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Rheumatoid Arthritis. Dr Jaya Ravindran Consultant Rheumatologist Walsgrave Hospital. RHEUMATOID ARTHRITIS. Background Chronic erosive symmetrical arthritis (extra-articular features) 1% population 2-3X more common in women Peak age onset 3rd to 5th decade

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Rheumatoid Arthritis

Dr Jaya Ravindran

Consultant Rheumatologist

Walsgrave Hospital


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RHEUMATOID ARTHRITIS

Background

  • Chronic erosive symmetrical arthritis (extra-articular features)

  • 1% population

  • 2-3X more common in women

  • Peak age onset 3rd to 5th decade

    (Macgregor et al 1998 in Klippel and Dieppe Rheumatology)

  • Erosions occur early in disease

    (Fuchs et al 1989 J Rheumatol)


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RHEUMATOID ARTHRITIS

Background

  • Functional decline - 10 years work disability 40-60%

    • (Jantti et al 1999 Rheumatol)

  • Premature mortality comparable to coronary artery disease and Hodgkin’s lymphoma

    • (Pincus et al 1994 Ann Intern Med)

  • Economic burden £1.3 billion /year in UK

  • Early treatment works and RA responds better, earlier

    • (Munroe et al 1998 Ann Rheum Dis)



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REFER EARLY!

Who and when to refer (In theory)

  • ARA 1987 Revised Criteria for the classification of Rheumatoid arthritis

  • At least 4 criteria must be filled

  • Morning stiffness > 1 hour > 6 weeks

  • Arthritis of 3 or more joints PIP, MCP, wrist elbow, knee, ankle, MTP > 6 weeks

  • Arthritis of hand joints wrist, PIP, MCP > 6 weeks

  • Symmetric arthritis at least one area > 6 weeks

  • Rheumatoid nodules

  • Positive Rheumatoid factor

  • Radiographic changes


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REFER EARLY!

In practice

  • Anyone with > 3 inflamed joints with symptoms > 6 weeks

  • At presentation

    • rheumatoid factor negative in 60%

    • normal x-rays in 50%

    • no acute phase in 60%

      • (Green et al 2002 Collected reports on the Rheumatic diseases)

  • Atypical presentations - polymyalgic, palindromic, monoarthritis



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Useful Baseline Investigations

  • ESR/PV/CRP

  • FBC

  • U&E/LFT

  • RhF (CCP)

  • ANA

  • Urine dip

  • Radiology (Hands and Feet)

  • (Synovial fluid analysis)



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Clinical spectrum

Articular

  • PIP, MCP, wrists, elbows, shoulders, knees, ankles, MTP

  • C-Spine

  • DIP usually spared

  • Early changes

    • fusiform swelling PIP, MCP and wrist swelling



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Clinical spectrum

Articular

  • Later deformities

    • Swan neck & Boutonniere

    • Z-shaped thumb

    • Ulnar deviation (MCP)

    • Volar subluxation (wrist)

  • Later deformities

    • Hammer, overlapping and claw toes

    • Splayfoot, valgus deviation (MTP)

    • MTP head subluxation

    • pes planus, valgus hindfoot


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Clinical spectrum

  • C/spine

    • atlantoaxial subluxation

    • subaxial disease

    • Myelopathy

  • Tenosynovitis and tendon rupture




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Extra-articular

  • 40% patients

  • Sero-positive

  • Nodules

  • Systemic

    • weight loss, low-grade fever, lymphadenopathy, fatigue

  • Ocular

    • Keratoconjunctivitis sicca

    • scleritis (scleromalacia perforans)

    • episcleritis

  • Pulmonary

    • Alveolitis and lung fibrosis,

    • nodules

    • pleural effusions

    • BOOP

    • Caplans


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Extra-articular

  • Cardiac

    • Carditis, conduction disturbances, coronary arteritis

  • Vasculitis

    • ischaemia and infarction (eg leg ulcers, mononeuritis multiplex)

  • Felty’s syndrome

  • Amyloidosis

    • nephrotic syndrome, cardiac, malabsorption

  • Anaemia

    • chronic disease & drugs

  • Osteoporosis



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Management of RA

Multidisciplinary

  • Effective in RA

    • Vliet Vlieland et al 1997 Br J Rheumatol

  • GP, rheumatologist, nurse specialist, PT, OT, podiatrist, orthotist, surgery

  • Education - team, leaflets, resources from organisation/support groups

  • OT – activities of daily living, equipment and adaptations, splinting

  • PT – dynamic exercise therapy and hydrotherapy

  • Podiatry and orthotics – insoles, shoes, intervention for callosities


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Management of RA

Surgery

  • Joint arthroplasty

  • Tendon repair

  • Synovectomy

  • C/spine stabilisation


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DMARDs (adapted from BSR 2000 and ARC 2002 guidelines)

  • Monotherapy used in majority of patients

  • Combination therapy and use of steroids

    • evidence less clear-cut and perhaps reserved for poor responders/aggressive disease

    • Steroids - bridge therapy’

  • Onset of action 6 weeks to few months

  • Monitoring – “joint” responsibilty

    • GP / Rheumatologist / patient

    • local / national guidelines / shared cared monitoring cards

    • trends important


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Toxicity

Bone marrow toxicity

  • Thrombocytopenia, leucopenia or pancytopenia

    • WBC<4 (neut<2)

    • Plts<150

  • Sorethoat, mouth ulcers, flu-like illnesses, bleeding, bruising

  • Isolated anaemia very rare and tends to be due to other causes.

    • Methotrexate, sulphasalazine, gold, azathioprine, penicillamine, cyclosporin, leflunomide, cyclophosphamide, chlorambucil


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Toxicity

Liver toxicity

  • Raised ALP common in active RA and by itself does not usually suggest liver toxicity

  • >2 X increase in AST or ALT or unexplained falling albumin

    • Methotrexate, sulphasalazine, azathioprine, cyclosporin, leflunomide


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Toxicity

Renal toxicity and hypertension

  • >1+ blood and/or protein

  • quantify proteinuria (gold, penicillamine)

  • >30% rise in creatinine (cyclosporin)

  • hypertension (leflunomide, cyclosporin)


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Toxicity

Other

  • Mucocutaneous and GI

  • Pulmonary – dry cough and dyspnoea

    • MTX, SSZ, gold


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Biologics

  • TNF alpha blockade

  • NICE guidelines

  • Infections esp TB

  • ?Malignancy

  • Others eg MS,CCF


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