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What condition does Abatacept treat?
Abatacept, also known as Orencia IV, treats several conditions. It is used to treat Rheumatoid Arthritis, Chronic Joint Inflammatory Disease in children and young adults of unknown cause.
Rheumatoid arthritis?
DefinitionRheumatoid arthritis (RA) is a long-term disease that leads to inflammation of the joints and surrounding tissues. It can also affect other organs.Alternative NamesRA; Arthritis - rheumatoidCauses, incidence, and risk factorsThe cause of RA is unknown. It is considered an autoimmune disease. The body's immune system normally fights off foreign substances, like viruses. But in an autoimmune disease, the immune system confuses healthy tissue for foreign substances. As a result, the body attacks itself.RA can occur at any age. Women are affected more often than men.RA usually affects joints on both sides of the body equally. Wrists, fingers, knees, feet, and ankles are the most commonly affected. The course and the severity of the illness can vary considerably. Infection, genes, and hormones may contribute to the disease.SymptomsThe disease often begins slowly, with symptoms that are seen in many other illnesses:FatigueLoss of appetiteLow feverSwollen glandsWeaknessEventually, joint pain appears.Morning stiffness, which lasts more than 1 hour, is common. Joints can even become warm, tender, and stiff when not used for as little as an hour.Joint pain is often felt on both sides of the body.The fingers (but not the fingertips), wrists, elbows, shoulders, hips, knees, ankles, toes, jaw, and neck may be affected.The joints are often swollen and feel warm and boggy (or spongy) to the touch.Over time, joints lose their range of motion and may become deformed.Other symptoms include:Chest pains when taking a breath (pleurisy)Eye burning, itching, and dischargeNodules under the skin (usually a sign of more severe disease)Numbness, tingling, or burning in the hands and feetJoint destruction may occur within 1-2 years after the disease appears.Signs and testsA specific blood test is available for diagnosing RA and distinguishing it from other types of arthritis. It is called the anti-CCP antibody test. Other tests that may be done include:Complete blood countC-reactive proteinErythrocyte sedimentation rateJoint ultrasound or MRIJoint x-raysRheumatoid factor test (positive in about 75% of people with symptoms)Synovial fluid analysisRegular blood or urine tests should be done to determine how well medications are working and whether drugs are causing any side effects.TreatmentRA usually requires lifelong treatment, including medications, physical therapy, exercise, education, and possibly surgery. Early, aggressive treatment for RA can delay joint destruction.MEDICATIONSDisease modifying antirheumatic drugs (DMARDs): These drugs are the current standard of care for RA, in addition to rest, strengthening exercises, and anti-inflammatory drugs.Methotrexate (Rheumatrex) is the most commonly used DMARD for rheumatoid arthritis. Leflunomide (Arava) may be substituted for methotrexate.These drugs may have serious side effects, so you will need frequent blood tests when taking them.Anti-inflammatory medications: These include aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen.Although NSAIDs work well, long-term use can cause stomach problems, such as ulcers and bleeding, and possible heart problems.Celecoxib (Celebrex) is another anti-inflammatory drug, but it is labeled with strong warnings about heart disease and stroke. Talk to your doctor about whether COX-2 inhibitors are right for you.Antimalarial medications: This group of medicines includes hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine), and is usually used along with methotrexate. It may be weeks or months before you see any benefit from these medications.Corticosteroids: These medications work very well to reduce joint swelling and inflammation. Because of long-term side effects, corticosteroids should be taken only for a short time and in low doses when possible.BIOLOGIC AGENTS:Biologic drugs are designed to affect parts of the immune system that play a role in the disease process of rheumatoid arthritis.They may be given when other medicines for rheumatoid arthritis have not worked. At times, your doctor will start biologic drugs sooner, along with other rheumatoid arthritis drugs.Most of them are given either under the