Rheumatoid

ArthritisMuhammad HussainGoran Muhammad

Huzaifa Hamid

INTRODUCTION EPIDEMOLOGY ETIOLOGY PATHOGENESIS RISK FACTORS DISTINCTIVE CLINICAL FEATURES COMPLICATIONS INVESTIGATIONS TREATMENT Non –Pharmacological pharmacological• PREVENTION CONCLUSION

CONTENTS

Rheumatoid arthritis (RA) is an autoimmune disease that causes

chronic inflammation of the joints & can also cause inflammation of the tissue around the joints, as well as in

other organs in the body.

An autoimmune disease is a disease where the immune

system attacks healthy parts of the body.

As it can affect multiple other organs of the body, RA is referred to as a systemic illness and is sometimes called rheumatoid disease.

Introduction

Diagram showing the affected organ

Comparison of normal joint and

affected joint

A joint (the place where two bones meet) is surrounded by a capsule

that protects and supports & it is lined with a type of tissue called Synovium, which produces synovial fluid that lubricates and nourishes joint tissues

It becomes inflamed, causing warmth, redness, swelling, and pain & unable to move freely

As the disease progresses, the inflamed synovium invades and damages the cartilage and bone of the joint. Surrounding muscles, ligaments, and tendons become weakened

This process eventually leads to deformity and destruction of the joints

RA also can cause more generalized bone loss that may lead to osteoporosis (fragile bones that are prone to fracture)

RA Contd…

The incidence of RA is in the region of 3 cases per 10,000

population per annum. Onset is uncommon under the age of 15 and from then on the incidence rises with age until the age of 80.

Some Native American groups have higher prevalence rates (5–6%) and people from the Carribean region have lower prevalence rates.

First-degree relatives prevalence rate is 2–3% and disease genetic concordance in monozygotic twins is approximately 15–20%.

Epidemiology

The cause of RA is unknown. It is assumed that a genetically

susceptible host is exposed to an unknown antigen & this interaction gives rise to a persistent immunological response

The activation of immune response is triggered by the following factors.

They are:- GENETIC FACTORS:-RA is documented by presence of

immune cell reactivity and production of antibodies to endogenous elements such as immunoglobulins,collagen,andcellular components

Etiology

PRESENCE OF HLA (human lymphocyte antigen):-The most

definite genetic association with RA is with HLA alleles.The HLA-DR4 allele is associated with development & severity of RA.

Risk of an individual with HLA-DR4 to develop the disease is between 2 & 6. In American Whites,60-70% of RA patients are positive for HLA-DR4.

Frequency of this allele among Dutch patients is greater than 90%.

Contd…

There is a 30% concordance in monozygotic twins compared to

5% in fraternal twins and first degree relatives.

First degree relatives of patients develop RA at 4-6 times the rate of standard population rate.

INFECTIOUS FACTORS:- Presence of Epstein-Barr virus as antigen. Of patients with RA ,80% have a circulating antibody directed against antigens specific for this virus.

Parvovirus particularly B19 & also Mycobacteria(as it expresses HSP,heat sensitive protein)have been linked to RA.

Contd…

ENDOCRINOLOGIC FACTORS:-. disease may improve

during pregnancy and flare after pregnancy. Breastfeeding may also aggravate the disease

Contraceptive use reduces the risk of developing RA. This suggests possible deficiencies or changes in certain hormones, may promote the development of RA

ENVIRONMENTAL FACTORS:-Changes in barometric pressures are associated with acute worsening of RA. Besides climate,diet,trauma are also known to influence RA.

Contd…

RA is characterised by the infilteration of various

inflammatory cells into the joint The synovial membrane becomes highly vascularised &

synovial fibroblasts proliferate & inflammatory cells release numerous CYTOKINES & GROWTH FACTORS into the joint

These agents cause synovial cells to release proteolytic enzymes &Proliferating inflammatory tissue (PANNUS-tissue serving as origin of joint erosions) subsequently leads to the destruction of intra articular & peri articular structures leading to the joint deformities and dysfunction

Pathogenesis

Gender Age Family history Smoking Overweight HLA gene

Risk factors

Tender, warm, swollen joints Symmetrical pattern of affected joints Joint inflammation often affecting the wrist and finger joints

closest to the hand Joint inflammation sometimes affecting other joints, including

the neck, shoulders, elbows, hips, knees, ankles, and feet Fatigue, occasional fevers, a general sense of not feeling well Pain and stiffness lasting for more than 30 minutes in the

morning or after a long rest Variability of symptoms among people with the disease

Distinctive clinical features of RA

Symmetrical pattern of affected joints

Since RA is a systemic disease, its inflammation can affect

organs and areas of the body other than the joints like eyes,skin,lungs,heart & blood vessels

Examples of other areas that may be affected include:- SJOGREN’S SYNDROME:-inflammation of the glands of the

eyes and mouth and causes dryness of these areas PLEURITIS causes chest pain with deep breathing or coughing Tissue inflammation surrounding the heart, PERICARDITIS

Complications

Rheumatoid disease can reduce the number of red blood cells

ANEMIA and white blood cells. Decreased white cells can be associated with an enlarged spleen

i.e FELTY'S SYNDROME and can increase the risk of infections.

RHEUMATOID NODULES can occur around the elbows and fingers where there is frequent pressure.

VASCULITIS rare and serious complication is blood-vessel inflammation which can impair blood supply to tissues and lead to tissue death. This is most often initially visible as tiny black areas around the nail beds or as leg ulcers.

EROSIVE CHANGES GIVE RISE TO JOINT INSTABILITY

&SUBLUXATION.CHARACTERISTIC DEFORMITIES INCLUDE ULNAR

DEVIATION,SWAN NECK,BOUTONNIERE SYNDROME.

