Rheumatoid Arthritis
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Transcript of Rheumatoid Arthritis
Rheumatoid arthritis
Dr.Pranob karmakerAssistant Registrar
Medicine Unit-3
Shaheed Suhrawardy Medical College Hospital
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