skin (subcutaneously) or into a vein (intravenously). There are different types of biologic agents:White blood cell modulators include: abatacept (Orencia) and rituximab (Rituxan)Tumor necrosis factor (TNF) inhibitors include: adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), golimumab (Simponi), and certolizumab (Cimzia)Interleukin-6 (IL-6) inhibitors: tocilizumab (Actemra)Biologic agents can be very helpful in treating rheumatoid arthritis. However, people taking these drugs must be watched very closely because of serious risk factors:Infections from bacteria, viruses, and fungiLeukemiaPossibly psoriasisSURGERYOccasionally, surgery is needed to correct severely affected joints. Surgeries can relieve joint pain and deformities.The first surgical treatment may be a synovectomy, which is the removal of the joint lining (synovium).At some point, total joint replacement is needed. In extreme cases, total knee, hip replacement, ankle replacement, shoulder replacement, and others may be done. These surgeries can mean the difference between being totally dependent on others and having an independent life at home.PHYSICAL THERAPYRange-of-motion exercises and exercise programs prescribed by a physical therapist can delay the loss of joint function.Joint protection techniques, heat and cold treatments, and splints or orthotic devices to support and align joints may be very helpful.Sometimes therapists will use special machines to apply deep heat or electrical stimulation to reduce pain and improve joint mobility.Occupational therapists can create splints for the hand and wrist, and teach how to best protect and use joints when they are affected by arthritis. They also show people how to better cope with day-to-day tasks at work and at home, despite limitations caused by RA.Frequent rest periods between activities, as well as 8 to 10 hours of sleep per night, are recommended.Support GroupsFor additional information and resources, see arthritis support group.Expectations (prognosis)The course of rheumatoid arthritis differs from person to person. For some patients, the disease becomes less aggressive over time and symptoms may improve.Other people develop a more severe form of the disease.People with rheumatoid factor, the anti-CCP antibody, or subcutaneous nodules seem to have a more severe form of the disease. People who develop RA at younger ages also seem to get worse more quickly.Treatment for rheumatoid arthritis has improved. Many people with RA work full-time. However, after many years, about 10% of those with RA are severely disabled, and unable to do simple daily living tasks such as washing, dressing, and eating.ComplicationsRheumatoid arthritis is not only a disease of joint destruction. It can involve almost all organs.Problems that may occur include:Anemia due to failure of the bone marrow to produce enough new red blood cellsDamage to the lung tissue (rheumatoid lung)Injury to the spinal cord when the cervical spine (neck bones) becomes unstable as a result of RARheumatoid vasculitis (inflammation of the blood vessels), which can lead to skin ulcers and infections, bleeding stomach ulcers, and nerve problems that cause pain, numbness, or tingling. Vasculitis may also affect the brain, nerves, and heart, which can cause stroke, heart attack, or heart failure.Swelling and inflammation of the outer lining of the heart (pericarditis) and of the heart muscle (myocarditis). Both of these conditions can lead to congestive heart failure.Sjogren syndromeThe treatments for RA can also cause serious side effects. If you experience any side effects, immediately tell your health care provider.Calling your health care providerCall your health care provider if you think you have symptoms of rheumatoid arthritis.PreventionRheumatoid arthritis has no known prevention. However, it is often possible to prevent further damage to the joints with proper early treatment.ReferencesYazici Y. Treatment of rheumatoid arthritis: we are getting there. Lancet. 2009;374:178-180. Epub 2009 Jun 26.Deighton C, O'Mahony R, Tosh J, Turner C, Rudolf M; Guideline Development Group. Management of rheumatoid arthritis: summary of NICE guidelines. BMJ. 2009;338:b702. doi: 10.1136/bmj/b702.Harris ED Jr, Firestein GS. Clinical features of rheumatoid arthritis. In: Firestein GS, Budd RC, Harris ED Jr, et al, eds. Kelley's Textbook of Rheumatology. 8th ed. Philadelphia, Pa: Saunders Elsevier;2008:chap 66.
Arthritis?
