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Management of Rheumatoid Arthritis. *Note: At least four criteria must be fulfilled for classification as RA. Autoimmune/Genetic factors?. Other factors. Silica Dust Exposure Increased risk for RA in smokers Infections?- (EBV) Dietary Factors- ? red meat

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Management of Rheumatoid Arthritis

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Management of rheumatoid arthritis

Management of Rheumatoid Arthritis

Management of rheumatoid arthritis

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

Autoimmune genetic factors

Autoimmune/Genetic factors?

Other factors

Other factors

  • Silica Dust Exposure

  • Increased risk for RA in smokers

  • Infections?-(EBV)

  • Dietary Factors-

    ? red meat

    ? intake of fruit and oily fish may protect against RA

    (Mediterranean diet)

  • ?Interactions between genes and environment

    and stochastic factor contributions

Other nutrient factors

Other nutrient factors

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

Articular and peri articular manifestations

Articular and Peri-articularManifestations

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

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

  • Slow, insidious disease onset (70%)

  • Intermediate onset (20%)

  • Sudden acute onset (10%)

  • Complain of pain, stiffness, and swelling of their peripheral joints

Clinical findings

Clinical Findings

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

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

  • Upper limb (50%)

    multiple joints affected (30%)

    hand only (25%)

Clinical findings1

Clinical 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.

Management of rheumatoid arthritis

Radiograph of the left hand. Soft tissue swelling is present around the MCP joints and wrist with diffuse narrowing of

MCP, PIP, and radiocarpal joint spaces.

Erosions are seen at the first CMC joint and distal ulna.

Periarticular osteopenia surrounds all of the articulations.

Management of rheumatoid arthritis

  • Radiograph of the left wrist reveals soft-tissue swelling with narrowing about the radial carpal joint associated with early reactive sclerosis involving the radial articular surface.

  • There is widening of the distal radial–ulnar joint and cysts are present within the carpal navicular and distal ulna.

Management of rheumatoid arthritis

  • 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 shift

  • Exuberant 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

Management of rheumatoid arthritis

  • Diffuse swelling of the hand with polyarthritis of the MCPs, PIPs, and wrists seen in remitting seronegative symmetric

    synovitis with pitting edema

Extra articular manifestations

Rheumatoid Nodules

Anemia of chronic disease, lymphadenopathy

Vasculitis- sensorimotor neuropathy, nail-fold infarcts, leg ulcers, purpura, and digital gangrene


Treatment of early arthritis

Treatment of Early Arthritis

  • Nonsteroidal Anti-Inflammatory Drugs- do not alter the course of the arthritis and its outcome

  • Glucocorticoids-

  • Disease-Modifying Antirheumatic Drugs

  • Methotrexate- favorable risk–benefit ratio, is (as in established RA) regarded to be the drug of

    first choice

  • hydroxychloroquine or sulfasalazine

Qol assessment

QOL assessment

● Mobility

● Self-care

● Usual activities

● Pain/discomfort

● Anxiety/depression

Specific drugs methotrexate

Specific drugs: Methotrexate

  • Anti folic acid- inhibition of proliferation of cells responsible for synovial inflammation

  • Decreases markers of inflammation, including the erythrocyte sedimentation rate and c-reactive protein (CRP)

  • Adverse Effects-low-dose weekly-7.5 to 10 mg

  • anorexia, nausea, vomiting, and diarrhea(10%)

  • Hematologic-leukopenia (3%)

  • ? cirrhosis and liver failure (1/1000)

  • acute interstitial pneumonitis

Management of rheumatoid arthritis

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



  • A second choice DMARD to be used after methotrexate

  • has a long half-life (2 wks)

  • dose:20 mg daily

  • lefl unomide, sulfasalazine, and methotrexate reduced radiologic progression

Other drugs

Other Drugs

  • Antimalarials

  • Sulfasalazine

  • Tetracyclines

  • Gold Salts

  • D-penicillamine

  • Azathioprine

  • Cyclosporine

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