervous system: The deformity and damage to joints in RA may lead to within 2 years, and ~80% of these patients develop long-term disability If the patient does not meet these criteria but has at least 1 swollen • Acute dyspnea and cough in a patient on MTX may represent pneumonitis
See panel 2A Clifton O. Bingham III, MD n May be detectable earlier than RF VACCINATIONS AND DMARD THERAPY
The information presented in this enduring material is for continuing medical education
• Peak age of onset: 30 to 60 years entrapment of nerves • Successful long-term management requires a partnership between or tender joint and a positive RF or anti-CCP test, he or she should
Joyce P. Carlone, MN, RN, FNP-BC, CCRC purposes only and is not meant to substitute for the independent medical judgment of a the PCP and the rheumatologist, the patient, and other health care n Extremely high specificity for RA
Mary Suzanne Cleveland, JD (Patient/Patient Educator) physician regarding diagnosis and treatment of a specific patient’s medical condition. • 2 to 4 times more common in women than men • Patient may present with carpal tunnel syndrome be referred to a rheumatologist. • Recommended before therapy begins
team members – C-reactive protein, erythrocyte sedimentation rate – Influenza and pneumococcal vaccinations
Jeanne G. Cole, MS The views or opinions expressed in the resources provided do not necessarily reflect those • RA patients 7 times as likely to have greater-than-moderate disability Osteoporosis: Generalized bone loss may result from immobility, the A rheumatologist will make a definitive diagnosis of RA based on the – Hepatitis B immunization if appropriate
Director, Office of CME, Jefferson Medical College of Thomas Jefferson University, of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson Benefits of early detection: – Complete blood count (CBC), liver function tests (LFTs)
than age- or sex-matched individuals inflammatory process, and/or treatments such as steroids following criteria: • Safe
Philadelphia, Pennsylvania Health System or staff. • Decreased RA severity, disability, and mortality with effective treat- – Optional x-rays of the hands, wrists, and feet
SIDE B is for patients Karen H. Costenbader, MD, MPH • If undertreated, life expectancy is reduced by 5 to 15 years • Periarticular demineralization may result from mediators of inflammation 1. Clinical signs and symptoms – Influenza (injection), tetanus, pneumococcus, meningococcus, hepatitis A,
This program is supported by educational grants from Abbott, Centocor Ortho Biotech Inc., and Pfizer. ments, such as disease-modifying antirheumatic drugs (DMARDs) • Monitor for alarm signs (infection, dyspnea, neck pain, rheumatoid eye hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV)
Associate Physician, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s – RA accounts for 22% of all deaths from arthritis and other Infections: RA patients have a 6- to 9-fold increase in the rate of serious 2. Pattern and numbers of joints involved
• Lower rates of RA complications disease, painful red eye) • Avoid
Hospital, Assistant Professor of Medicine, Harvard Medical School, Boston, Massachusetts rheumatic conditions infections, including tuberculosis (TB) 3. Laboratory measures (RF and anti-CCP antibody) – Live virus vaccines such as intranasal influenza, mumps/measles/rubella (MMR),
Paul P. Doghramji, MD, FAAFP • Lower rates of lower-extremity orthopedic surgical procedures • Early treatment by the PCP is intended to relieve pain and enhance
Malignancy: RA doubles the risk of some malignancies, particularly 4. Radiographic findings yellow fever, and typhoid should be avoided in patients on immunomodulators
Medical Director for Health Services at Ursinus College, Family Physician, Collegeville It is never too late to stop further damage. • Decreased cardiac risks with control of inflammation mobility
Family Practice, Collegeville, Pennsylvania You can download a free barcode lymphoma 5. Ruling out other causes of inflammatory arthritis – Wait at least 2 weeks after giving these vaccines before initiating immunomodulators
reader app for your smartphone by – NSAIDs, short course of low-dose prednisone; rarely, opioids for – Zoster vaccine, should be avoided in patients on biologic agents, but can be
Daniel Duch, PhD searching for QR CODE SCANNER QR Code
Hochberg MC, Silman AJ, Smolen JS, et al. eds. Rheumatology. 3rd ed. New York, NY: Mosby; 2003. McQueen FM, Stewart N, Crabbe J, et al. Magnetic resonance imaging of the wrist in early rheumatoid arthritis severe pain
Deane K. Managing comorbidities in RA. J Musculoskel Med. 2006;23(suppl):S24-S31. given to patients taking MTX and prednisone <20 mg/day
Medical Director, Curatio CME Institute, Exton, Pennsylvania in the iPhone App Store, Android American College of Rheumatology. Fact sheet. Available at: http://www.rheumatology.org/practice/clinical/patients/
Böttcher J, Pfeil A. Diagnosis of periarticular osteoporosis in rheumatoid arthritis using digital X-ray radiogrammetry.
reveals a high prevalence of erosions at four months after symptom onset. Ann Rheum Dis. 1998;57:350-356.
Co-sponsored by David S. Kountz, MD, MBA, FACP Market, or Blackberry App World.
diseases_and_conditions/ra.asp. Accessed October 1, 2010.
Arthritis Res Ther. 2008;10:103. Bykerk VP, Keystone EC. RA in primary care: 20 clinical pearls. J Musculoskelet Med. 2004;21:133-146. A patient who is RF and anti-CCP negative may still have RA. Deane K. J Musculoskel Med. 2006;23(suppl Nov):S24-S31. Ravikumar R, et al. Curr Rheumatol Rep.
MacLean CH, Louie R, Leake B, et al. Quality of care for patients with rheumatoid arthritis. JAMA. 2000;284:984-992. 2007;9:407-415; CDC. MMWR. 2004;53:Q1-Q4; Avery RK. Rheum Dis Clin North Am. 1999;25:567-584;
Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical
Chalmers A, et al. J Rheumatol. 1994;21:1203-1206; Harpaz R, et al. MMWR Recomm Rep. 2008;57
Center, Associate Professor of Medicine, Robert Wood Johnson Medical School, New Aletaha D, Neogi T, Silman AJ. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/ Bridges SL. Spotting aggressive RA early: the physical examination, testing, and imaging. J Musculoskelet Med. (RR-5):1-30; ACR. Herpes zoster (shingles) vaccine guidelines for immunocompromised patients. Available at:
Brunswick, New Jersey European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010 Sept; 62:2569-2581. 2006;23(suppl Nov):S10-S14. http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp. Accessed October 1, 2010.
 2A 3A 4A 5A 6A 7A 8A 9A
C L I N I C I A N E D U C AT O R VOLUME 4
Issue date: February 2011 • Expiration date: February 29, 2012 Participation in this activity includes reviewing the clinician educator Immune response Pathologic inflammatory
CVD Collaboration

© 2010 American College of Rheumatology. Used with permission.

OVERVIEW and completing a posttest and evaluation. For additional information, 4 Months develops response
and to obtain 0.5 CME credits for participating in this activity, please visit
10 years earlier
This pocket educator is designed to aid primary care providers (PCPs) in recognizing the RA symptom onset Primary Care Rheumatologist
Joint destruction
early signs of rheumatoid arthritis (RA) and determining when to refer a patient to a http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
t destruc 6–9�� Serious Rheumatologists: PCP: • Provisional diagnosis • Confirm diagnosis
�Osteoporosis in ti
Rheumatoid Arthritis: Primary care Initiative rheumatologist. Side A discusses the role of the PCP in the early diagnosis of RA and infection rate • Await early referral • Suspect diagnosis • Immediate referral to rheumatologist • Initiate early, aggressive DMARD

o
Jo
ACCREDITATION AND DESIGNATION • Confirm diagnosis • “Immediate” referral Lymphomas
describes how the PCP can work in tandem with the patient’s rheumatologist to effectively • Monitor for toxicities and disease therapy

n
for improved Diagnosis and outcomes This activity has been planned and implemented in accordance with the Essential Areas • Initiate DMARD/ • Baseline labs
progression • Monitor for toxicities and Genes Environment Clinical RA CVD Complications
manage this disease. Side B is designed to help patients understand RA. onset Comorbidities
and Policies of the Accreditation Council for Continuing Medical Education (ACCME). biologics treatment Bony erosions • Address CVD risk and extra- disease progression
Learning Objectives 2 Years Time
Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to 70%–80% articular issues

lity
• Identify patients who have probable early RA and should be referred to a rheumatologist PCP:

Pa
provide continuing medical education for physicians. Jefferson Medical College of Thomas Reprinted from The Lancet 373, Klareskog L et al. Rheumatoid arthritis, 659-672. Copyright 2009, with
• Employ the squeeze test to assist with diagnosis of RA Rheumatologists: • Surveillance permission from Elsevier.

bi
Jefferson University designates this enduring material for a maximum of 0.5 AMA PRA

in
3
• Order appropriate laboratory tests when RA is suspected Long-term

3
• Comorbidity
2��Rate of �Pulmonary LONG-TERM MANAGEMENT OF RA PATIENTS
13 /

a
s
Di
13 /
Category 1 Credit™. Physicians should claim only the credit commensurate with the management Squeeze test Collaboration between primary care

3 13 /
3
Intended Audience malignancy disease management
of RA

13 /
extent of their participation in the activity. CVD: Patients with RA and persistent inflammation may have additional risk for CVD

13 /
3 3
• CVD risk reduction
This tool is intended for PCPs. Long-term disability and rheumatology ensures optimal care
PROVISIONAL DIAGNOSIS OF RA
16 16 13 / 11 /
DISCLOSURE and require more aggressive cholesterol lowering

3
16
Faculty 10–20 Years 80%
Successful management of RA requires long-term team involvement. In
13 / 16 16
Clifton O. Bingham III, MD Jefferson Medical College of Thomas Jefferson University endorses the Standards of the �GI bleeding Patients who have at least 1 joint with definitive clinical synovitis (swelling) • Minimize CVD risk factors (eg, smoking, lipids, blood pressure)
the first stages, the PCP is responsible for identifying possible cases of
16 16
ACCME and the Guidelines for Commercial Support. • Maintain high index of suspicion for CVD
and in whom the synovitis is not better explained by another disease

3
Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical

16
The following individuals have declared no financial interests and/or affiliations: Swelling on the proximal interphalangeal (PIP) joints RA, providing early referral to a rheumatologist and early pain control. The Fever and infections: RA patients on steroids, methotrexate (MTX), leflunomide, or

3/
Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, should be examined for RA.
Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; biologic agents are at increased risk of serious infection
Johns Hopkins University, Baltimore, Maryland rheumatologist confirms the diagnosis and initiates DMARD therapy.
Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; RHEUMATOID ARTHRITIS FACTS RA IS A DISEASE OF THE ENTIRE BODY PRIMARY CARE: EARLY DETECTION Make the Diagnosis • Assess RA patients with fever, suspected infection