DefinitionArthritis is inflammation of one or more joints, which results in pain, swelling, stiffness, and limited movement. There are over 100 different types of arthritis.See also: Joint painAlternative NamesJoint inflammationCauses, incidence, and risk factorsArthritis involves the breakdown of cartilage. Cartilage normally protects the joint, allowing for smooth movement. Cartilage also absorbs shock when pressure is placed on the joint, like when you walk. Without the usual amount of cartilage, the bones rub together, causing pain, swelling (inflammation), and stiffness.You may have joint inflammation for a variety of reasons, including:An autoimmune disease (the body attacks itself because the immune system believes a body part is foreign)Broken boneGeneral "wear and tear" on jointsInfection (usually caused by bacteria or viruses)Often, the inflammation goes away after the injury has healed, the disease is treated, or the infection has been cleared.With some injuries and diseases, the inflammation does not go away or destruction results in long-term pain and deformity. When this happens, you have chronic arthritis. Osteoarthritis is the most common type and is more likely to occur as you age. You may feel it in any of your joints, but most commonly in your hips, knees or fingers. Risk factors for osteoarthritis include:Being overweightPreviously injuring the affected jointUsing the affected joint in a repetitive action that puts stress on the joint (baseball players, ballet dancers, and construction workers are all at risk)Arthritis can occur in men and women of all ages. About 37 million people in America have arthritis of some kind, which is almost 1 out of every 7 people.Other types or cause of arthritis include:Adult Still's diseaseAnkylosing spondylitisFungal infections such as blastomycosisGonococcal arthritisGoutJuvenile rheumatoid arthritis (in children)Other bacterial infections (nongonococcal bacterial arthritis)Psoriatic arthritisReactive arthritis (Reiter syndrome)Rheumatoid arthritis (in adults)SclerodermaSystemic lupus erythematosus (SLE)Tertiary Lyme diseaseTuberculous arthritisViral arthritisSymptomsIf you have arthritis, you may experience:Joint painJoint swellingReduced ability to move the jointRedness of the skin around a jointStiffness, especially in the morningWarmth around a jointSigns and testsFirst, your doctor will take a detailed medical history to see if arthritis or another musculoskeletal problem is the likely cause of your symptoms.Next, a thorough physical examination may show that fluid is collecting in the joint. (This is called an "effusion.") The joint may be tender when it is gently pressed, and may be warm and red (especially in infectious arthritis and autoimmune arthritis). It may be painful or difficult to rotate the joints in some directions. This is known as "limited range-of-motion."In some autoimmune forms of arthritis, the joints may become deformed if the disease is not treated. Such joint deformities are the hallmarks of severe, untreated rheumatoid arthritis.Tests vary depending on the suspected cause. They often include blood tests and joint x-rays. To check for infection and other causes of arthritis (like gout caused by crystals), joint fluid is removed from the joint with a needle and examined under a microscope. See the specific types of arthritis for further information.TreatmentTreatment of arthritis depends on the cause, which joints are affected, the severity, and how the condition affects your daily activities. Your age and occupation will also be taken into consideration when your doctor works with you to create a treatment plan.If possible, treatment will focus on eliminating the cause of the arthritis. However, the cause is NOT necessarily curable, as with osteoarthritis and rheumatoid arthritis. Treatment, therefore, aims at reducing your pain and discomfort and preventing further disability.It is possible to greatly improve your symptoms from osteoarthritis and other long-term types of arthritis without medications. In fact, making lifestyle changes without medications is preferable for osteoarthritis and other forms of joint inflammation. If needed, medications should be used in addition to lifestyle changes.Exercise for arthritis is necessary to maintain healthy joints, relieve