Rheumatoid ArthritisRheumatoid Arthritis

Anila MalikAnila Malik

GPVTSGPVTS

AimsAims

To cover the following:To cover the following:

What is RA?What is RA?

Diagnostic criteria and clinical featuresDiagnostic criteria and clinical features

Rheumatoid FactorRheumatoid Factor

InvestigationsInvestigations

When to refer?When to refer?

Management of RAManagement of RA

Rheumatoid ArthritisRheumatoid Arthritis

Chronic systemic inflammatory disease Chronic systemic inflammatory disease characterised by symmetrical joint involvement.characterised by symmetrical joint involvement.Typically affects the small joints of the hands Typically affects the small joints of the hands and the feet.and the feet.There are around 400 000 people with RA with There are around 400 000 people with RA with approximately 12000 new diagnoses per year in approximately 12000 new diagnoses per year in the Uk.the Uk.Affects 3 times as many women as men.Affects 3 times as many women as men.Total costs in the Uk has been estimated Total costs in the Uk has been estimated between 3.8 and 4.75£ billion/yearbetween 3.8 and 4.75£ billion/year

OnsetOnset

InsidiousInsidious

AcuteAcute

PalindromicPalindromic

ACR RA Criteria 1987ACR RA Criteria 1987

Morning stiffness >6/52 in and around joints Morning stiffness >6/52 in and around joints lasting> 1hr/daylasting> 1hr/dayArthritis of three or more joint areas involved Arthritis of three or more joint areas involved simultaneouslysimultaneouslyArthritis of at least one area in a wrist, MC or PIP Arthritis of at least one area in a wrist, MC or PIP jointsjointsSymmetrical arthritisSymmetrical arthritisRheumatoid nodulesRheumatoid nodulesPositive serum RFPositive serum RFRadiological changes typical of RA on hand and Radiological changes typical of RA on hand and wrist xrayswrist xrays

NICE GuidelinesNICE Guidelines

NICE recommends clinical diagnosis of NICE recommends clinical diagnosis of RA is more important than meeting all the RA is more important than meeting all the criteria listed in ACR RA classification.criteria listed in ACR RA classification.

The rationale for this is the need to treat a The rationale for this is the need to treat a persistent synovitis quickly in order to try persistent synovitis quickly in order to try and stop irreversible damage to joints.and stop irreversible damage to joints.

When To ReferWhen To Refer

Small joints of the hands or feet are affectedSmall joints of the hands or feet are affected

More than one joint is involvedMore than one joint is involved

There has been delay of 3months or longer There has been delay of 3months or longer between onset of symptoms and seeking between onset of symptoms and seeking medical advice.medical advice.

Also refer persistent synovitis of undetermined Also refer persistent synovitis of undetermined cause whose bloods show normal acute phase cause whose bloods show normal acute phase response and negative rheumatoid factor.response and negative rheumatoid factor.

Clinical FeaturesClinical Features

Poly-arthritisPoly-arthritis

FatigueFatigue

Diffuse musculoskeletal painDiffuse musculoskeletal pain

SwellingSwelling

Morning stiffnessMorning stiffness

Functional lossFunctional loss

Rheumatoid FactorRheumatoid Factor

NICE recommends RF blood test in NICE recommends RF blood test in patients with suspected history and patients with suspected history and examination.examination.

RFs are antibodies against the Fc portion RFs are antibodies against the Fc portion of immunoglobulin G.of immunoglobulin G.

Not specific for RANot specific for RA

Detected in acute and chronic infectionsDetected in acute and chronic infections

RFRF

RF is positive in 60-70% of patient with RA RF is positive in 60-70% of patient with RA and the reminder stay negative throughout and the reminder stay negative throughout the disease.the disease.

RF is abnormal in 5% of the normal RF is abnormal in 5% of the normal population and up to 25% in the elderly.population and up to 25% in the elderly.

Other InvestigationsOther Investigations

FBC, Inflammatory markers, Liver and FBC, Inflammatory markers, Liver and renal function is required before initiating renal function is required before initiating any treatment.any treatment.

NICE recommends anti-cyclic citrullinated NICE recommends anti-cyclic citrullinated peptide (CCP) measurement in patients peptide (CCP) measurement in patients who are negative for RF.who are negative for RF.