4
Joyce P. Carlone, MN, RN, FNP-BC, CCRC • Early referral to a rheumatologist is critical to early initiation of DMARD
Jonathan S. Simmons, ELS IS CRITICAL – Prompt and thorough evaluation of symptoms, antibiotics if warranted
Nurse Practitioner, Division of Rheumatology, Emory University, Atlanta, Georgia
The following individuals have declared financial interests and/or affiliations: RA is a chronic, progressive, systemic inflammatory disease Heart: Cardiovascular disease (CVD) occurs on average 10 years earlier in Does your patient have: therapy and to stop joint damage
Mary Suzanne Cleveland, JD (Patient/Patient Educator) RA patients than in the general population – Biologics may need to be held until infection is resolved
Clifton O. Bingham III, MD • Characterized by: To prevent the progressive destruction of synovial joints and improve long- 3 Swollen or tender joints • To facilitate the evaluation of the patient by the rheumatologist, it is
Senior Analyst, Kansas Health Institute, Topeka, Kansas – Prompt initiation of antibiotics (especially for patients on biologics)
Grant/Research Support: BMS, Genentech, UCB, Roche – Progressive destruction of synovial joints with bony erosions and • Accelerated atherosclerosis term outcomes, RA must be detected and treated early. – Either >1 large or ≥1 small joint of the hands or feet, or advisable to obtain: n Avoid use of trimethoprim/sulfamethoxazole in patients on MTX
Lauren G. Collins, MD Consultant: Genentech, Roche, Centocor Ortho Biotech, Merck, UCB, Flexion, Celgene
Assistant Professor of Family and Community Medicine, Jefferson Medical College of loss of cartilage Lungs: Increased risk of multiple pulmonary comorbidities • Joint damage can be rapid; without treatment, bony erosions may be – Positive squeeze test (pain when gently squeezing across the – Rheumatoid factor (RF) • If patients on immunosuppressive agents and biologics do not respond rapidly to initial
Joyce P. Carlone, MN, RN, FNP-BC, CCRC
Thomas Jefferson University, Philadelphia, Pennsylvania Consultant, Product/Speakers Bureau, Other: UCB – Symptoms usually begin in the small joints of the fingers, wrists, and • Pleuritis may occur detectable by magnetic resonance imaging (MRI) within 4 months of metacarpophalangeal/metatarsophalangeal joints) treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc)
n 30%–70% of RA patients are positive, although positive RF can • Consider septic arthritis when there is
Steering Committee David S. Kountz, MD, MBA, FACP feet • Interstitial lung diseases disease onset 3 Symptoms lasting ≥6 weeks
Michael E. Weinblatt, MD–Co-Chair Consultant: NiCox, Novartis
be caused by many conditions – Isolated monoarthritis when all other joints stable
– Swollen, tender joints are painful and difficult to move Gastrointestinal (GI): RA patients have a high incidence of GI bleeding, • Rate of x-ray progression is more rapid in the first year than in the
John R. and Eileen K. Riedman Professor of Medicine, Harvard Medical School, Michael E. Weinblatt, MD If patient has swollen joints or a positive squeeze test as above for – Anti-CCP antibody – Swelling and tenderness in a patient with total joint replacement
Co-Director, Clinical Rheumatology, Division of Rheumatology, Immunology, and Allergy, – Loss of physical function and quality of life which may be attributable to use of nonsteroidal anti-inflammatory drugs second and third n RA patients may not mount a febrile response and the white blood cell count
Grant/Research Support: Abbott n 40%–60% of RA patients are positive (may be years before
SIDE A is for clinicians Brigham and Women’s Hospital, Boston, Massachusetts (NSAIDs) and steroids during therapy • Without optimal treatment, most patients develop bony erosions ≥6 weeks, refer to a rheumatologist for provisional RA. may not be elevated in this setting
Consultant: Abbott, Centocor Ortho Biotech, Pfizer/Wyeth – Decreased work productivity and increased disability and job loss clinical manifestation)
FREE CME Lauren G. Collins, MD–Co-Chair Content Disclaimer • 1.3 million adult Americans have been diagnosed with RA Nervous system: The deformity and damage to joints in RA may lead to within 2 years, and ~80% of these patients develop long-term disability If the patient does not meet these criteria but has at least 1 swollen • Acute dyspnea and cough in a patient on MTX may represent pneumonitis
See panel 2A Clifton O. Bingham III, MD n May be detectable earlier than RF VACCINATIONS AND DMARD THERAPY
The information presented in this enduring material is for continuing medical education
• Peak age of onset: 30 to 60 years entrapment of nerves • Successful long-term management requires a partnership between or tender joint and a positive RF or anti-CCP test, he or she should
Joyce P. Carlone, MN, RN, FNP-BC, CCRC purposes only and is not meant to substitute for the independent medical judgment of a the PCP and the rheumatologist, the patient, and other health care n Extremely high specificity for RA
Mary Suzanne Cleveland, JD (Patient/Patient Educator) physician regarding diagnosis and treatment of a specific patient’s medical condition. • 2 to 4 times more common in women than men • Patient may present with carpal tunnel syndrome be referred to a rheumatologist. • Recommended before therapy begins
team members – C-reactive protein, erythrocyte sedimentation rate – Influenza and pneumococcal vaccinations
Jeanne G. Cole, MS The views or opinions expressed in the resources provided do not necessarily reflect those • RA patients 7 times as likely to have greater-than-moderate disability Osteoporosis: Generalized bone loss may result from immobility, the A rheumatologist will make a definitive diagnosis of RA based on the – Hepatitis B immunization if appropriate
Director, Office of CME, Jefferson Medical College of Thomas Jefferson University, of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson Benefits of early detection: – Complete blood count (CBC), liver function tests (LFTs)
than age- or sex-matched individuals inflammatory process, and/or treatments such as steroids following criteria: • Safe
Philadelphia, Pennsylvania Health System or staff. • Decreased RA severity, disability, and mortality with effective treat- – Optional x-rays of the hands, wrists, and feet
SIDE B is for patients Karen H. Costenbader, MD, MPH • If undertreated, life expectancy is reduced by 5 to 15 years • Periarticular demineralization may result from mediators of inflammation 1. Clinical signs and symptoms – Influenza (injection), tetanus, pneumococcus, meningococcus, hepatitis A,
This program is supported by educational grants from Abbott, Centocor Ortho Biotech Inc., and Pfizer. ments, such as disease-modifying antirheumatic drugs (DMARDs) • Monitor for alarm signs (infection, dyspnea, neck pain, rheumatoid eye hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV)
Associate Physician, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s – RA accounts for 22% of all deaths from arthritis and other Infections: RA patients have a 6- to 9-fold increase in the rate of serious 2. Pattern and numbers of joints involved
• Lower rates of RA complications disease, painful red eye) • Avoid
Hospital, Assistant Professor of Medicine, Harvard Medical School, Boston, Massachusetts rheumatic conditions infections, including tuberculosis (TB) 3. Laboratory measures (RF and anti-CCP antibody) – Live virus vaccines such as intranasal influenza, mumps/measles/rubella (MMR),
Paul P. Doghramji, MD, FAAFP • Lower rates of lower-extremity orthopedic surgical procedures • Early treatment by the PCP is intended to relieve pain and enhance
Malignancy: RA doubles the risk of some malignancies, particularly 4. Radiographic findings yellow fever, and typhoid should be avoided in patients on immunomodulators
Medical Director for Health Services at Ursinus College, Family Physician, Collegeville It is never too late to stop further damage. • Decreased cardiac risks with control of inflammation mobility
Family Practice, Collegeville, Pennsylvania You can download a free barcode lymphoma 5. Ruling out other causes of inflammatory arthritis – Wait at least 2 weeks after giving these vaccines before initiating immunomodulators
reader app for your smartphone by – NSAIDs, short course of low-dose prednisone; rarely, opioids for – Zoster vaccine, should be avoided in patients on biologic agents, but can be
Daniel Duch, PhD searching for QR CODE SCANNER QR Code
Hochberg MC, Silman AJ, Smolen JS, et al. eds. Rheumatology. 3rd ed. New York, NY: Mosby; 2003. McQueen FM, Stewart N, Crabbe J, et al. Magnetic resonance imaging of the wrist in early rheumatoid arthritis severe pain
Deane K. Managing comorbidities in RA. J Musculoskel Med. 2006;23(suppl):S24-S31. given to patients taking MTX and prednisone <20 mg/day
Medical Director, Curatio CME Institute, Exton, Pennsylvania in the iPhone App Store, Android American College of Rheumatology. Fact sheet. Available at: http://www.rheumatology.org/practice/clinical/patients/
Böttcher J, Pfeil A. Diagnosis of periarticular osteoporosis in rheumatoid arthritis using digital X-ray radiogrammetry.
reveals a high prevalence of erosions at four months after symptom onset. Ann Rheum Dis. 1998;57:350-356.
Co-sponsored by David S. Kountz, MD, MBA, FACP Market, or Blackberry App World.
diseases_and_conditions/ra.asp. Accessed October 1, 2010.
Arthritis Res Ther. 2008;10:103. Bykerk VP, Keystone EC. RA in primary care: 20 clinical pearls. J Musculoskelet Med. 2004;21:133-146. A patient who is RF and anti-CCP negative may still have RA. Deane K. J Musculoskel Med. 2006;23(suppl Nov):S24-S31. Ravikumar R, et al. Curr Rheumatol Rep.
MacLean CH, Louie R, Leake B, et al. Quality of care for patients with rheumatoid arthritis. JAMA. 2000;284:984-992. 2007;9:407-415; CDC. MMWR. 2004;53:Q1-Q4; Avery RK. Rheum Dis Clin North Am. 1999;25:567-584;
Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical
Chalmers A, et al. J Rheumatol. 1994;21:1203-1206; Harpaz R, et al. MMWR Recomm Rep. 2008;57
Center, Associate Professor of Medicine, Robert Wood Johnson Medical School, New Aletaha D, Neogi T, Silman AJ. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/ Bridges SL. Spotting aggressive RA early: the physical examination, testing, and imaging. J Musculoskelet Med. (RR-5):1-30; ACR. Herpes zoster (shingles) vaccine guidelines for immunocompromised patients. Available at:
Brunswick, New Jersey European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010 Sept; 62:2569-2581. 2006;23(suppl Nov):S10-S14. http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp. Accessed October 1, 2010.
 2A 3A 4A 5A 6A 7A 8A 9A
C L I N I C I A N E D U C AT O R VOLUME 4
Issue date: February 2011 • Expiration date: February 29, 2012 Participation in this activity includes reviewing the clinician educator Immune response Pathologic inflammatory
CVD Collaboration

© 2010 American College of Rheumatology. Used with permission.

OVERVIEW and completing a posttest and evaluation. For additional information, 4 Months develops response
and to obtain 0.5 CME credits for participating in this activity, please visit
10 years earlier
This pocket educator is designed to aid primary care providers (PCPs) in recognizing the RA symptom onset Primary Care Rheumatologist
Joint destruction
early signs of rheumatoid arthritis (RA) and determining when to refer a patient to a http://jeffline.jefferson.edu/jeffcme/RAPID or scan the QR code below.
t destruc 6–9�� Serious Rheumatologists: PCP: • Provisional diagnosis • Confirm diagnosis
�Osteoporosis in ti
Rheumatoid Arthritis: Primary care Initiative rheumatologist. Side A discusses the role of the PCP in the early diagnosis of RA and infection rate • Await early referral • Suspect diagnosis • Immediate referral to rheumatologist • Initiate early, aggressive DMARD

o
Jo
ACCREDITATION AND DESIGNATION • Confirm diagnosis • “Immediate” referral Lymphomas
describes how the PCP can work in tandem with the patient’s rheumatologist to effectively • Monitor for toxicities and disease therapy

n
for improved Diagnosis and outcomes This activity has been planned and implemented in accordance with the Essential Areas • Initiate DMARD/ • Baseline labs
progression • Monitor for toxicities and Genes Environment Clinical RA CVD Complications
manage this disease. Side B is designed to help patients understand RA. onset Comorbidities
and Policies of the Accreditation Council for Continuing Medical Education (ACCME). biologics treatment Bony erosions • Address CVD risk and extra- disease progression
Learning Objectives 2 Years Time
Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to 70%–80% articular issues

lity
• Identify patients who have probable early RA and should be referred to a rheumatologist PCP:

Pa
provide continuing medical education for physicians. Jefferson Medical College of Thomas Reprinted from The Lancet 373, Klareskog L et al. Rheumatoid arthritis, 659-672. Copyright 2009, with
• Employ the squeeze test to assist with diagnosis of RA Rheumatologists: • Surveillance permission from Elsevier.