stiffness, reduce pain and fatigue, and improve muscle and bone strength. Your exercise program should be tailored to you as an individual. Work with a physical therapist to design an individualized program, which should include:Low-impact aerobic activity (also called endurance exercise)Range of motion exercises for flexibilityStrength training for muscle toneA physical therapist can apply heat and cold treatments as needed and fit you for splints or orthotic (straightening) devices to support and align joints. This may be particularly necessary for rheumatoid arthritis. Your physical therapist may also consider water therapy, ice massage, or transcutaneous nerve stimulation (TENS).Rest is just as important as exercise. Sleeping 8 to 10 hours per night and taking naps during the day can help you recover from a flare-up more quickly and may even help prevent exacerbations. You should also:Avoid holding one position for too long.Avoid positions or movements that place extra stress on your affected joints.Modify your home to make activities easier. For example, have grab bars in the shower, the tub, and near the toilet.Reduce stress, which can aggravate your symptoms. Try meditation or guided imagery. And talk to your physical therapist about yoga or tai chi.Other measures to try include:Apply capsaicin cream (derived from hot chili peppers) to the skin over your painful joints. You may feel improvement after applying the cream for 3-7 days.Eat a diet rich in vitamins and minerals, especially antioxidants like vitamin E. These are found in fruits and vegetables. Get selenium from Brewer's yeast, wheat germ, garlic, whole grains, sunflower seeds, and Brazil nuts. Get omega-3 fatty acids from cold water fish (like salmon, mackerel, and herring), flaxseed, rapeseed (canola) oil, soybeans, soybean oil, pumpkin seeds, and walnuts.Taking glucosamine and chondroitin -- these form the building blocks of cartilage, the substance that lines joints. These supplements are available at health food stores or supermarkets. While some studies show such supplements may reduce osteoarthritis symptoms, others show no benefit. However, since these products are regarded as safe, they are reasonable to try and many patients find their symptoms improve.Lose weight, if you are overweight. Weight loss can greatly improve joint pain in the legs and feet.MEDICATIONSYour doctor will choose from a variety of medications as needed. Generally, the first drugs to try are available without a prescription. These include:Acetaminophen (Tylenol) -- recommended by the American College of Rheumatology and the American Geriatrics Society as first-line treatment for osteoarthritis. Take up to 4 grams a day (two arthritis-strength Tylenol every 8 hours). This can provide significant relief of arthritis pain without many of the side effects of prescription drugs. DO NOT exceed the recommended doses of acetaminophen or take the drug in combination with large amounts of alcohol. These actions may damage your liver.Aspirin, ibuprofen, or naproxen -- these nonsteroidal anti-inflammatory drugs (NSAIDs) are often effective in combating arthritis pain. However, they have many potential risks, especially if used for a long time. They should not be taken in any amount without consulting your doctor. Potential side effects include heart attack, stroke, stomach ulcers, bleeding from the digestive tract, and kidney damage. In 2005, the U.S. Food and Drug Administration (FDA) asked makers of NSAIDs to include a warning label on their product that alerts users of an increased risk for heart attack, stroke, and gastrointestinal bleeding. If you have kidney or liver disease, or a history of gastrointestinal bleeding, you should not take these medicines unless your doctor specifically recommends them.Prescription medicines include:Biologics-- these are the most recent breakthrough for the treatment of rheumatoid arthritis. Such medications, including etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira), are administered by injection and can dramatically improve your quality of life. Newer biologics include abatacept (Orencia), rituximab (Rituxan), golimumab (Simponi), certolizumab (Cimzia), and tocilizumab (Actemra).Corticosteroids ("steroids") -- these are medications that suppress the immune system and symptoms