Rheumatoid arthritis

Dr.Pranob karmakerAssistant Registrar

Medicine Unit-3

Shaheed Suhrawardy Medical College Hospital

dr.pranob@yahoo.com

Key Features• Chronic diesease • Symmetric, inflammatory polyarthritis • Autoimmune• Females > Males• Symptoms > 6 wks• Morning stiffness > 1 hr• > 3 joints involved• Spares:

Thoracolumbar spine DIP of fingers

Prevalence of RA• 1.2 million have RA

• 46 million have an arthritic condition, including

RA

• Incidence of RA peaks around age 60

Pathogenesis

• Synovial Hyperplasia• Hypercellularity• Inflammatory cells• Joint effusions• Pannus

– Invasive synovium– Erodes cartilage and bone– Unique to RA

Etiology/Risk Factors• Genetic

– Monozygotic twins• 15-30% concordance

– HLA-DR4• Shared epitope• HLA-DRB1

– Homozygosity• Increased risk• Increased severity

• Gender– Nulliparity– 3 mo. after pregnancy

• Infections– Proteus, Mycoplasma– EBV, Parvo, HTLV-1

• Cigarette smoking• Age

Clinical Features• Morning stiffness = hallmark of inflammatory

joint disease

• Joint inflammation – Synovitis/Effusions

– Warmth, swelling, (erythema)

• Structural changes

– Cartilage loss, bony erosions, periarticular damage

Joint Distribution

• Predominantly peripheral synovial joints– Hand and Feet

• Hands predominate– Wrist– MCP’s– PIP’s– Not DIP’s

Rheumatoid arthritis

• small joints of hands and feet affected first, larger joints later

RA Hand Deformity

• Ulnar deviation at MCP’s

• Radial deviation at wrists

• Swan-neck deformities• Boutonniere

deformities

• Tendon nodules• Tendon rupture

– 3rd, 4th, and 5th extensor tendons

• Carpal tunnel syndrome

• Ulnar neuropathy

Synovitis

RA - hands

Swan neck and Boutonniere

Ulnar deviation

extensor tendon rupture

Raynaud’s Phenomenon

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome

RA - Knees• Symmetric lateral and medial joint space loss

• Effusions

• Synovial proliferation

• Baker’s cyst

– Posterior herniation of joint capsule

– May rupture

Popliteal Cyst

Ruptured Baker’s Cyst

RA - feet• MTP synovitis

– Direct palpation

– Global lateral/medial squeezing

• MTP subluxation

– Cock-up deformities of toes

– Callous formation on soles

• Ankles - synovitis/effusions

– Tarsal tunnel syndrome -- medial foot and sole paresthesias

MTP subluxation

Cock-up deformity

RA - Cervical Spine• Apophyseal joint destruction

– C4-5 and C5-6 most common

• Atlantoaxial Instability

– C1-C2

– Tenosynovitis of transverse ligament of C1

– Erosion of odontoid process of C2

• Cranial settling

– Neck/Occiput pain, Paresthesias, Pathologic reflexes

Atlantoaxial Instability

RA—Extraarticular Features

• Constitutional sx’s– Fever/fatigue/wt loss

• Osteopenia• Muscle weakness• Skin• Eye• Lung

• Kidney• Cardiac• Vascular• Sjogren’s• Neurologic• Hematologic

– Felty’s

Extraarticular Features

• Rheumatoid nodules (15%)

– Central necrosis surrounded by palisading

fibroblasts and lymphocytes

– Subcutaneous, bursal, tendon sheaths

– Extensor surfaces / Pressure points• Forearms• Achilles• Ischial area• MTP’s • Flexor surface of fingers

Rheumatoid nodules

Rheumatoid nodules

Rheumatoid nodules

RA - Chronic changes

Extraarticular manifestations

• Vasculitis

– Leukocytoclastic vasculitis

• Palpable purpura

– Vasculitic lesions on fingers

– Mononeuritis multiplex

– Visceral involvement (PAN)

RA - Vasculitis

RA - Vasculitis

Extraarticular RA -- Ocular• Sicca symptoms• Episcleritis• Scleritis

Scleromalacia perforans

Xerophthalmia (Dry Eyes)