bi
Jefferson University designates this enduring material for a maximum of 0.5 AMA PRA

in
3
• Order appropriate laboratory tests when RA is suspected Long-term

3
• Comorbidity
2��Rate of �Pulmonary LONG-TERM MANAGEMENT OF RA PATIENTS
13 /

a
s
Di
13 /
Category 1 Credit™. Physicians should claim only the credit commensurate with the management Squeeze test Collaboration between primary care

3 13 /
3
Intended Audience malignancy disease management
of RA

13 /
extent of their participation in the activity. CVD: Patients with RA and persistent inflammation may have additional risk for CVD

13 /
3 3
• CVD risk reduction
This tool is intended for PCPs. Long-term disability and rheumatology ensures optimal care
PROVISIONAL DIAGNOSIS OF RA
16 16 13 / 11 /
DISCLOSURE and require more aggressive cholesterol lowering

3
16
Faculty 10–20 Years 80%
Successful management of RA requires long-term team involvement. In
13 / 16 16
Clifton O. Bingham III, MD Jefferson Medical College of Thomas Jefferson University endorses the Standards of the �GI bleeding Patients who have at least 1 joint with definitive clinical synovitis (swelling) • Minimize CVD risk factors (eg, smoking, lipids, blood pressure)
the first stages, the PCP is responsible for identifying possible cases of
16 16
ACCME and the Guidelines for Commercial Support. • Maintain high index of suspicion for CVD
and in whom the synovitis is not better explained by another disease

3
Associate Professor of Medicine, Divisions of Rheumatology and Allergy and Clinical

16
The following individuals have declared no financial interests and/or affiliations: Swelling on the proximal interphalangeal (PIP) joints RA, providing early referral to a rheumatologist and early pain control. The Fever and infections: RA patients on steroids, methotrexate (MTX), leflunomide, or

3/
Rheumatology, Director, Johns Hopkins Arthritis Center, Director, Rheumatology Clinics, should be examined for RA.
Mary Suzanne Cleveland, JD; Jeanne G. Cole, MS; Lauren G. Collins, MD; biologic agents are at increased risk of serious infection
Johns Hopkins University, Baltimore, Maryland rheumatologist confirms the diagnosis and initiates DMARD therapy.
Karen H. Costenbader, MD, MPH; Paul P. Doghramji, MD, FAAFP; Daniel Duch, PhD; RHEUMATOID ARTHRITIS FACTS RA IS A DISEASE OF THE ENTIRE BODY PRIMARY CARE: EARLY DETECTION Make the Diagnosis • Assess RA patients with fever, suspected infection

4
Joyce P. Carlone, MN, RN, FNP-BC, CCRC • Early referral to a rheumatologist is critical to early initiation of DMARD
Jonathan S. Simmons, ELS IS CRITICAL – Prompt and thorough evaluation of symptoms, antibiotics if warranted
Nurse Practitioner, Division of Rheumatology, Emory University, Atlanta, Georgia
The following individuals have declared financial interests and/or affiliations: RA is a chronic, progressive, systemic inflammatory disease Heart: Cardiovascular disease (CVD) occurs on average 10 years earlier in Does your patient have: therapy and to stop joint damage
Mary Suzanne Cleveland, JD (Patient/Patient Educator) RA patients than in the general population – Biologics may need to be held until infection is resolved
Clifton O. Bingham III, MD • Characterized by: To prevent the progressive destruction of synovial joints and improve long- 3 Swollen or tender joints • To facilitate the evaluation of the patient by the rheumatologist, it is
Senior Analyst, Kansas Health Institute, Topeka, Kansas – Prompt initiation of antibiotics (especially for patients on biologics)
Grant/Research Support: BMS, Genentech, UCB, Roche – Progressive destruction of synovial joints with bony erosions and • Accelerated atherosclerosis term outcomes, RA must be detected and treated early. – Either >1 large or ≥1 small joint of the hands or feet, or advisable to obtain: n Avoid use of trimethoprim/sulfamethoxazole in patients on MTX
Lauren G. Collins, MD Consultant: Genentech, Roche, Centocor Ortho Biotech, Merck, UCB, Flexion, Celgene
Assistant Professor of Family and Community Medicine, Jefferson Medical College of loss of cartilage Lungs: Increased risk of multiple pulmonary comorbidities • Joint damage can be rapid; without treatment, bony erosions may be – Positive squeeze test (pain when gently squeezing across the – Rheumatoid factor (RF) • If patients on immunosuppressive agents and biologics do not respond rapidly to initial
Joyce P. Carlone, MN, RN, FNP-BC, CCRC
Thomas Jefferson University, Philadelphia, Pennsylvania Consultant, Product/Speakers Bureau, Other: UCB – Symptoms usually begin in the small joints of the fingers, wrists, and • Pleuritis may occur detectable by magnetic resonance imaging (MRI) within 4 months of metacarpophalangeal/metatarsophalangeal joints) treatment, consider atypical infections (TB, histoplasmosis, coccidioidomycosis, etc)
n 30%–70% of RA patients are positive, although positive RF can • Consider septic arthritis when there is
Steering Committee David S. Kountz, MD, MBA, FACP feet • Interstitial lung diseases disease onset 3 Symptoms lasting ≥6 weeks
Michael E. Weinblatt, MD–Co-Chair Consultant: NiCox, Novartis
be caused by many conditions – Isolated monoarthritis when all other joints stable
– Swollen, tender joints are painful and difficult to move Gastrointestinal (GI): RA patients have a high incidence of GI bleeding, • Rate of x-ray progression is more rapid in the first year than in the
John R. and Eileen K. Riedman Professor of Medicine, Harvard Medical School, Michael E. Weinblatt, MD If patient has swollen joints or a positive squeeze test as above for – Anti-CCP antibody – Swelling and tenderness in a patient with total joint replacement
Co-Director, Clinical Rheumatology, Division of Rheumatology, Immunology, and Allergy, – Loss of physical function and quality of life which may be attributable to use of nonsteroidal anti-inflammatory drugs second and third n RA patients may not mount a febrile response and the white blood cell count
Grant/Research Support: Abbott n 40%–60% of RA patients are positive (may be years before
SIDE A is for clinicians Brigham and Women’s Hospital, Boston, Massachusetts (NSAIDs) and steroids during therapy • Without optimal treatment, most patients develop bony erosions ≥6 weeks, refer to a rheumatologist for provisional RA. may not be elevated in this setting
Consultant: Abbott, Centocor Ortho Biotech, Pfizer/Wyeth – Decreased work productivity and increased disability and job loss clinical manifestation)
FREE CME Lauren G. Collins, MD–Co-Chair Content Disclaimer • 1.3 million adult Americans have been diagnosed with RA Nervous system: The deformity and damage to joints in RA may lead to within 2 years, and ~80% of these patients develop long-term disability If the patient does not meet these criteria but has at least 1 swollen • Acute dyspnea and cough in a patient on MTX may represent pneumonitis
See panel 2A Clifton O. Bingham III, MD n May be detectable earlier than RF VACCINATIONS AND DMARD THERAPY
The information presented in this enduring material is for continuing medical education
• Peak age of onset: 30 to 60 years entrapment of nerves • Successful long-term management requires a partnership between or tender joint and a positive RF or anti-CCP test, he or she should
Joyce P. Carlone, MN, RN, FNP-BC, CCRC purposes only and is not meant to substitute for the independent medical judgment of a the PCP and the rheumatologist, the patient, and other health care n Extremely high specificity for RA
Mary Suzanne Cleveland, JD (Patient/Patient Educator) physician regarding diagnosis and treatment of a specific patient’s medical condition. • 2 to 4 times more common in women than men • Patient may present with carpal tunnel syndrome be referred to a rheumatologist. • Recommended before therapy begins
team members – C-reactive protein, erythrocyte sedimentation rate – Influenza and pneumococcal vaccinations
Jeanne G. Cole, MS The views or opinions expressed in the resources provided do not necessarily reflect those • RA patients 7 times as likely to have greater-than-moderate disability Osteoporosis: Generalized bone loss may result from immobility, the A rheumatologist will make a definitive diagnosis of RA based on the – Hepatitis B immunization if appropriate
Director, Office of CME, Jefferson Medical College of Thomas Jefferson University, of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson Benefits of early detection: – Complete blood count (CBC), liver function tests (LFTs)
than age- or sex-matched individuals inflammatory process, and/or treatments such as steroids following criteria: • Safe
Philadelphia, Pennsylvania Health System or staff. • Decreased RA severity, disability, and mortality with effective treat- – Optional x-rays of the hands, wrists, and feet
SIDE B is for patients Karen H. Costenbader, MD, MPH • If undertreated, life expectancy is reduced by 5 to 15 years • Periarticular demineralization may result from mediators of inflammation 1. Clinical signs and symptoms – Influenza (injection), tetanus, pneumococcus, meningococcus, hepatitis A,
This program is supported by educational grants from Abbott, Centocor Ortho Biotech Inc., and Pfizer. ments, such as disease-modifying antirheumatic drugs (DMARDs) • Monitor for alarm signs (infection, dyspnea, neck pain, rheumatoid eye hepatitis B, Haemophilus influenzae B (HiB), human papillomavirus (HPV)
Associate Physician, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s – RA accounts for 22% of all deaths from arthritis and other Infections: RA patients have a 6- to 9-fold increase in the rate of serious 2. Pattern and numbers of joints involved
• Lower rates of RA complications disease, painful red eye) • Avoid
Hospital, Assistant Professor of Medicine, Harvard Medical School, Boston, Massachusetts rheumatic conditions infections, including tuberculosis (TB) 3. Laboratory measures (RF and anti-CCP antibody) – Live virus vaccines such as intranasal influenza, mumps/measles/rubella (MMR),
Paul P. Doghramji, MD, FAAFP • Lower rates of lower-extremity orthopedic surgical procedures • Early treatment by the PCP is intended to relieve pain and enhance
Malignancy: RA doubles the risk of some malignancies, particularly 4. Radiographic findings yellow fever, and typhoid should be avoided in patients on immunomodulators
Medical Director for Health Services at Ursinus College, Family Physician, Collegeville It is never too late to stop further damage. • Decreased cardiac risks with control of inflammation mobility
Family Practice, Collegeville, Pennsylvania You can download a free barcode lymphoma 5. Ruling out other causes of inflammatory arthritis – Wait at least 2 weeks after giving these vaccines before initiating immunomodulators
reader app for your smartphone by – NSAIDs, short course of low-dose prednisone; rarely, opioids for – Zoster vaccine, should be avoided in patients on biologic agents, but can be
Daniel Duch, PhD searching for QR CODE SCANNER QR Code
Hochberg MC, Silman AJ, Smolen JS, et al. eds. Rheumatology. 3rd ed. New York, NY: Mosby; 2003. McQueen FM, Stewart N, Crabbe J, et al. Magnetic resonance imaging of the wrist in early rheumatoid arthritis severe pain
Deane K. Managing comorbidities in RA. J Musculoskel Med. 2006;23(suppl):S24-S31. given to patients taking MTX and prednisone <20 mg/day
Medical Director, Curatio CME Institute, Exton, Pennsylvania in the iPhone App Store, Android American College of Rheumatology. Fact sheet. Available at: http://www.rheumatology.org/practice/clinical/patients/
Böttcher J, Pfeil A. Diagnosis of periarticular osteoporosis in rheumatoid arthritis using digital X-ray radiogrammetry.
reveals a high prevalence of erosions at four months after symptom onset. Ann Rheum Dis. 1998;57:350-356.
Co-sponsored by David S. Kountz, MD, MBA, FACP Market, or Blackberry App World.
diseases_and_conditions/ra.asp. Accessed October 1, 2010.
Arthritis Res Ther. 2008;10:103. Bykerk VP, Keystone EC. RA in primary care: 20 clinical pearls. J Musculoskelet Med. 2004;21:133-146. A patient who is RF and anti-CCP negative may still have RA. Deane K. J Musculoskel Med. 2006;23(suppl Nov):S24-S31. Ravikumar R, et al. Curr Rheumatol Rep.
MacLean CH, Louie R, Leake B, et al. Quality of care for patients with rheumatoid arthritis. JAMA. 2000;284:984-992. 2007;9:407-415; CDC. MMWR. 2004;53:Q1-Q4; Avery RK. Rheum Dis Clin North Am. 1999;25:567-584;
Senior Vice President, Medical and Academic Affairs, Jersey Shore University Medical
Chalmers A, et al. J Rheumatol. 1994;21:1203-1206; Harpaz R, et al. MMWR Recomm Rep. 2008;57
Center, Associate Professor of Medicine, Robert Wood Johnson Medical School, New Aletaha D, Neogi T, Silman AJ. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/ Bridges SL. Spotting aggressive RA early: the physical examination, testing, and imaging. J Musculoskelet Med. (RR-5):1-30; ACR. Herpes zoster (shingles) vaccine guidelines for immunocompromised patients. Available at:
Brunswick, New Jersey European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010 Sept; 62:2569-2581. 2006;23(suppl Nov):S10-S14. http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp. Accessed October 1, 2010.
 1B 2B 3B 4B 5B 6B 7B 8B