Radiology Radiology

Plain Film xray: peri articular swelling, Plain Film xray: peri articular swelling, erosions, osteoporosis, cysts, subluxation erosions, osteoporosis, cysts, subluxation joint space narrowing, ankylosis reactive joint space narrowing, ankylosis reactive sclerosis and osteophytes.sclerosis and osteophytes.

MRI and USS show inflammation of MRI and USS show inflammation of synovial membrane and erosions.synovial membrane and erosions.

Monitoring Disease ActivityMonitoring Disease Activity

Monthly CRP and Disease Activity Score Monthly CRP and Disease Activity Score (DAS28) until treatment has controlled the (DAS28) until treatment has controlled the disease to a pre-determined level agreed disease to a pre-determined level agreed between the patient and the clinician.between the patient and the clinician.DAS28 – consists of following parameters:DAS28 – consists of following parameters:

Number of tender jointsNumber of tender joints Number of swollen jointsNumber of swollen joints inflammatory markers (ESR or CRP)inflammatory markers (ESR or CRP) Patient’s assessment of disease activityPatient’s assessment of disease activity

Cases in remission score < 2.6 and severe Cases in remission score < 2.6 and severe cases >5.1cases >5.1

ManagementManagement

Main Goals:Main Goals:

1.1. Pain reliefPain relief

2.2. Reduction of joint inflammation and Reduction of joint inflammation and damagedamage

3.3. Control of systemic diseaseControl of systemic disease

4.4. Maintaining function and supportingMaintaining function and supporting

5.5. Patient educationPatient education

Non PharmacologicalNon Pharmacological

All patients with RA should have access to a All patients with RA should have access to a multidisciplinary team for periodic assessment of multidisciplinary team for periodic assessment of the disease and its effect on their lives.the disease and its effect on their lives.

This includes a named specialist rheumatology This includes a named specialist rheumatology nurse who is responsible for co-ordinating their nurse who is responsible for co-ordinating their care.care.

Patients should also have access to specialist Patients should also have access to specialist physiotherapist, occupational therapist, physiotherapist, occupational therapist, podiatrist and to behavioural therapists.podiatrist and to behavioural therapists.

PharmacologicalPharmacological

Combination therapy of Disease modifying anti-Combination therapy of Disease modifying anti-rheumatic drugs is the first line treatment in the rheumatic drugs is the first line treatment in the newly diagnosed active RA.newly diagnosed active RA.

Offer short-term glucocorticoids (oral Offer short-term glucocorticoids (oral intramuscular and intra-articular) to rapidly intramuscular and intra-articular) to rapidly improve symptoms.improve symptoms.

Biological therapy is recommended in case of Biological therapy is recommended in case of unsuccessful trials of two DMARDs with a unsuccessful trials of two DMARDs with a disease score of 5.1 on two occassions.disease score of 5.1 on two occassions.

AnalgesiaAnalgesia

NICE recommends the following analgesia for NICE recommends the following analgesia for symptom control:symptom control:

ParacetamolParacetamol codeinecodeine compound analgesicscompound analgesics NSAIDS/COX – 2 inhibitors (lowest effective NSAIDS/COX – 2 inhibitors (lowest effective

dose for the shortest possible time.dose for the shortest possible time.If the above analgesics are not providing If the above analgesics are not providing adequate pain relief then review disease adequate pain relief then review disease modifying or biological drug regimemodifying or biological drug regime

General MeasuresGeneral Measures

Vaccination Vaccination 1.1. annual influenza and one off annual influenza and one off

penumococcal vaccination.penumococcal vaccination.2.2. Live vaccines are contraindicated if Live vaccines are contraindicated if

treated with immunosuppressive agents.treated with immunosuppressive agents.Patient education and self help Patient education and self help

1.1. ARC patient information leafletsARC patient information leaflets2.2. The National Rheumatoid Arthritis The National Rheumatoid Arthritis

SocietySociety

Health ScreeningHealth Screening

CVSCVS

Depression – NICE depression screening Depression – NICE depression screening QsQs

Osteoporosis Osteoporosis

Neurology – sudden loss of function in Neurology – sudden loss of function in lower limbs should prompt exclusion of lower limbs should prompt exclusion of cervical cord myelopathy.cervical cord myelopathy.

Thankyou!Thankyou!