Extraarticular Manifestations• Pulmonary

– Pleural effusions

– Interstitial lung disease

– Nodules

• Cardiac

– Pericarditis -- < 10% clinically

– Myocarditis

– Atherosclerosis – 3X increased risk of CAD

RA: Pulmonary nodules

RA: Pulmonary fibrosis

Pleural Effusion

Hematologic– Anemia of chronic disease

• Low Fe, Low TIBC, Ferritin > 40 - 100

– Felty’s syndrome

• Triad

– RA

– Splenomegaly

– Neutropenia

• Frequent infections/Leg ulcers

– Iron deficiency anemia (NSAIDs)

Laboratory tests

• ESR & CRP

• RF (usually IgM)

• ANA

• Anti-CCP (cyclic citrullinated peptide)

Laboratory – RF

• Rheumatoid Factor

– Antibody against the Fc fragment of Ig

– Not sensitive

• 80% of RA patients

– RF+ patients more likely to have

• More severe disease

• Extraarticular manifestations

Radiography• Periarticular osteopenia

• Symmetric joint space loss

• Marginal erosions

• Absence of productive changes

• Best films for diagnosis:

– Bilateral Hand Arthritis Series

– Bilateral Foot Series

• Larger joints may not show erosions early due to

thicker cartilage.

RA - Erosions

Periarticular OsteopeniaJoint Space Narrowing

ErosionsMal-Alignment

Classification Criteria for RA ≥ 4 criteria present > 6 wks

• Morning stiffness > 1

hour

• Arthritis of ≥ 3 joints

areas (PIP, MCP, wrist,

elbow, knee, ankle, and

MTP)

• Arthritis of hand joints

(wrist, MCP, PIP)

• Symmetric arthritis

• Rheumatoid nodules

• RF+

• Radiographic

changes

– Erosions

– Unequivocal

periarticular

osteopenia

Definitions

≥6 = definite RA

JOINT DISTRIBUTION (0-5)1 large joint 0

2-10 large joints 1

1-3 small joints (large joints not counted) 2

4-10 small joints (large joints not counted) 3

>10 joints (at least one small joint) 5

SEROLOGY (0-3)Negative RF AND negative ACPA 0

Low positive RF OR low positive ACPA 2

High positive RF OR high positive ACPA 3

SYMPTOM DURATION (0-1)<6 weeks 0

≥6 weeks 1

ACUTE PHASE REACTANTS (0-1)Normal CRP AND normal ESR 0

Abnormal CRP OR abnormal ESR 1

Definition of “SYMPTOM DURATION”Refers to the patient’s self-report on the maximum duration of signs and symptoms of any joint that is clinically involved at the time of assessment.

DAS 28

DAS28 provides you with a number on a scale

from 0 to 10(9.3) indicating the current activity

of the rheumatoid arthritis of the patient.

• DAS28 above 5.1 : high disease activity

• DAS28 below 3.2 : low disease activity

• DAS28 lower than 2.6 : Remission

(comparable to ARA remission criteria)

Pleasure

Work

Cooking

Cleaning

Shopping

Dressing

Bathing

Grooming

The Big Bang90% of the joints involved in RA are affected

within the first year

SO TREAT IT EARLY

Treatment• NSAIDs

• DMARDs = disease modifying anti-rheumatic drugs.

• Biologic:anti- TNF, Abatacept, Etanercept, Rituximab,

Infliximab, Adalimumab

• Non- biologic:Methotrexate, Leflunamide,

Sulfasalazine, Hydroxychloroquine, Minocycline, Gold

• Steroids

DMARDs• 1st line: MTX, leflunomide,

hydroxychloroquine, or sulfasalazine

• 2nd line: anti-TNF Ab’s

– Etanercept

– Infliximab

– Adalimumab

• 2nd line: also Cyclsporine and combo’s

Treatment of Rheumatoid Arthritis: DMARDs

*Physicians’ Desk Reference, 1998. Recommended doses are not necessarily those utilized in clinical practice.

Agent

AzathioprineCyclosporinGold, oralGold, parenteral

HydroxychloroquineLeflunomideMethotrexateD-PenicillamineSulfasalazine

Recommended Dose *

1.0-2.5 mg/kg/d2.5-4.0 mg/kg/d6-9 mg/d

25-50 mg every 2-4 weeks following initial weekly titration doses

200-400 mg/d

100 mg x 3 days loading; 20

mg/q.d.

7.5-20 mg/wk125-750 mg/d0.5-3.0 g/d

Prognostic Features

• RF & Anti-CCP antibodies

• Early development of multiple inflamed joints and

joint erosions

• Severe functional limitation

• Female

• HLA epitope presence

• Lower socioeconomic status & Less education

• Persistent joint inflammation for >12 weeks