Are other parts of the body affected besides the joints? Healthy joint Damaged joint ALSO AVAILABLE
Treatment With Disease-Modifiying Antirheumatic Drugs
(DMARDs) Improves Long-Term Outcomes An interactive version of this Rheumatoid Arthritis: Primary care

Unable
Destruction

to do
of cartilage 70 Initiative for improved Diagnosis and outcomes (RAPID) clinician
Without DMARDs, problems
Joints affected: Other organs that may increase rapidly
educator is now available as an iPhone app. The enhanced app
60
version includes the following features:

Medical Illustration Copyright© 2010 Nucleus Medical Media,

Jaw be affected if RA is

difficulty
50

much
Disease Progress

With
not treated early: • Video demonstration of the squeeze test and provisional RA
40
Eyes: dryness and diagnosis

Self-Report Questionnaire for Rheumatoid Arthritis

3

All rights reserved. www.nucleusinc.com

3
Shoulder
31
3
30

31
damage to delicate With DMARDs, • Video discussion of patient point of view towards primary care

3
31
3

Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
/

difficulty
31 / 31
3 3
/
fewer problems

some
20 providers and the need for early diagnosis

With
structures
61
Wrist, hand,
11 31 / 61 /
3
/
fingers
/ Lungs: much greater
61
10
61 What happens 6 1 31
• Video discussion of recommended vaccinations for RA patients

61 61 /
3
risk of getting serious Cutaway view I have some pain in my joints. next? and the presence of comorbid conditions
61
0

3
Elbow

difficulty
Without
Target cell 0 1 2 3 4 5 How can I tell if I have RA?
/
infections and other • If your health care provider thinks you may have RA, he

any
Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical
Years of Disease
4
features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
complications What happens when RA • If you think you may have RA, you need to tell your health care The free iPhone app is available in either of the following ways:
What is rheumatoid arthritis (RA)? Spine Immune cell or she will prescribe medication to reduce the pain and
causes an autoimmune response? provider. He or she will examine you and ask the following
Heart disease: may inflammation in the joints. He or she will also refer you to a • Download the app at http://www.curatiocme.com/RAPID/iphone
• RA is a chronic condition that damages the joints of the When an immune response is triggered, inflammation occurs questions:

1. Dressing yourself, including tying shoelaces and doing buttons?

Hip occur about 10 years How can RA be controlled? rheumatologist, which is a doctor who specializes in RA and • Using the camera on your iPhone, scan the QR code below
body. Chronic conditions are long lasting (greater than 3 in the areas that are attacked by the immune system. – What hurts as you get out of bed in the morning?

If we asked someone who spends a good deal of time with

sooner than in people There has been great improvement in the drugs used to treat RA. related diseases.
months) and do not go away easily or quickly. RA affects – How long does it take to feel as limber as you’re going to
without RA • Inflammation causes redness and warmth, swelling, • The rheumatologist will confirm the diagnosis of RA and

Please check (3) the ONE best answer for your abilities.
women more than twice as much as men. Although it may • A class of drugs referred to as “DMARDs” acts to slow or feel for the day?
What causes RA? stiffness, and pain in the affected joints prescribe appropriate medication to slow or stop the

Share your answers with your primary care provider.

stop the progression of RA to more advanced stages of the – When is your pain the worst (AM or PM)?

6. Bending down to pick up clothing from the floor?

occur at any age, it usually starts in patients when they Stomach: high risk

you, would they say that you have difficulty with:

are between 30 and 60 years old. RA causes continuing of bleeding • It is not known what causes RA, but it is an autoimmune • If the autoimmune response is not slowed or stopped, it can disease – Do any members of your family have RA? autoimmune process and joint damage.
disease. This means that the body attacks itself permanently damage the affected joints and other tissues – Is it difficult for you to:

7. Turning regular faucets (taps) on and off?

joint damage and associated conditions for many patients. • Depending on the extent of injury caused by RA, you may be

3. Lifting a full cup or glass to your mouth?

Double the risk of • If you look at the graph above, you will see that when a n Turn faucet handles?

5. Washing and drying your entire body?

To reduce complications, RA should be diagnosed and • The body’s immune system fights off infections caused by over time DMARD is not used (the red line), the problems caused by

referred to a physical or occupational therapist, a podiatrist,
Knee some types of cancer, n Hold a hairbrush/toothbrush?

4. Walking outdoors on flat ground?

treated early and optimally managed throughout life. invading bacteria and viruses Can RA be prevented? RA increase rapidly, especially in the first 2 years or other specialists, such as an orthopedic surgeon.
so increased screening n Dress/bathe independently?

What are the symptoms? • In autoimmune diseases like RA, the body responds as if its Rheumatoid Arthritis

8. Getting in and out of a car?

is advisable Because we do not know why RA happens, there is no known • However, when treated with DMARDs (the blue line), the n Fix your own breakfast?

2. Getting in and out of bed?

Early signs of RA include: normal cells are foreign cells and attacks them way to prevent the disease. However, early diagnosis and disease progresses much more slowly, and fewer problems n Walk outdoors on flat ground? Resources and Information
• Swelling, stiffness, aching, or pain in one or more joints • Genetics may play a part in the development of RA, but early treatment are the best ways to fight RA. occur – How is your energy level? The American College of Rheumatology
Early diagnosis – Do you smoke?
• Morning stiffness that lasts for at least 30 minutes and many people who get RA do not have any relatives with the • Treatment is first focused on reducing inflammation and http://www.rheumatology.org/
and treatment • DMARDs such as methotrexate, hydroxychloroquine, – Signs that may suggest other reasons for your pain:
often for several hours condition relieving pain The Arthritis Foundation
may prevent these sulfasalazine, or biologic DMARDs are most often used to n Fever n Night sweats
http://www.arthritis.org/

• Difficulty grasping objects as strongly as you used to Ankle, foot, toes complications. • When a diagnosis of RA is confirmed, treatment also aims at control RA n Unexpected weight loss n Rash, tick exposure

RA commonly affects the small joints of the fingers, wrists, and n Recent contact with sick children
The National Library of Medicine/Medline Plus
stopping or slowing joint damage and damage to other parts
http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
feet, but it may also affect other joints as the disease progresses, of the body You may also fill out the questionnaire on panel 8B, which will
including the ankles, knees, hips, elbows, and shoulders. help identify the cause of your discomfort.
 1B 2B 3B 4B 5B 6B 7B 8B

Are other parts of the body affected besides the joints? Healthy joint Damaged joint ALSO AVAILABLE
Treatment With Disease-Modifiying Antirheumatic Drugs
(DMARDs) Improves Long-Term Outcomes An interactive version of this Rheumatoid Arthritis: Primary care

Unable
Destruction

to do
of cartilage 70 Initiative for improved Diagnosis and outcomes (RAPID) clinician
Without DMARDs, problems
Joints affected: Other organs that may increase rapidly
educator is now available as an iPhone app. The enhanced app
60
version includes the following features:

Medical Illustration Copyright© 2010 Nucleus Medical Media,

Jaw be affected if RA is

difficulty
50

much
Disease Progress

With
not treated early: • Video demonstration of the squeeze test and provisional RA
40
Eyes: dryness and diagnosis

Self-Report Questionnaire for Rheumatoid Arthritis

3

All rights reserved. www.nucleusinc.com

3
Shoulder
31
3
30

31
damage to delicate With DMARDs, • Video discussion of patient point of view towards primary care

3
31
3

Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
/

difficulty
31 / 31
3 3
/
fewer problems

some
20 providers and the need for early diagnosis

With
structures
61
Wrist, hand,
11 31 / 61 /
3
/
fingers
/ Lungs: much greater
61
10
61 What happens 6 1 31
• Video discussion of recommended vaccinations for RA patients

61 61 /
3
risk of getting serious Cutaway view I have some pain in my joints. next? and the presence of comorbid conditions
61
0

3
Elbow

difficulty
Without
Target cell 0 1 2 3 4 5 How can I tell if I have RA?
/
infections and other • If your health care provider thinks you may have RA, he

any
Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical
Years of Disease
4
features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
complications What happens when RA • If you think you may have RA, you need to tell your health care The free iPhone app is available in either of the following ways:
What is rheumatoid arthritis (RA)? Spine Immune cell or she will prescribe medication to reduce the pain and
causes an autoimmune response? provider. He or she will examine you and ask the following
Heart disease: may inflammation in the joints. He or she will also refer you to a • Download the app at http://www.curatiocme.com/RAPID/iphone
• RA is a chronic condition that damages the joints of the When an immune response is triggered, inflammation occurs questions:

1. Dressing yourself, including tying shoelaces and doing buttons?

Hip occur about 10 years How can RA be controlled? rheumatologist, which is a doctor who specializes in RA and • Using the camera on your iPhone, scan the QR code below
body. Chronic conditions are long lasting (greater than 3 in the areas that are attacked by the immune system. – What hurts as you get out of bed in the morning?

If we asked someone who spends a good deal of time with

sooner than in people There has been great improvement in the drugs used to treat RA. related diseases.
months) and do not go away easily or quickly. RA affects – How long does it take to feel as limber as you’re going to
without RA • Inflammation causes redness and warmth, swelling, • The rheumatologist will confirm the diagnosis of RA and

Please check (3) the ONE best answer for your abilities.
women more than twice as much as men. Although it may • A class of drugs referred to as “DMARDs” acts to slow or feel for the day?
What causes RA? stiffness, and pain in the affected joints prescribe appropriate medication to slow or stop the

Share your answers with your primary care provider.

stop the progression of RA to more advanced stages of the – When is your pain the worst (AM or PM)?

6. Bending down to pick up clothing from the floor?

occur at any age, it usually starts in patients when they Stomach: high risk

you, would they say that you have difficulty with:

are between 30 and 60 years old. RA causes continuing of bleeding • It is not known what causes RA, but it is an autoimmune • If the autoimmune response is not slowed or stopped, it can disease – Do any members of your family have RA? autoimmune process and joint damage.
disease. This means that the body attacks itself permanently damage the affected joints and other tissues – Is it difficult for you to:

7. Turning regular faucets (taps) on and off?

joint damage and associated conditions for many patients. • Depending on the extent of injury caused by RA, you may be

3. Lifting a full cup or glass to your mouth?

Double the risk of • If you look at the graph above, you will see that when a n Turn faucet handles?

