What is the first choice of biologics according to efficacy & safety?
Based upon the available data, there is nearly 100% agreement that the TNF inhibitors represent first-line therapy in a patient with RA. A TNF inhibitor is generally used in combination with methotrexate.

In a patient with refractory RA (not responding to Anti -TNF alfa&DMARDs) Which is better to switch to Abatacept or Rituximab?
There is no consensus about whether to switch to abatacept or rituximab following treatment with DMARDs or TNF inhibitors. One caution to consider is the risk of PML associated with rituximab use. PML has been reported rarely after rituximab, in both cancer patients and patients with RA .

Is it safe to prescribe interferon without treating Rheumatoid arthritis?
Interferon can both induce and exacerbate rheumatoid arthritis (RA).  Interferon must be given with caution when a patient with RA needs IFN for conditions such as hepatitis B or C.

What is it's pathophisiology?
This is a complex question but basically it is an immunologically driven illness that occurs in genetically susceptible hosts. It involves T cells, B cells, fibroblasts, macrophages  and osteoslasts.  Unfortunately the antigenic stimulus is presently unknown.

What are some therapeutic activities for women with RA to improve function in activities of daily living? Activities that will help improve the simple occupational tasks like dressing , etc? Does the use of adaptive equipment improve activities of daily living in women over 50 with RA?
In addition to effective therapy with a remitive agent (either non biologic or biologic agent) aggressive physical and occupational therapy is essential.

I am a 34-year-old woman from Caracas, Venezuela. I have rheumatoid arthritis and I want to know if rheumatoid arthritis could be caused by the big infection I had the last couple of months. Thank you.
There is no evidence that RA is caused by an infection.

I have a 62-year-old woman with sero-positive erosive RA, MTX induced ILD and pul. HTN, active synovitis with elevated ESR and CRP, ground glass changes on HRCT chest. Has been on 30 mg/day prednisone for over 5 years. What theraputic intervention would you recommend?
The presence of IPF at baseline makes the choice of therapy difficult.  MTX-based therapies are to be avoided for obvious reasons.  With regards to TNFi, data from the British Society Rheumatology Biologics Registry (BSRBR) is informative. A complete review of the BSRBR database revealed that treatment with any TNFi in patients with preexisting pulmonary disease (n=184) had a mortality rate of 90 per 1000 person-years of follow-up compared to 14 per 1000 person-years of follow-up in those without pulmonary disease (n=6061), which translates into a 6.4-fold higher mortality rate among patients in the former group. After adjustment for age and sex, patients with baseline pulmonary disease treated with biologics had a 4.4 times higher mortality rate (95% CI 1.8-10.7) than patients without pulmonary disease treated with biologic agents.  Thus TNFi would not be my first choice.  Leflunomide appears safe even in people with underlying pulmonary disease when used cautiously.  We have little data on abatacept or rituximab though abatacept has been somewhat problematic in patients with underlying pulmonary disase. Thus I would gravitate to combination (leflunomide based) non-biologic DMARDS or leflunomide plus rituximab.  
(BSRBR Newsletter August  2004 by BSRBR - published in BSR, 2005-08-31)

Prevention of Infection in Rheumatoid Arthritis Patients Receiving Biologic Agents

What is the magnitude of infection risk with use of abatacept?
In general, the magnitude of infection risk with abatacept is within the range of the other biologics, about 2-6 cases per 100 patient years. However, long-term safety studies totaling over 10,000 patient years have shown a low incidence of opportunistic infections.  Nevertheless, the same safety precautions with regard to infection risk and biologics apply when using abatacept.  

Session: Treating a Patient with RA and Hepatitis B or C

Can Sulfasalazine be used in patients with RA and hepatitis B or C?
Good question. Actually there are no data on using sulfasalazine in patients with RA who have hepatitis B or C.  It has been suggested, but I still prefer TNF blockers in Childs Pugh A.

Session: Rheumatoid Arthritis and Malignancy

If the patient described in this activity (RA and malignancy, Dr. Latinis) shows worsening disease despite MTX and prednisone, would Rituxan be considered a first line biologic?
Yes,  if malignancy becomes an issue regarding TNF inhibitor selection rituximab is generally my second choice.  Abatacept is an unknown given lack of data.

What about skin sqamous cell or basal cell cancer in patient with RA? can we use Biologic tx?
Non melanoma skin cancers are common and 'manageable'.  I do not believe they are a contraindication from TNF inhibitors. If confronted by a patient with such history, I would send for screening exam per a dermatologist and treat. I would have them have regular 6- 12 month skin screens.

Session: Managing RA Patients with an Inadequate Response to TNF Inhibitors

How long after abatacept would you consider rituximab in a patient with TNF alfa(Enbrel) secondary failure.  Note: patient has pulmonary fibrosis. Would you choose adalimumab or tocizilumab instead? DAS 28 5.2 
The presence of IPF confounds this decision.  I have strong concerns about abatacept as well as all class TNF inhibitors. Rituximab is logical (although there are no significant data on safety in this population), probably with leflunomide background.  The pk of abatacept permits rapid switching.

Session: RA and Heart Failure

In patients with heart failure, acute exacerbation of rheumatoid arthritis poses problems for selection of an effective drug. What would be the best choice of antirheumatic drug? 
Although there are strong warnings in the labeling of all TNFi with regards to CHF, it should be noted that the most explicit issues are patients with poorly controlled (Class II or IV) with all agents and especially with higher doses of infliximab.  I do not hesitate to use TNFi, especially etanercept in patients 1) requiring a biologic for RA control 2) with well-controlled CHF, and 3) who have had a baseline echocardiogram.  Only anecdotes exist for any problem with abatacept and none I am aware of for rituximab.