| South African Rheumatism and Arthritis Association | ||
| Therapeutic Guidelines
26th February 2001
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Joint
injections |
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The following guidelines have been drawn up by the Rheumatology Private Practice Group (RPPG) under the auspices of the South African Rheumatism and Arthritis Association, for the use of Healthcare Funders with regard to Rheumatic Diseases. They should be seen as broad principles and not rigid criteria. Allowance should be made for exceptional cases, which should be discussed between the Rheumatologist and Healthcare Funder. Intraarticular injections
of cortisone Intraarticular injections of cortisone Indications for the use
of COXIBs. Whereas all patients with chronic rheumatic conditions should
receive COXIBs rather than NSAIDs due to the superior safety of these
drugs, we recommend that these drugs should be mandatory in high risk
patients requiring chronic NSAIDs as identified below. Biologicals: Infliximab and Etanercept Indications for the use
of Infliximab / Enbrel Scientific evidence supports the use of these
drugs in Rheumatoid Arthritis, Seronegative spondyloarthropathy,
including Ankylosing Spondylitis, Psoriatic Arthritis and Juvenile
Chronic Arthritis, particularly where other therapies have failed. They
should only be used by Rheumatologists and in patients who fulfill the
following modified international criteria: (Based on the Working Party for the
British Society of Rheumatology April 2000) C. Failure or intolerance
of Standard Disease Modifying Antirheumatic Drugs (DMARDs) NOTE: Infliximab should be infused at a supervised day facility with appropriately trained staff and resuscitation equipment available. Contraindications Pregnancy / Breastfeeding Withdrawal Criteria Malignancy These Guidelines will be
constantly reviewed. TB Guidelines SARAA 2003 Consensus statement re Revellex and anti TB therapy / prophylaxis policy With the urgency related to reports of Tuberculosis cases related to use of biologicals a special meeting was held with the assistance of Schering Plough to address the issue of Tuberculosis and use of biologicals in this case - Revellex / Infliximab. These guidelines are to be seen in the context of use of anti TNF drugs where used in South Africa. Recommendations 1. Ensure the appropriate indications for use 2. Registry – A registry is to be compiled of all patients on Anti TNF inhibitors…. a.
Numbers. 3. Unique problems faced in the South African Situation.. a.
Exposure - All of us exposed at some time i. Data suggests that treatment with prophylaxis can reduce TB by 70% if compliance in immuno-compromised patients. ii. Definition and diagnosis of the LATENT state. This Implies treatment is essential
iii.
Treatment choice for latency: INH – RIF combined - The
benefit may last longer – in HIV patients, benefit is observed for up
to 3 years.
iv. Duration of treatment. See clause iii. v. Time to start TNF after latency treatment started – Information limited - recommend full treatment but practitioner judgement allowed vs. activity of disease…No data available. vi. INH – RIF regimen may be more useful here as shorter regimen. vii. Monitoring of prophylaxis treatment.
viii. Repetition of screening program: Is there evidence of benefit to rescreening the MANTOUX – There is no evidence in adults. c.
Active
disease – Must exclude in all cases…as there is absolute contraindication
to TNF Rx. If active TB is present. If
there is a history of previously treated TB – ensure no active
disease. Anti TNF
Rx is allowed if the patient had > 6 months of full
therapy, or the disease was in the distant / remote past. Role
for empirical latency treatment in these cases is unclear as there is no
data available.
4. Treatment in disease whilst on TNF. Diagnosis
and Treatment in Patients with TNF drug Rx in situ. Ongoing vigilance in all
patients on therapy is required at all times- even if mantoux negative Dr David Gotlieb |
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