5. Washing and drying your entire body?

To reduce complications, RA should be diagnosed and • The body’s immune system fights off infections caused by over time DMARD is not used (the red line), the problems caused by

referred to a physical or occupational therapist, a podiatrist,
Knee some types of cancer, n Hold a hairbrush/toothbrush?

4. Walking outdoors on flat ground?

treated early and optimally managed throughout life. invading bacteria and viruses Can RA be prevented? RA increase rapidly, especially in the first 2 years or other specialists, such as an orthopedic surgeon.
so increased screening n Dress/bathe independently?

What are the symptoms? • In autoimmune diseases like RA, the body responds as if its Rheumatoid Arthritis

8. Getting in and out of a car?

is advisable Because we do not know why RA happens, there is no known • However, when treated with DMARDs (the blue line), the n Fix your own breakfast?

2. Getting in and out of bed?

Early signs of RA include: normal cells are foreign cells and attacks them way to prevent the disease. However, early diagnosis and disease progresses much more slowly, and fewer problems n Walk outdoors on flat ground? Resources and Information
• Swelling, stiffness, aching, or pain in one or more joints • Genetics may play a part in the development of RA, but early treatment are the best ways to fight RA. occur – How is your energy level? The American College of Rheumatology
Early diagnosis – Do you smoke?
• Morning stiffness that lasts for at least 30 minutes and many people who get RA do not have any relatives with the • Treatment is first focused on reducing inflammation and http://www.rheumatology.org/
and treatment • DMARDs such as methotrexate, hydroxychloroquine, – Signs that may suggest other reasons for your pain:
often for several hours condition relieving pain The Arthritis Foundation
may prevent these sulfasalazine, or biologic DMARDs are most often used to n Fever n Night sweats
http://www.arthritis.org/

• Difficulty grasping objects as strongly as you used to Ankle, foot, toes complications. • When a diagnosis of RA is confirmed, treatment also aims at control RA n Unexpected weight loss n Rash, tick exposure

RA commonly affects the small joints of the fingers, wrists, and n Recent contact with sick children
The National Library of Medicine/Medline Plus
stopping or slowing joint damage and damage to other parts
http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
feet, but it may also affect other joints as the disease progresses, of the body You may also fill out the questionnaire on panel 8B, which will
including the ankles, knees, hips, elbows, and shoulders. help identify the cause of your discomfort.
 1B 2B 3B 4B 5B 6B 7B 8B

Are other parts of the body affected besides the joints? Healthy joint Damaged joint ALSO AVAILABLE
Treatment With Disease-Modifiying Antirheumatic Drugs
(DMARDs) Improves Long-Term Outcomes An interactive version of this Rheumatoid Arthritis: Primary care

Unable
Destruction

to do
of cartilage 70 Initiative for improved Diagnosis and outcomes (RAPID) clinician
Without DMARDs, problems
Joints affected: Other organs that may increase rapidly
educator is now available as an iPhone app. The enhanced app
60
version includes the following features:

Medical Illustration Copyright© 2010 Nucleus Medical Media,

Jaw be affected if RA is

difficulty
50

much
Disease Progress

With
not treated early: • Video demonstration of the squeeze test and provisional RA
40
Eyes: dryness and diagnosis

Self-Report Questionnaire for Rheumatoid Arthritis

3

All rights reserved. www.nucleusinc.com

3
Shoulder
31
3
30

31
damage to delicate With DMARDs, • Video discussion of patient point of view towards primary care

3
31
3

Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
/

difficulty
31 / 31
3 3
/
fewer problems

some
20 providers and the need for early diagnosis

With
structures
61
Wrist, hand,
11 31 / 61 /
3
/
fingers
/ Lungs: much greater
61
10
61 What happens 6 1 31
• Video discussion of recommended vaccinations for RA patients

61 61 /
3
risk of getting serious Cutaway view I have some pain in my joints. next? and the presence of comorbid conditions
61
0

3
Elbow

difficulty
Without
Target cell 0 1 2 3 4 5 How can I tell if I have RA?
/
infections and other • If your health care provider thinks you may have RA, he

any
Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical
Years of Disease
4
features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
complications What happens when RA • If you think you may have RA, you need to tell your health care The free iPhone app is available in either of the following ways:
What is rheumatoid arthritis (RA)? Spine Immune cell or she will prescribe medication to reduce the pain and
causes an autoimmune response? provider. He or she will examine you and ask the following
Heart disease: may inflammation in the joints. He or she will also refer you to a • Download the app at http://www.curatiocme.com/RAPID/iphone
• RA is a chronic condition that damages the joints of the When an immune response is triggered, inflammation occurs questions:

1. Dressing yourself, including tying shoelaces and doing buttons?

Hip occur about 10 years How can RA be controlled? rheumatologist, which is a doctor who specializes in RA and • Using the camera on your iPhone, scan the QR code below
body. Chronic conditions are long lasting (greater than 3 in the areas that are attacked by the immune system. – What hurts as you get out of bed in the morning?

If we asked someone who spends a good deal of time with

sooner than in people There has been great improvement in the drugs used to treat RA. related diseases.
months) and do not go away easily or quickly. RA affects – How long does it take to feel as limber as you’re going to
without RA • Inflammation causes redness and warmth, swelling, • The rheumatologist will confirm the diagnosis of RA and

Please check (3) the ONE best answer for your abilities.
women more than twice as much as men. Although it may • A class of drugs referred to as “DMARDs” acts to slow or feel for the day?
What causes RA? stiffness, and pain in the affected joints prescribe appropriate medication to slow or stop the

Share your answers with your primary care provider.

stop the progression of RA to more advanced stages of the – When is your pain the worst (AM or PM)?

6. Bending down to pick up clothing from the floor?

occur at any age, it usually starts in patients when they Stomach: high risk

you, would they say that you have difficulty with:

are between 30 and 60 years old. RA causes continuing of bleeding • It is not known what causes RA, but it is an autoimmune • If the autoimmune response is not slowed or stopped, it can disease – Do any members of your family have RA? autoimmune process and joint damage.
disease. This means that the body attacks itself permanently damage the affected joints and other tissues – Is it difficult for you to:

7. Turning regular faucets (taps) on and off?

joint damage and associated conditions for many patients. • Depending on the extent of injury caused by RA, you may be

3. Lifting a full cup or glass to your mouth?

Double the risk of • If you look at the graph above, you will see that when a n Turn faucet handles?

5. Washing and drying your entire body?

To reduce complications, RA should be diagnosed and • The body’s immune system fights off infections caused by over time DMARD is not used (the red line), the problems caused by

referred to a physical or occupational therapist, a podiatrist,
Knee some types of cancer, n Hold a hairbrush/toothbrush?

4. Walking outdoors on flat ground?

treated early and optimally managed throughout life. invading bacteria and viruses Can RA be prevented? RA increase rapidly, especially in the first 2 years or other specialists, such as an orthopedic surgeon.
so increased screening n Dress/bathe independently?

What are the symptoms? • In autoimmune diseases like RA, the body responds as if its Rheumatoid Arthritis

8. Getting in and out of a car?

is advisable Because we do not know why RA happens, there is no known • However, when treated with DMARDs (the blue line), the n Fix your own breakfast?

2. Getting in and out of bed?

Early signs of RA include: normal cells are foreign cells and attacks them way to prevent the disease. However, early diagnosis and disease progresses much more slowly, and fewer problems n Walk outdoors on flat ground? Resources and Information
• Swelling, stiffness, aching, or pain in one or more joints • Genetics may play a part in the development of RA, but early treatment are the best ways to fight RA. occur – How is your energy level? The American College of Rheumatology
Early diagnosis – Do you smoke?
• Morning stiffness that lasts for at least 30 minutes and many people who get RA do not have any relatives with the • Treatment is first focused on reducing inflammation and http://www.rheumatology.org/
and treatment • DMARDs such as methotrexate, hydroxychloroquine, – Signs that may suggest other reasons for your pain:
often for several hours condition relieving pain The Arthritis Foundation
may prevent these sulfasalazine, or biologic DMARDs are most often used to n Fever n Night sweats
http://www.arthritis.org/

• Difficulty grasping objects as strongly as you used to Ankle, foot, toes complications. • When a diagnosis of RA is confirmed, treatment also aims at control RA n Unexpected weight loss n Rash, tick exposure

RA commonly affects the small joints of the fingers, wrists, and n Recent contact with sick children
The National Library of Medicine/Medline Plus
stopping or slowing joint damage and damage to other parts
http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
feet, but it may also affect other joints as the disease progresses, of the body You may also fill out the questionnaire on panel 8B, which will
including the ankles, knees, hips, elbows, and shoulders. help identify the cause of your discomfort.
 1B 2B 3B 4B 5B 6B 7B 8B

Are other parts of the body affected besides the joints? Healthy joint Damaged joint ALSO AVAILABLE
Treatment With Disease-Modifiying Antirheumatic Drugs
(DMARDs) Improves Long-Term Outcomes An interactive version of this Rheumatoid Arthritis: Primary care

Unable
Destruction

to do
of cartilage 70 Initiative for improved Diagnosis and outcomes (RAPID) clinician
Without DMARDs, problems
Joints affected: Other organs that may increase rapidly
educator is now available as an iPhone app. The enhanced app
60
version includes the following features:

Medical Illustration Copyright© 2010 Nucleus Medical Media,

Jaw be affected if RA is

difficulty
50

much
Disease Progress

With
not treated early: • Video demonstration of the squeeze test and provisional RA
40
Eyes: dryness and diagnosis

Self-Report Questionnaire for Rheumatoid Arthritis

3

All rights reserved. www.nucleusinc.com

3
Shoulder
31
3
30

31
damage to delicate With DMARDs, • Video discussion of patient point of view towards primary care

3
31
3

Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
/

difficulty
31 / 31
3 3
/
fewer problems

some
20 providers and the need for early diagnosis

With
structures
61
Wrist, hand,
11 31 / 61 /
3
/
fingers
/ Lungs: much greater
61
10
61 What happens 6 1 31
• Video discussion of recommended vaccinations for RA patients

61 61 /
3
risk of getting serious Cutaway view I have some pain in my joints. next? and the presence of comorbid conditions
61
0

3
Elbow

difficulty
Without
Target cell 0 1 2 3 4 5 How can I tell if I have RA?
/
infections and other • If your health care provider thinks you may have RA, he

any
Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical
Years of Disease
4
features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
complications What happens when RA • If you think you may have RA, you need to tell your health care The free iPhone app is available in either of the following ways:
What is rheumatoid arthritis (RA)? Spine Immune cell or she will prescribe medication to reduce the pain and
causes an autoimmune response? provider. He or she will examine you and ask the following
Heart disease: may inflammation in the joints. He or she will also refer you to a • Download the app at http://www.curatiocme.com/RAPID/iphone
• RA is a chronic condition that damages the joints of the When an immune response is triggered, inflammation occurs questions:

1. Dressing yourself, including tying shoelaces and doing buttons?

Hip occur about 10 years How can RA be controlled? rheumatologist, which is a doctor who specializes in RA and • Using the camera on your iPhone, scan the QR code below
body. Chronic conditions are long lasting (greater than 3 in the areas that are attacked by the immune system. – What hurts as you get out of bed in the morning?

If we asked someone who spends a good deal of time with

sooner than in people There has been great improvement in the drugs used to treat RA. related diseases.
months) and do not go away easily or quickly. RA affects – How long does it take to feel as limber as you’re going to
without RA • Inflammation causes redness and warmth, swelling, • The rheumatologist will confirm the diagnosis of RA and

Please check (3) the ONE best answer for your abilities.
women more than twice as much as men. Although it may • A class of drugs referred to as “DMARDs” acts to slow or feel for the day?
What causes RA? stiffness, and pain in the affected joints prescribe appropriate medication to slow or stop the

Share your answers with your primary care provider.

stop the progression of RA to more advanced stages of the – When is your pain the worst (AM or PM)?