of inflammation. They are often injected into painful osteoarthritic joints. Steroids are used to treat autoimmune forms of arthritis but should be avoided in infectious arthritis. Steroids have multiple side effects, including upset stomach and gastrointestinal bleeding, high blood pressure, thinning of bones, cataracts, and increased infections. The risks are most pronounced when steroids are taken for long periods of time or at high doses. Close supervision by a physician is essential.Cyclooxygenase-2 (COX-2) inhibitors -- These drugs block an inflammation-promoting enzyme called COX-2. This class of drugs was initially believed to work as well as traditional NSAIDs, but with fewer stomach problems. However, numerous reports of heart attacks and stroke have prompted the FDA to re-evaluate the risks and benefits of the COX-2s. Celecoxib (Celebrex) is still available, but labeled with strong warnings and a recommendation that it be prescribed at the lowest possible dose for the shortest duration possible. Talk to your doctor about whether COX-2s are right for you.Disease-modifying anti-rheumatic drugs -- these have been used traditionally to treat rheumatoid arthritis and other autoimmune causes of arthritis. These drugs include gold salts, penicillamine, sulfasalazine, and hydroxychloroquine. More recently, methotrexate has been shown to slow the progression of rheumatoid arthritis and improve your quality of life. Methotrexate itself can be highly toxic and requires frequent blood tests for patients on the medication.Immunosuppressants -- these drugs, like azathioprine or cyclophosphamide, are used for serious cases of rheumatoid arthritis when other medications have failed.It is very important to take your medications as directed by your doctor. If you are having difficulty doing so (for example, due to intolerable side effects), you should talk to your doctor.SURGERY AND OTHER APPROACHESIn some cases, surgery to rebuild the joint (arthroplasty) or to replace the joint (such as a total knee joint replacement) may help maintain a more normal lifestyle. The decision to perform joint replacement surgery is normally made when other alternatives, such as lifestyle changes and medications, are no longer effective.Normal joints contain a lubricant called synovial fluid. In joints with arthritis, this fluid is not produced in adequate amounts. In some cases, a doctor may inject the arthritic joint with a manmade version of joint fluid. The synthetic fluid may postpone the need for surgery at least temporarily and improve the quality of life for persons with arthritis.Expectations (prognosis)A few arthritis-related disorders can be completely cured with treatment. Most are chronic (long-term) conditions, however, and the goal of treatment is to control the pain and minimize joint damage. Chronic arthritis frequently goes in and out of remission.ComplicationsChronic painLifestyle restrictions or disabilityCalling your health care providerCall your doctor if:Your joint pain persists beyond 3 days.You have severe unexplained joint pain.The affected joint is significantly swollen.You have a hard time moving the joint.Your skin around the joint is red or hot to the touch.You have a fever or have lost weight unintentionally.PreventionIf arthritis is diagnosed and treated early, you can prevent joint damage. Find out if you have a family history of arthritis and share this information with your doctor, even if you have no joint symptoms.Osteoarthritismay be more likely to develop if you abuse your joints (injure them many times or over-use them while injured). Take care not to overwork a damaged or sore joint. Similarly, avoid excessive repetitive motions.Excess weight also increases the risk for developing osteoarthritis in the knees and possibly in the hips. See the article on body mass index to learn whether your weight is healthy.ReferencesD'Cruz DP, Khamashta MA, Hughes GR. Systemic lupus erythematosus. Lancet. 2007;369(9561):587-96.Glass GG. Osteoarthritis. Dis Mon. 2006;52:343-362.Gregory PJ, Sperry M, Wilson AF. Dietary supplements for osteoarthritis. Am Fam Physician. 2008;77:177-184.Smolen JS, Aletaha D, Koeller M, Weisman MH, Emery P. New therapies for treatment of rheumatoid arthritis. Lancet. 2007;270(9602):1861-74.
Juvenile rheumatoid arthritis?