Are made after a full medical and family history and physical

and diagnostic testing are evaluated by a qualified health care professional.

Medical testing may include a wide variety of tests like:- ESR (Erythrocyte Sedimentation Rate CRP (C – Reactive prot ) INFLAMMATORY RF (Rheumatoid factor)blood tests MARKERS ANA (Anti nuclear antibodies) JOINT X-RAYS MRI (Magnetic resonance imaging) & US (ultra sound)

Investigations

ESR…It is a test that measures how fast red blood cells

(erythrocytes) drop to the bottom of a collection tube.

CRP…C-reactive protein, another common test for inflammation is useful both in making a diagnosis and monitoring disease activity and response to anti-inflammatory therapy.

RA FACTOR… is an autoantibody that is present in the blood of most people with RA & directed against host immunoglobulin & present in 75-80% in patients with RA.

• ANA ….These are investigated to rule out possibility of other

connective tissue disorders like SLE. ANA’s are raised in 80% of patients with SLE & 20% of patients with RA.

• X-RAYS….Erosions can be seen at the joint margins & loss of joint space due to erosion of cartilage & bone may be identified.

• MRI & US SCAN…used to detect inflammatory activity. so these are increasingly used to detect early changes in RA patients.

Laboratory tests include an • elevated alkaline phosphatase, elevated platelet count, decreased serum albumin level

Anti-CCP antibodies: This blood test detects antibodies to cyclic citrullinated peptide (anti-CCP). This test is positive in most people with RA

and can even be positive years before rheumatoid arthritis symptoms develop.

Goals of Treatment Relieve pain Reduce inflammation Slow down or stop joint damage Improve a person's sense of well-being and ability to

function. Current Treatment Approaches Lifestyle Medications Surgery Routine monitoring and ongoing care.

Treatment

Physiotherapy is a vital part of treating RA Heat,cold and electrotherapy helps to reduce pain and swelling program of exercise strengthens joints & minimize deformity

and increase the range of movement and functions Natural treatments include using massage with herbs,magneto

therapy etc Occupational therapy educates patients to protect joints with the

use of appliances and splints. Surgical techniques can be effective in relieving pain and

restoring function.

Non-Pharmacological

• ANALGESICS –used only for pain relief

Eg:-Paracetamol-325 to 650mg every 4-6hrs or 1gm 3-4 times/day

Topical Analgesic(Capsaicin)-apply 3-4 times/day• NSAID’s-used as an adjunct along with DMARD’s to reduce

the inflammation

Eg:-Ibuprofen-1.2-3.2 gms/day in 4 divided doses TID

Aspirin-325-650mg for every 4hrs for pain

3,600mg for inflammation 4 times daily

NSAID’S mainly act by inhibiting COX -1 &2 enzymes blocking COX enzyme site & thus reduces inflamation

Pharmacological

CORTICOSTEROIDS-used because of their anti inflammatory &

immunosuppressive property

Eg:-Prednisone & methyl prednisolone given orally or IV,IM-7.5mg daily as single dose/infusion

-Act by suppressing the cytokines

• DMARD,s(disease modifying anti-rheumatic drugs)-used to slow down the progression of disease

• These include METHOTREXATE-5 to 25 mg once weekly;Oral or IM• SULFASALAZINE-initially 500mg OD,increasing in weekly steps 0f

500mg to 1gm BD

The primary purpose is to reduce pain, improve the affected

joint’s function, and improve the patient’s ability to perform daily activities

Joint replacement:involves removing all or part of a damaged joint and replacing it with synthetic components.

Most commonly replaced joints are the hips and knees.

Current Surgery Approaches

Arthrodesis (fusion): is a surgical procedure that involves

removing the joint and fusing the bones into one immobile unit, often using bonegrafts from the person’s own pelvis

useful for increasing stability and relieving pain in affected joints

Tendon reconstruction: RA can damage and even rupture tendons, the tissues that attach muscle to bone

reconstructs the damaged tendon by attaching an intact tendon to it

Routine monitoring and ongoing care: Regular medical care is

important to monitor the course of the disease, determine the effectiveness and any negative effects of medications, and change therapies as needed

Healthful diet:- overall nutritious diet with enough—but not an excess of—calories, protein, and calcium is important

Those taking methotrexate need to avoid alcohol as most serious long-term side effects is liver damage

General Approaches

Stress reduction:- Stress also may affect the amount of pain a

person feels Regular rest periods can help, as can relaxation, distraction, or

visualization exercises Joint care:- using a splint for a short time around a painful joint

reduces pain and swelling by supporting the joint and letting it rest

Rest and exercise:- good balance between rest and exercise is required

They reduce active joint inflammation and pain and to fight fatigue,maintaining healthy and strong muscles, preserving joint mobility, and maintaining flexibility

There is no known way to prevent RA because the exact cause of the

disease is not known

Preventive measures can be taken only after diagnosis of the disease.

But making some modifications in :-

Diet(consume nutritious food )

Relaxed Life style

Avoiding smoking & alcohol consumption

Maintaining ideal body weight

Exercises like swimming,cycling ,yoga can prevent the increased risk of RA.

Prevention

RA is the most common inflammatory disease affecting 1% of

population & can affect virtually every area of a person’s life from work life to family life

One study showed that more than a quarter of women stopped working within 4 years after being diagnosed with rheumatoid arthritis &also interferes with the joys and responsibilities of family life

Fortunately, current treatment strategies, including pain-relieving drugs and medications that slow joint damage, a balance between rest and exercise, and patient education and support programs, allow most people with the disease to lead active and productive lives

Conclusion

Thank You