6. Bending down to pick up clothing from the floor?

occur at any age, it usually starts in patients when they Stomach: high risk

you, would they say that you have difficulty with:

are between 30 and 60 years old. RA causes continuing of bleeding • It is not known what causes RA, but it is an autoimmune • If the autoimmune response is not slowed or stopped, it can disease – Do any members of your family have RA? autoimmune process and joint damage.
disease. This means that the body attacks itself permanently damage the affected joints and other tissues – Is it difficult for you to:

7. Turning regular faucets (taps) on and off?

joint damage and associated conditions for many patients. • Depending on the extent of injury caused by RA, you may be

3. Lifting a full cup or glass to your mouth?

Double the risk of • If you look at the graph above, you will see that when a n Turn faucet handles?

5. Washing and drying your entire body?

To reduce complications, RA should be diagnosed and • The body’s immune system fights off infections caused by over time DMARD is not used (the red line), the problems caused by

referred to a physical or occupational therapist, a podiatrist,
Knee some types of cancer, n Hold a hairbrush/toothbrush?

4. Walking outdoors on flat ground?

treated early and optimally managed throughout life. invading bacteria and viruses Can RA be prevented? RA increase rapidly, especially in the first 2 years or other specialists, such as an orthopedic surgeon.
so increased screening n Dress/bathe independently?

What are the symptoms? • In autoimmune diseases like RA, the body responds as if its Rheumatoid Arthritis

8. Getting in and out of a car?

is advisable Because we do not know why RA happens, there is no known • However, when treated with DMARDs (the blue line), the n Fix your own breakfast?

2. Getting in and out of bed?

Early signs of RA include: normal cells are foreign cells and attacks them way to prevent the disease. However, early diagnosis and disease progresses much more slowly, and fewer problems n Walk outdoors on flat ground? Resources and Information
• Swelling, stiffness, aching, or pain in one or more joints • Genetics may play a part in the development of RA, but early treatment are the best ways to fight RA. occur – How is your energy level? The American College of Rheumatology
Early diagnosis – Do you smoke?
• Morning stiffness that lasts for at least 30 minutes and many people who get RA do not have any relatives with the • Treatment is first focused on reducing inflammation and http://www.rheumatology.org/
and treatment • DMARDs such as methotrexate, hydroxychloroquine, – Signs that may suggest other reasons for your pain:
often for several hours condition relieving pain The Arthritis Foundation
may prevent these sulfasalazine, or biologic DMARDs are most often used to n Fever n Night sweats
http://www.arthritis.org/

• Difficulty grasping objects as strongly as you used to Ankle, foot, toes complications. • When a diagnosis of RA is confirmed, treatment also aims at control RA n Unexpected weight loss n Rash, tick exposure

RA commonly affects the small joints of the fingers, wrists, and n Recent contact with sick children
The National Library of Medicine/Medline Plus
stopping or slowing joint damage and damage to other parts
http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
feet, but it may also affect other joints as the disease progresses, of the body You may also fill out the questionnaire on panel 8B, which will
including the ankles, knees, hips, elbows, and shoulders. help identify the cause of your discomfort.
 1B 2B 3B 4B 5B 6B 7B 8B

Are other parts of the body affected besides the joints? Healthy joint Damaged joint ALSO AVAILABLE
Treatment With Disease-Modifiying Antirheumatic Drugs
(DMARDs) Improves Long-Term Outcomes An interactive version of this Rheumatoid Arthritis: Primary care

Unable
Destruction

to do
of cartilage 70 Initiative for improved Diagnosis and outcomes (RAPID) clinician
Without DMARDs, problems
Joints affected: Other organs that may increase rapidly
educator is now available as an iPhone app. The enhanced app
60
version includes the following features:

Medical Illustration Copyright© 2010 Nucleus Medical Media,

Jaw be affected if RA is

difficulty
50

much
Disease Progress

With
not treated early: • Video demonstration of the squeeze test and provisional RA
40
Eyes: dryness and diagnosis

Self-Report Questionnaire for Rheumatoid Arthritis

3

All rights reserved. www.nucleusinc.com

3
Shoulder
31
3
30

31
damage to delicate With DMARDs, • Video discussion of patient point of view towards primary care

3
31
3

Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
/

difficulty
31 / 31
3 3
/
fewer problems

some
20 providers and the need for early diagnosis

With
structures
61
Wrist, hand,
11 31 / 61 /
3
/
fingers
/ Lungs: much greater
61
10
61 What happens 6 1 31
• Video discussion of recommended vaccinations for RA patients

61 61 /
3
risk of getting serious Cutaway view I have some pain in my joints. next? and the presence of comorbid conditions
61
0

3
Elbow

difficulty
Without
Target cell 0 1 2 3 4 5 How can I tell if I have RA?
/
infections and other • If your health care provider thinks you may have RA, he

any
Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical
Years of Disease
4
features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
complications What happens when RA • If you think you may have RA, you need to tell your health care The free iPhone app is available in either of the following ways:
What is rheumatoid arthritis (RA)? Spine Immune cell or she will prescribe medication to reduce the pain and
causes an autoimmune response? provider. He or she will examine you and ask the following
Heart disease: may inflammation in the joints. He or she will also refer you to a • Download the app at http://www.curatiocme.com/RAPID/iphone
• RA is a chronic condition that damages the joints of the When an immune response is triggered, inflammation occurs questions:

1. Dressing yourself, including tying shoelaces and doing buttons?

Hip occur about 10 years How can RA be controlled? rheumatologist, which is a doctor who specializes in RA and • Using the camera on your iPhone, scan the QR code below
body. Chronic conditions are long lasting (greater than 3 in the areas that are attacked by the immune system. – What hurts as you get out of bed in the morning?

If we asked someone who spends a good deal of time with

sooner than in people There has been great improvement in the drugs used to treat RA. related diseases.
months) and do not go away easily or quickly. RA affects – How long does it take to feel as limber as you’re going to
without RA • Inflammation causes redness and warmth, swelling, • The rheumatologist will confirm the diagnosis of RA and

Please check (3) the ONE best answer for your abilities.
women more than twice as much as men. Although it may • A class of drugs referred to as “DMARDs” acts to slow or feel for the day?
What causes RA? stiffness, and pain in the affected joints prescribe appropriate medication to slow or stop the

Share your answers with your primary care provider.

stop the progression of RA to more advanced stages of the – When is your pain the worst (AM or PM)?

6. Bending down to pick up clothing from the floor?

occur at any age, it usually starts in patients when they Stomach: high risk

you, would they say that you have difficulty with:

are between 30 and 60 years old. RA causes continuing of bleeding • It is not known what causes RA, but it is an autoimmune • If the autoimmune response is not slowed or stopped, it can disease – Do any members of your family have RA? autoimmune process and joint damage.
disease. This means that the body attacks itself permanently damage the affected joints and other tissues – Is it difficult for you to:

7. Turning regular faucets (taps) on and off?

joint damage and associated conditions for many patients. • Depending on the extent of injury caused by RA, you may be

3. Lifting a full cup or glass to your mouth?

Double the risk of • If you look at the graph above, you will see that when a n Turn faucet handles?

5. Washing and drying your entire body?

To reduce complications, RA should be diagnosed and • The body’s immune system fights off infections caused by over time DMARD is not used (the red line), the problems caused by

referred to a physical or occupational therapist, a podiatrist,
Knee some types of cancer, n Hold a hairbrush/toothbrush?

4. Walking outdoors on flat ground?

treated early and optimally managed throughout life. invading bacteria and viruses Can RA be prevented? RA increase rapidly, especially in the first 2 years or other specialists, such as an orthopedic surgeon.
so increased screening n Dress/bathe independently?

What are the symptoms? • In autoimmune diseases like RA, the body responds as if its Rheumatoid Arthritis

8. Getting in and out of a car?

is advisable Because we do not know why RA happens, there is no known • However, when treated with DMARDs (the blue line), the n Fix your own breakfast?

2. Getting in and out of bed?

Early signs of RA include: normal cells are foreign cells and attacks them way to prevent the disease. However, early diagnosis and disease progresses much more slowly, and fewer problems n Walk outdoors on flat ground? Resources and Information
• Swelling, stiffness, aching, or pain in one or more joints • Genetics may play a part in the development of RA, but early treatment are the best ways to fight RA. occur – How is your energy level? The American College of Rheumatology
Early diagnosis – Do you smoke?
• Morning stiffness that lasts for at least 30 minutes and many people who get RA do not have any relatives with the • Treatment is first focused on reducing inflammation and http://www.rheumatology.org/
and treatment • DMARDs such as methotrexate, hydroxychloroquine, – Signs that may suggest other reasons for your pain:
often for several hours condition relieving pain The Arthritis Foundation
may prevent these sulfasalazine, or biologic DMARDs are most often used to n Fever n Night sweats
http://www.arthritis.org/

• Difficulty grasping objects as strongly as you used to Ankle, foot, toes complications. • When a diagnosis of RA is confirmed, treatment also aims at control RA n Unexpected weight loss n Rash, tick exposure

RA commonly affects the small joints of the fingers, wrists, and n Recent contact with sick children
The National Library of Medicine/Medline Plus
stopping or slowing joint damage and damage to other parts
http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
feet, but it may also affect other joints as the disease progresses, of the body You may also fill out the questionnaire on panel 8B, which will
including the ankles, knees, hips, elbows, and shoulders. help identify the cause of your discomfort.
 1B 2B 3B 4B 5B 6B 7B 8B

Are other parts of the body affected besides the joints? Healthy joint Damaged joint ALSO AVAILABLE
Treatment With Disease-Modifiying Antirheumatic Drugs
(DMARDs) Improves Long-Term Outcomes An interactive version of this Rheumatoid Arthritis: Primary care

Unable
Destruction

to do
of cartilage 70 Initiative for improved Diagnosis and outcomes (RAPID) clinician
Without DMARDs, problems
Joints affected: Other organs that may increase rapidly
educator is now available as an iPhone app. The enhanced app
60
version includes the following features:

Medical Illustration Copyright© 2010 Nucleus Medical Media,

Jaw be affected if RA is

difficulty
50

much
Disease Progress

With
not treated early: • Video demonstration of the squeeze test and provisional RA
40
Eyes: dryness and diagnosis

Self-Report Questionnaire for Rheumatoid Arthritis

3

All rights reserved. www.nucleusinc.com

3
Shoulder
31
3
30

31
damage to delicate With DMARDs, • Video discussion of patient point of view towards primary care

3
31
3

Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
/

difficulty
31 / 31
3 3
/
fewer problems

some
20 providers and the need for early diagnosis

With
structures
61
Wrist, hand,
11 31 / 61 /
3
/
fingers
/ Lungs: much greater
61
10
61 What happens 6 1 31
• Video discussion of recommended vaccinations for RA patients

61 61 /
3
risk of getting serious Cutaway view I have some pain in my joints. next? and the presence of comorbid conditions
61
0

3
Elbow

difficulty
Without
Target cell 0 1 2 3 4 5 How can I tell if I have RA?
/
infections and other • If your health care provider thinks you may have RA, he

any
Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical
Years of Disease
4
features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
complications What happens when RA • If you think you may have RA, you need to tell your health care The free iPhone app is available in either of the following ways:
What is rheumatoid arthritis (RA)? Spine Immune cell or she will prescribe medication to reduce the pain and
causes an autoimmune response? provider. He or she will examine you and ask the following
Heart disease: may inflammation in the joints. He or she will also refer you to a • Download the app at http://www.curatiocme.com/RAPID/iphone
• RA is a chronic condition that damages the joints of the When an immune response is triggered, inflammation occurs questions:

1. Dressing yourself, including tying shoelaces and doing buttons?

Hip occur about 10 years How can RA be controlled? rheumatologist, which is a doctor who specializes in RA and • Using the camera on your iPhone, scan the QR code below
body. Chronic conditions are long lasting (greater than 3 in the areas that are attacked by the immune system. – What hurts as you get out of bed in the morning?