DefinitionJuvenile rheumatoid arthritis (JRA) is a term used to describe a common type of arthritis in children. It is a long-term (chronic) disease resulting in joint pain and swelling.Alternative NamesJuvenile chronic polyarthritis; JRA; Still's disease; Juvenile idiopathic arthritisCauses, incidence, and risk factorsThe cause of JRA is not known. It is thought to be an autoimmune illness. In this type of condition, the body's immune system mistakenly attacks and destroys healthy body tissue.JRA usually occurs before age 16.It is divided into several categories:Systemic JRA involves joint swelling or pain, fevers, and rash. It is the least common category.Polyarticular JRA involves many joints. This form of JRA may turn into rheumatoid arthritis. It may involve large and small joints of the legs and arms, as well as the TMJ and cervical spine.Pauciarticular JRA involves only a few joints, usually the hips, knees, or ankles.Many other medical problems can cause symptoms similar to those of juvenile rheumatoid arthritis, including:Lyme disease, rheumatic fever, bone infections (osteomyelitis), and other infectionsSarcoidosis, psoriatic arthritis, vasculitisInflammatory bowel diseaseSymptomsArthritis symptoms:Joint stiffnesswhen you wake up in the morningJoint painLimited range of motionJoints may be warm or swollen and sometimes redA child may stop using an affected limb or may limpBack painBody-wide JRA symptoms:Fever, usually high fevers every dayRash (trunk and extremities) that comes and goes with the feverSwollen lymph nodes (glands)JRA can also cause eye inflammation called uveitis. This problem can occur without any eye symptoms, or someone may have:Red eyesEye painIncreased pain when looking at light (photophobia)Vision changesSigns and testsThe physical examination may show swollen, warm, and tender joints that hurt to move. The child may have a rash. Other signs include:Enlarged liverEnlarged spleenSwollen lymph nodesBlood tests may include:Rheumatoid factor (may be raised, but not in all patients)Erythrocyte sedimentation rate (ESR)ANA (may be high)Complete blood count (CBC)HLA antigensfor HLA B27Any or all of these blood tests may be normal in patients with JRA.The doctor may need to tap a joint. This means putting a small needle into a joint that is swollen. This can help to find the cause of the arthritis. By removing fluid, the joint may feel better, too. Sometimes, the doctor will inject steroids into the joint to help decrease the swelling.Other tests:X-ray of a jointX-ray of the chestECGEye exam by an ophthalmologist (should be done on a regular basis, even if there are no eye symptoms)TreatmentWhen only a small number of joints are involved, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen may be enough to control symptoms.Corticosteroids may be used for more severe flare-ups to help control symptoms.Children who have arthritis in many joints, or who have fever, rash, and swollen glands may need other medicines. These medicines are called disease-modifying antirheumatic drugs (DMARDs). They can decrease or prevent swelling or inflammation in the body. DMARDs include:Methotrexate is often the first drug used.Biologic drugs, such as such as etanercept, infliximab, and related drugs block high levels of proteins that cause inflammation.It is important for children with JRA to stay active and keep their muscles strong. Walking, bicycling, and swimming may be good activities. Children should learn to warm up before exercising.Support and help for children who experience sadness or anger about their arthritis is also very important.Some children with JRA may need surgery, including joint replacement.Expectations (prognosis)JRA is seldom life threatening.Children who have many joints involved, or who have a positive rheumatoid factor are more likely to have chronic pain and poor school attendance, and to be disabled.Long periods with no symptoms are more common in those who have only a small number of joints involved. Many patients with JRA eventually go into remission with very little loss of function and deformity.For additional information and resources, see arthritis support group.ComplicationsWearing away or destruction of joints (can occur in patients with more severe JRA)Slow rate of growthUneven growth of an arm or legLoss of visionor decreased visionfrom chronic uveitis (this problem may be severe, even when the arthritis is not very severe)AnemiaSwelling around the heart (pericarditis)Chronic pain, poor school attendanceCalling your health care providerCall for an appointment with your health care provider if:You notice symptoms of juvenile rheumatoid arthritisSymptoms get worse or do not improve with treatmentNew symptoms developPreventionThere is no known prevention for JRA.ReferencesMiller ML, Cassidy JT. Juvenile rheumatoid arthritis. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: Saunders Elsevier; 2007: chap 154.Lovell DJ, Ruperto N, Goodman S, Reiff A, Jung L, Jarosova K, et al. Pediatric Rheumatology Collaborative Study Group: Pediatric Rheumatology International Trials Organisation. Adalimumab with or without methotrexate in juvenile rheumatoid arthritis. N Engl J Med. 2008;359:810-820.Cespedes-Cruz A, Gutierrez-Suarez R, Pistorio A, Ravelli A, Loy A, Murray KJ, et al. Pediatric Rheumatology International Trials Organization (PRINTO). Methotrexate improves the health-related quality of life of children with juvenile rheumatoid arthritis. Ann Rheum Dis. 2008;67:309-314.Ravelli A, Martini A. Juvenile idiopathic arthritis. Lancet. 2007;369:767-778.
