Management of Management of Rheumatoid ArthritisRheumatoid Arthritis

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1. 1. Morning Morning stiffnessstiffness

Morning stiffness in and around the joints, lasting at least 1 Morning stiffness in and around the joints, lasting at least 1 hour before maximal improvement at any time inthe disease hour before maximal improvement at any time inthe disease course.course.

2. Arthritis in at 2. Arthritis in at least three least three joint Areas*joint Areas*

Soft tissue swelling or fluid observed by a physician, with Soft tissue swelling or fluid observed by a physician, with swelling at current examination or deformity and a swelling at current examination or deformity and a documented history of swelling.documented history of swelling.

3.Arthritis of Arthritis of handshands

Swelling of wrist, MCP, or PIP with swelling at current Swelling of wrist, MCP, or PIP with swelling at current examination or deformity and a documented history of examination or deformity and a documented history of swelling.swelling.

4. Symmetric 4. Symmetric arthritisarthritis

Simultaneous involvement of the same joint areas (defined Simultaneous involvement of the same joint areas (defined in 2) on both sides of the body (bilateral involvement of in 2) on both sides of the body (bilateral involvement of PIPs, MCPs, or MTPs is acceptable without absolute PIPs, MCPs, or MTPs is acceptable without absolute symmetry) with swelling at current examination or deformity symmetry) with swelling at current examination or deformity and a documented history of swelling.and a documented history of swelling.

5. Rheumatoid5. Rheumatoid

nodulesnodulesOver bony prominences or extensor surfaces, or in peri-Over bony prominences or extensor surfaces, or in peri-articular regionsarticular regions

6.Rheumatoid6.Rheumatoid

factorfactorDetected by a method positive in less than 5% normal Detected by a method positive in less than 5% normal controls at current examination or documented to have been controls at current examination or documented to have been positive in the past by any assay method.positive in the past by any assay method.

7. Radiographic7. Radiographic

changeschangesTypical of RA on posteroanterior hand and wrist radiographs Typical of RA on posteroanterior hand and wrist radiographs which must include erosions or unequivocal bony which must include erosions or unequivocal bony decalcification localized to or most marked adjacent to the decalcification localized to or most marked adjacent to the involved joints (osteoarthritis changesalone do not qualify).involved joints (osteoarthritis changesalone do not qualify).

*Note: At least four criteria must be fulfilled for classification as RA.

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Autoimmune/Genetic factors?Autoimmune/Genetic factors?

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Other factorsOther factorsSilica Dust ExposureSilica Dust ExposureIncreased risk for RA in smokersIncreased risk for RA in smokersInfections?-Infections?-(EBV)Dietary Factors-Dietary Factors-

? red meat ? red meat

? intake of fruit and oily fish may protect against RA? intake of fruit and oily fish may protect against RA

(Mediterranean diet)(Mediterranean diet)

?Interactions between genes and environment?Interactions between genes and environment

and stochastic factor contributionsand stochastic factor contributions

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Other nutrient factorsOther nutrient factors

Lower intakes of Lower intakes of vitamin C, fruit and vegetables fruit and vegetables (high consumption of the antioxidants (high consumption of the antioxidants cryptoxanthin and zeaxanthin) increased the risk cryptoxanthin and zeaxanthin) increased the risk of inflammatory polyarthritisof inflammatory polyarthritis

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Articular and Peri-articularManifestations

Duration of signs and symptoms at more than 3 Duration of signs and symptoms at more than 3 months was the strongest predictor of RAmonths was the strongest predictor of RA

Duration of signs and symptoms at more than 3 Duration of signs and symptoms at more than 3 months was the strongest predictor of RAmonths was the strongest predictor of RA

Slow, insidious disease onset (70%)Slow, insidious disease onset (70%)Intermediate onset (20%)Sudden acute onset (10%)Complain of pain, stiffness, and swelling of their Complain of pain, stiffness, and swelling of their peripheral jointsperipheral joints

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Clinical FindingsClinical Findings

Examination of the joints reveals tenderness to Examination of the joints reveals tenderness to palpation, synovial thickening, joint effusion, palpation, synovial thickening, joint effusion, redness and warmthredness and warmth

May show decreased range of motion, ankylosis, May show decreased range of motion, ankylosis, and subluxationand subluxation

Upper limb (50%)Upper limb (50%)

multiple joints affected (30%)multiple joints affected (30%)hand only (25%)

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Clinical FindingsClinical Findings

Symmetrical joints involvement (85%)Joints most commonly affected are-The proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints of the hands and wrists, followed by The metatarsophalangeal (MTP) joints of the feet, ankles, and shoulders.