If we asked someone who spends a good deal of time with

sooner than in people There has been great improvement in the drugs used to treat RA. related diseases.
months) and do not go away easily or quickly. RA affects – How long does it take to feel as limber as you’re going to
without RA • Inflammation causes redness and warmth, swelling, • The rheumatologist will confirm the diagnosis of RA and

Please check (3) the ONE best answer for your abilities.
women more than twice as much as men. Although it may • A class of drugs referred to as “DMARDs” acts to slow or feel for the day?
What causes RA? stiffness, and pain in the affected joints prescribe appropriate medication to slow or stop the

Share your answers with your primary care provider.

stop the progression of RA to more advanced stages of the – When is your pain the worst (AM or PM)?

6. Bending down to pick up clothing from the floor?

occur at any age, it usually starts in patients when they Stomach: high risk

you, would they say that you have difficulty with:

are between 30 and 60 years old. RA causes continuing of bleeding • It is not known what causes RA, but it is an autoimmune • If the autoimmune response is not slowed or stopped, it can disease – Do any members of your family have RA? autoimmune process and joint damage.
disease. This means that the body attacks itself permanently damage the affected joints and other tissues – Is it difficult for you to:

7. Turning regular faucets (taps) on and off?

joint damage and associated conditions for many patients. • Depending on the extent of injury caused by RA, you may be

3. Lifting a full cup or glass to your mouth?

Double the risk of • If you look at the graph above, you will see that when a n Turn faucet handles?

5. Washing and drying your entire body?

To reduce complications, RA should be diagnosed and • The body’s immune system fights off infections caused by over time DMARD is not used (the red line), the problems caused by

referred to a physical or occupational therapist, a podiatrist,
Knee some types of cancer, n Hold a hairbrush/toothbrush?

4. Walking outdoors on flat ground?

treated early and optimally managed throughout life. invading bacteria and viruses Can RA be prevented? RA increase rapidly, especially in the first 2 years or other specialists, such as an orthopedic surgeon.
so increased screening n Dress/bathe independently?

What are the symptoms? • In autoimmune diseases like RA, the body responds as if its Rheumatoid Arthritis

8. Getting in and out of a car?

is advisable Because we do not know why RA happens, there is no known • However, when treated with DMARDs (the blue line), the n Fix your own breakfast?

2. Getting in and out of bed?

Early signs of RA include: normal cells are foreign cells and attacks them way to prevent the disease. However, early diagnosis and disease progresses much more slowly, and fewer problems n Walk outdoors on flat ground? Resources and Information
• Swelling, stiffness, aching, or pain in one or more joints • Genetics may play a part in the development of RA, but early treatment are the best ways to fight RA. occur – How is your energy level? The American College of Rheumatology
Early diagnosis – Do you smoke?
• Morning stiffness that lasts for at least 30 minutes and many people who get RA do not have any relatives with the • Treatment is first focused on reducing inflammation and http://www.rheumatology.org/
and treatment • DMARDs such as methotrexate, hydroxychloroquine, – Signs that may suggest other reasons for your pain:
often for several hours condition relieving pain The Arthritis Foundation
may prevent these sulfasalazine, or biologic DMARDs are most often used to n Fever n Night sweats
http://www.arthritis.org/

• Difficulty grasping objects as strongly as you used to Ankle, foot, toes complications. • When a diagnosis of RA is confirmed, treatment also aims at control RA n Unexpected weight loss n Rash, tick exposure

RA commonly affects the small joints of the fingers, wrists, and n Recent contact with sick children
The National Library of Medicine/Medline Plus
stopping or slowing joint damage and damage to other parts
http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
feet, but it may also affect other joints as the disease progresses, of the body You may also fill out the questionnaire on panel 8B, which will
including the ankles, knees, hips, elbows, and shoulders. help identify the cause of your discomfort.
 1B 2B 3B 4B 5B 6B 7B 8B

Are other parts of the body affected besides the joints? Healthy joint Damaged joint ALSO AVAILABLE
Treatment With Disease-Modifiying Antirheumatic Drugs
(DMARDs) Improves Long-Term Outcomes An interactive version of this Rheumatoid Arthritis: Primary care

Unable
Destruction

to do
of cartilage 70 Initiative for improved Diagnosis and outcomes (RAPID) clinician
Without DMARDs, problems
Joints affected: Other organs that may increase rapidly
educator is now available as an iPhone app. The enhanced app
60
version includes the following features:

Medical Illustration Copyright© 2010 Nucleus Medical Media,

Jaw be affected if RA is

difficulty
50

much
Disease Progress

With
not treated early: • Video demonstration of the squeeze test and provisional RA
40
Eyes: dryness and diagnosis

Self-Report Questionnaire for Rheumatoid Arthritis

3

All rights reserved. www.nucleusinc.com

3
Shoulder
31
3
30

31
damage to delicate With DMARDs, • Video discussion of patient point of view towards primary care

3
31
3

Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
/

difficulty
31 / 31
3 3
/
fewer problems

some
20 providers and the need for early diagnosis

With
structures
61
Wrist, hand,
11 31 / 61 /
3
/
fingers
/ Lungs: much greater
61
10
61 What happens 6 1 31
• Video discussion of recommended vaccinations for RA patients

61 61 /
3
risk of getting serious Cutaway view I have some pain in my joints. next? and the presence of comorbid conditions
61
0

3
Elbow

difficulty
Without
Target cell 0 1 2 3 4 5 How can I tell if I have RA?
/
infections and other • If your health care provider thinks you may have RA, he

any
Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical
Years of Disease
4
features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
complications What happens when RA • If you think you may have RA, you need to tell your health care The free iPhone app is available in either of the following ways:
What is rheumatoid arthritis (RA)? Spine Immune cell or she will prescribe medication to reduce the pain and
causes an autoimmune response? provider. He or she will examine you and ask the following
Heart disease: may inflammation in the joints. He or she will also refer you to a • Download the app at http://www.curatiocme.com/RAPID/iphone
• RA is a chronic condition that damages the joints of the When an immune response is triggered, inflammation occurs questions:

1. Dressing yourself, including tying shoelaces and doing buttons?

Hip occur about 10 years How can RA be controlled? rheumatologist, which is a doctor who specializes in RA and • Using the camera on your iPhone, scan the QR code below
body. Chronic conditions are long lasting (greater than 3 in the areas that are attacked by the immune system. – What hurts as you get out of bed in the morning?

If we asked someone who spends a good deal of time with

sooner than in people There has been great improvement in the drugs used to treat RA. related diseases.
months) and do not go away easily or quickly. RA affects – How long does it take to feel as limber as you’re going to
without RA • Inflammation causes redness and warmth, swelling, • The rheumatologist will confirm the diagnosis of RA and

Please check (3) the ONE best answer for your abilities.
women more than twice as much as men. Although it may • A class of drugs referred to as “DMARDs” acts to slow or feel for the day?
What causes RA? stiffness, and pain in the affected joints prescribe appropriate medication to slow or stop the

Share your answers with your primary care provider.

stop the progression of RA to more advanced stages of the – When is your pain the worst (AM or PM)?

6. Bending down to pick up clothing from the floor?

occur at any age, it usually starts in patients when they Stomach: high risk

you, would they say that you have difficulty with:

are between 30 and 60 years old. RA causes continuing of bleeding • It is not known what causes RA, but it is an autoimmune • If the autoimmune response is not slowed or stopped, it can disease – Do any members of your family have RA? autoimmune process and joint damage.
disease. This means that the body attacks itself permanently damage the affected joints and other tissues – Is it difficult for you to:

7. Turning regular faucets (taps) on and off?

joint damage and associated conditions for many patients. • Depending on the extent of injury caused by RA, you may be

3. Lifting a full cup or glass to your mouth?

Double the risk of • If you look at the graph above, you will see that when a n Turn faucet handles?

5. Washing and drying your entire body?

To reduce complications, RA should be diagnosed and • The body’s immune system fights off infections caused by over time DMARD is not used (the red line), the problems caused by

referred to a physical or occupational therapist, a podiatrist,
Knee some types of cancer, n Hold a hairbrush/toothbrush?

4. Walking outdoors on flat ground?

treated early and optimally managed throughout life. invading bacteria and viruses Can RA be prevented? RA increase rapidly, especially in the first 2 years or other specialists, such as an orthopedic surgeon.
so increased screening n Dress/bathe independently?

What are the symptoms? • In autoimmune diseases like RA, the body responds as if its Rheumatoid Arthritis

8. Getting in and out of a car?

is advisable Because we do not know why RA happens, there is no known • However, when treated with DMARDs (the blue line), the n Fix your own breakfast?

2. Getting in and out of bed?

Early signs of RA include: normal cells are foreign cells and attacks them way to prevent the disease. However, early diagnosis and disease progresses much more slowly, and fewer problems n Walk outdoors on flat ground? Resources and Information
• Swelling, stiffness, aching, or pain in one or more joints • Genetics may play a part in the development of RA, but early treatment are the best ways to fight RA. occur – How is your energy level? The American College of Rheumatology
Early diagnosis – Do you smoke?
• Morning stiffness that lasts for at least 30 minutes and many people who get RA do not have any relatives with the • Treatment is first focused on reducing inflammation and http://www.rheumatology.org/
and treatment • DMARDs such as methotrexate, hydroxychloroquine, – Signs that may suggest other reasons for your pain:
often for several hours condition relieving pain The Arthritis Foundation
may prevent these sulfasalazine, or biologic DMARDs are most often used to n Fever n Night sweats
http://www.arthritis.org/

• Difficulty grasping objects as strongly as you used to Ankle, foot, toes complications. • When a diagnosis of RA is confirmed, treatment also aims at control RA n Unexpected weight loss n Rash, tick exposure

RA commonly affects the small joints of the fingers, wrists, and n Recent contact with sick children
The National Library of Medicine/Medline Plus
stopping or slowing joint damage and damage to other parts
http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
feet, but it may also affect other joints as the disease progresses, of the body You may also fill out the questionnaire on panel 8B, which will
including the ankles, knees, hips, elbows, and shoulders. help identify the cause of your discomfort.
 1B 2B 3B 4B 5B 6B 7B 8B

Are other parts of the body affected besides the joints? Healthy joint Damaged joint ALSO AVAILABLE
Treatment With Disease-Modifiying Antirheumatic Drugs
(DMARDs) Improves Long-Term Outcomes An interactive version of this Rheumatoid Arthritis: Primary care

Unable
Destruction

to do
of cartilage 70 Initiative for improved Diagnosis and outcomes (RAPID) clinician
Without DMARDs, problems
Joints affected: Other organs that may increase rapidly
educator is now available as an iPhone app. The enhanced app
60
version includes the following features:

Medical Illustration Copyright© 2010 Nucleus Medical Media,

Jaw be affected if RA is

difficulty
50

much
Disease Progress

With
not treated early: • Video demonstration of the squeeze test and provisional RA
40
Eyes: dryness and diagnosis

Self-Report Questionnaire for Rheumatoid Arthritis

3

All rights reserved. www.nucleusinc.com

3
Shoulder
31
3
30

31
damage to delicate With DMARDs, • Video discussion of patient point of view towards primary care

3
31
3

Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
/

difficulty
31 / 31
3 3
/
fewer problems

some
20 providers and the need for early diagnosis

With
structures
61
Wrist, hand,
11 31 / 61 /
3
/
fingers
/ Lungs: much greater
61
10
61 What happens 6 1 31
• Video discussion of recommended vaccinations for RA patients

61 61 /
3
risk of getting serious Cutaway view I have some pain in my joints. next? and the presence of comorbid conditions
61
0

3
Elbow

difficulty
Without
Target cell 0 1 2 3 4 5 How can I tell if I have RA?
/
infections and other • If your health care provider thinks you may have RA, he

any
Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical
Years of Disease
4
features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
complications What happens when RA • If you think you may have RA, you need to tell your health care The free iPhone app is available in either of the following ways:
What is rheumatoid arthritis (RA)? Spine Immune cell or she will prescribe medication to reduce the pain and
causes an autoimmune response? provider. He or she will examine you and ask the following
Heart disease: may inflammation in the joints. He or she will also refer you to a • Download the app at http://www.curatiocme.com/RAPID/iphone
• RA is a chronic condition that damages the joints of the When an immune response is triggered, inflammation occurs questions:

1. Dressing yourself, including tying shoelaces and doing buttons?

Hip occur about 10 years How can RA be controlled? rheumatologist, which is a doctor who specializes in RA and • Using the camera on your iPhone, scan the QR code below
body. Chronic conditions are long lasting (greater than 3 in the areas that are attacked by the immune system. – What hurts as you get out of bed in the morning?