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Radiograph of the left hand. Soft tissue swelling is present around the MCP joints and wrist with diffuse narrowing ofMCP, PIP, and radiocarpal joint spaces. Erosions are seen at the first CMC joint and distal ulna. Periarticular osteopenia surrounds all of the articulations.

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Radiograph of the left wrist Radiograph of the left wrist reveals soft-tissue swelling reveals soft-tissue swelling with narrowing about the with narrowing about the radial carpal joint radial carpal joint associated with early associated with early reactive sclerosis involving reactive sclerosis involving the radial articular surface. the radial articular surface. There is widening of the There is widening of the distal radial–ulnar joint and distal radial–ulnar joint and cysts are present within the cysts are present within the carpal navicular and distal carpal navicular and distal ulna.ulna.

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An MRI of the left wrist of the same patient multiple bony erosions in the ulna, lunate, triquetrum, and distal radius. Complete loss of articular cartilage is with slight ulnar shiftExuberant synovial proliferation with inflamed synovium is seen to enter the large erosion within the distal ulna, illustrating the extensive synovitis that is missed on conventional radiography

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Diffuse swelling of the hand with polyarthritis of the MCPs, PIPs, and wrists seen in remitting seronegative symmetricsynovitis with pitting edema

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Extra-ArticularManifestations

Rheumatoid NodulesRheumatoid NodulesAnemia of chronic Anemia of chronic disease, disease, lymphadenopathylymphadenopathyVasculitis- Vasculitis- sensorimotor sensorimotor neuropathy, nail-fold neuropathy, nail-fold infarcts, leg ulcers, infarcts, leg ulcers, purpura, and digital purpura, and digital gangrenegangrene

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Treatment of Early Arthritis

Nonsteroidal Anti-Inflammatory Drugs- Nonsteroidal Anti-Inflammatory Drugs- do not alter the course of the arthritis and its outcomeGlucocorticoids- Glucocorticoids- Disease-Modifying Antirheumatic DrugsDisease-Modifying Antirheumatic DrugsMethotrexate- favorable risk–benefit ratio, is (as Methotrexate- favorable risk–benefit ratio, is (as in established RA) regarded to be the drug ofin established RA) regarded to be the drug of

first choicefirst choicehydroxychloroquine or sulfasalazine

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QOL assessmentQOL assessment

● ● MobilityMobility

● ● Self-careSelf-care

● ● Usual activitiesUsual activities

● ● Pain/discomfortPain/discomfort

● ● Anxiety/depressionAnxiety/depression

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Specific drugs: MethotrexateSpecific drugs: Methotrexate

Anti folic acid- Anti folic acid- inhibition of proliferation of cells responsible for synovial inflammationDecreases markers of inflammation, including the erythrocyte sedimentation rate and c-reactive protein (CRP)Adverse Effects-low-dose weekly-7.5 to 10 mganorexia, nausea, vomiting, and diarrhea(10%)Hematologic-leukopenia (3%)? cirrhosis and liver failure (1/1000)acute interstitial pneumonitis

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““MTX is currently considered a first-line agent MTX is currently considered a first-line agent in the treatment of RA, and the “anchor drug” in the treatment of RA, and the “anchor drug” for combination therapy with other DMARDs for combination therapy with other DMARDs and biologic agents. It has become the and biologic agents. It has become the standard of care and the most widely used standard of care and the most widely used drug in the treatment of RA.”drug in the treatment of RA.”

2020

Leflunomide

A second choice DMARD to be used after methotrexatehas a long half-life (2 wks) dose:20 mg dailylefl unomide, sulfasalazine, and methotrexate reduced radiologic progression

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Other DrugsOther Drugs

AntimalarialsAntimalarialsSulfasalazineSulfasalazineTetracyclinesTetracyclinesGold SaltsGold SaltsD-penicillamineD-penicillamineAzathioprineAzathioprineCyclosporineCyclosporine