If we asked someone who spends a good deal of time with

sooner than in people There has been great improvement in the drugs used to treat RA. related diseases.
months) and do not go away easily or quickly. RA affects – How long does it take to feel as limber as you’re going to
without RA • Inflammation causes redness and warmth, swelling, • The rheumatologist will confirm the diagnosis of RA and

Please check (3) the ONE best answer for your abilities.
women more than twice as much as men. Although it may • A class of drugs referred to as “DMARDs” acts to slow or feel for the day?
What causes RA? stiffness, and pain in the affected joints prescribe appropriate medication to slow or stop the

Share your answers with your primary care provider.

stop the progression of RA to more advanced stages of the – When is your pain the worst (AM or PM)?

6. Bending down to pick up clothing from the floor?

occur at any age, it usually starts in patients when they Stomach: high risk

you, would they say that you have difficulty with:

are between 30 and 60 years old. RA causes continuing of bleeding • It is not known what causes RA, but it is an autoimmune • If the autoimmune response is not slowed or stopped, it can disease – Do any members of your family have RA? autoimmune process and joint damage.
disease. This means that the body attacks itself permanently damage the affected joints and other tissues – Is it difficult for you to:

7. Turning regular faucets (taps) on and off?

joint damage and associated conditions for many patients. • Depending on the extent of injury caused by RA, you may be

3. Lifting a full cup or glass to your mouth?

Double the risk of • If you look at the graph above, you will see that when a n Turn faucet handles?

5. Washing and drying your entire body?

To reduce complications, RA should be diagnosed and • The body’s immune system fights off infections caused by over time DMARD is not used (the red line), the problems caused by

referred to a physical or occupational therapist, a podiatrist,
Knee some types of cancer, n Hold a hairbrush/toothbrush?

4. Walking outdoors on flat ground?

treated early and optimally managed throughout life. invading bacteria and viruses Can RA be prevented? RA increase rapidly, especially in the first 2 years or other specialists, such as an orthopedic surgeon.
so increased screening n Dress/bathe independently?

What are the symptoms? • In autoimmune diseases like RA, the body responds as if its Rheumatoid Arthritis

8. Getting in and out of a car?

is advisable Because we do not know why RA happens, there is no known • However, when treated with DMARDs (the blue line), the n Fix your own breakfast?

2. Getting in and out of bed?

Early signs of RA include: normal cells are foreign cells and attacks them way to prevent the disease. However, early diagnosis and disease progresses much more slowly, and fewer problems n Walk outdoors on flat ground? Resources and Information
• Swelling, stiffness, aching, or pain in one or more joints • Genetics may play a part in the development of RA, but early treatment are the best ways to fight RA. occur – How is your energy level? The American College of Rheumatology
Early diagnosis – Do you smoke?
• Morning stiffness that lasts for at least 30 minutes and many people who get RA do not have any relatives with the • Treatment is first focused on reducing inflammation and http://www.rheumatology.org/
and treatment • DMARDs such as methotrexate, hydroxychloroquine, – Signs that may suggest other reasons for your pain:
often for several hours condition relieving pain The Arthritis Foundation
may prevent these sulfasalazine, or biologic DMARDs are most often used to n Fever n Night sweats
http://www.arthritis.org/

• Difficulty grasping objects as strongly as you used to Ankle, foot, toes complications. • When a diagnosis of RA is confirmed, treatment also aims at control RA n Unexpected weight loss n Rash, tick exposure

RA commonly affects the small joints of the fingers, wrists, and n Recent contact with sick children
The National Library of Medicine/Medline Plus
stopping or slowing joint damage and damage to other parts
http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
feet, but it may also affect other joints as the disease progresses, of the body You may also fill out the questionnaire on panel 8B, which will
including the ankles, knees, hips, elbows, and shoulders. help identify the cause of your discomfort.
 1B 2B 3B 4B 5B 6B 7B 8B

Are other parts of the body affected besides the joints? Healthy joint Damaged joint ALSO AVAILABLE
Treatment With Disease-Modifiying Antirheumatic Drugs
(DMARDs) Improves Long-Term Outcomes An interactive version of this Rheumatoid Arthritis: Primary care

Unable
Destruction

to do
of cartilage 70 Initiative for improved Diagnosis and outcomes (RAPID) clinician
Without DMARDs, problems
Joints affected: Other organs that may increase rapidly
educator is now available as an iPhone app. The enhanced app
60
version includes the following features:

Medical Illustration Copyright© 2010 Nucleus Medical Media,

Jaw be affected if RA is

difficulty
50

much
Disease Progress

With
not treated early: • Video demonstration of the squeeze test and provisional RA
40
Eyes: dryness and diagnosis

Self-Report Questionnaire for Rheumatoid Arthritis

3

All rights reserved. www.nucleusinc.com

3
Shoulder
31
3
30

31
damage to delicate With DMARDs, • Video discussion of patient point of view towards primary care

3
31
3

Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
/

difficulty
31 / 31
3 3
/
fewer problems

some
20 providers and the need for early diagnosis

With
structures
61
Wrist, hand,
11 31 / 61 /
3
/
fingers
/ Lungs: much greater
61
10
61 What happens 6 1 31
• Video discussion of recommended vaccinations for RA patients

61 61 /
3
risk of getting serious Cutaway view I have some pain in my joints. next? and the presence of comorbid conditions
61
0

3
Elbow

difficulty
Without
Target cell 0 1 2 3 4 5 How can I tell if I have RA?
/
infections and other • If your health care provider thinks you may have RA, he

any
Published in Rheumatology, 3rd ed. Gordon DA, Hastings DE. Clinical
Years of Disease
4
features of rheumatoid arthritis, 765-780. Copyright Elsevier 2003.
complications What happens when RA • If you think you may have RA, you need to tell your health care The free iPhone app is available in either of the following ways:
What is rheumatoid arthritis (RA)? Spine Immune cell or she will prescribe medication to reduce the pain and
causes an autoimmune response? provider. He or she will examine you and ask the following
Heart disease: may inflammation in the joints. He or she will also refer you to a • Download the app at http://www.curatiocme.com/RAPID/iphone
• RA is a chronic condition that damages the joints of the When an immune response is triggered, inflammation occurs questions:

1. Dressing yourself, including tying shoelaces and doing buttons?

Hip occur about 10 years How can RA be controlled? rheumatologist, which is a doctor who specializes in RA and • Using the camera on your iPhone, scan the QR code below
body. Chronic conditions are long lasting (greater than 3 in the areas that are attacked by the immune system. – What hurts as you get out of bed in the morning?

If we asked someone who spends a good deal of time with

sooner than in people There has been great improvement in the drugs used to treat RA. related diseases.
months) and do not go away easily or quickly. RA affects – How long does it take to feel as limber as you’re going to
without RA • Inflammation causes redness and warmth, swelling, • The rheumatologist will confirm the diagnosis of RA and

Please check (3) the ONE best answer for your abilities.
women more than twice as much as men. Although it may • A class of drugs referred to as “DMARDs” acts to slow or feel for the day?
What causes RA? stiffness, and pain in the affected joints prescribe appropriate medication to slow or stop the

Share your answers with your primary care provider.

stop the progression of RA to more advanced stages of the – When is your pain the worst (AM or PM)?

6. Bending down to pick up clothing from the floor?

occur at any age, it usually starts in patients when they Stomach: high risk

you, would they say that you have difficulty with:

are between 30 and 60 years old. RA causes continuing of bleeding • It is not known what causes RA, but it is an autoimmune • If the autoimmune response is not slowed or stopped, it can disease – Do any members of your family have RA? autoimmune process and joint damage.
disease. This means that the body attacks itself permanently damage the affected joints and other tissues – Is it difficult for you to:

7. Turning regular faucets (taps) on and off?

joint damage and associated conditions for many patients. • Depending on the extent of injury caused by RA, you may be

3. Lifting a full cup or glass to your mouth?

Double the risk of • If you look at the graph above, you will see that when a n Turn faucet handles?

5. Washing and drying your entire body?

To reduce complications, RA should be diagnosed and • The body’s immune system fights off infections caused by over time DMARD is not used (the red line), the problems caused by

referred to a physical or occupational therapist, a podiatrist,
Knee some types of cancer, n Hold a hairbrush/toothbrush?

4. Walking outdoors on flat ground?

treated early and optimally managed throughout life. invading bacteria and viruses Can RA be prevented? RA increase rapidly, especially in the first 2 years or other specialists, such as an orthopedic surgeon.
so increased screening n Dress/bathe independently?

What are the symptoms? • In autoimmune diseases like RA, the body responds as if its Rheumatoid Arthritis

8. Getting in and out of a car?

is advisable Because we do not know why RA happens, there is no known • However, when treated with DMARDs (the blue line), the n Fix your own breakfast?

2. Getting in and out of bed?

Early signs of RA include: normal cells are foreign cells and attacks them way to prevent the disease. However, early diagnosis and disease progresses much more slowly, and fewer problems n Walk outdoors on flat ground? Resources and Information
• Swelling, stiffness, aching, or pain in one or more joints • Genetics may play a part in the development of RA, but early treatment are the best ways to fight RA. occur – How is your energy level? The American College of Rheumatology
Early diagnosis – Do you smoke?
• Morning stiffness that lasts for at least 30 minutes and many people who get RA do not have any relatives with the • Treatment is first focused on reducing inflammation and http://www.rheumatology.org/
and treatment • DMARDs such as methotrexate, hydroxychloroquine, – Signs that may suggest other reasons for your pain:
often for several hours condition relieving pain The Arthritis Foundation
may prevent these sulfasalazine, or biologic DMARDs are most often used to n Fever n Night sweats
http://www.arthritis.org/

• Difficulty grasping objects as strongly as you used to Ankle, foot, toes complications. • When a diagnosis of RA is confirmed, treatment also aims at control RA n Unexpected weight loss n Rash, tick exposure

RA commonly affects the small joints of the fingers, wrists, and n Recent contact with sick children
The National Library of Medicine/Medline Plus
stopping or slowing joint damage and damage to other parts
http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm
feet, but it may also affect other joints as the disease progresses, of the body You may also fill out the questionnaire on panel 8B, which will
including the ankles, knees, hips, elbows, and shoulders. help identify the cause of your discomfort.