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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

Rheumatoid Arthritis

Dr Jaya Ravindran

Consultant Rheumatologist

Walsgrave Hospital

rheumatoid arthritis2
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)

rheumatoid arthritis3
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)
refer early
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
refer early6
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
useful baseline investigations
Useful Baseline Investigations
  • ESR/PV/CRP
  • FBC
  • U&E/LFT
  • RhF (CCP)
  • ANA
  • Urine dip
  • Radiology (Hands and Feet)
  • (Synovial fluid analysis)
clinical spectrum
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
clinical spectrum12
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
clinical spectrum15
Clinical spectrum
  • C/spine
    • atlantoaxial subluxation
    • subaxial disease
    • Myelopathy
  • Tenosynovitis and tendon rupture
extra articular
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
extra articular22
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
management of ra
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
management of ra25
Management of RA

Surgery

  • Joint arthroplasty
  • Tendon repair
  • Synovectomy
  • C/spine stabilisation
dmards adapted from bsr 2000 and arc 2002 guidelines
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
toxicity
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
toxicity28
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
toxicity29
Toxicity

Renal toxicity and hypertension

  • >1+ blood and/or protein
  • quantify proteinuria (gold, penicillamine)
  • >30% rise in creatinine (cyclosporin)
  • hypertension (leflunomide, cyclosporin)
toxicity30
Toxicity

Other

  • Mucocutaneous and GI
  • Pulmonary – dry cough and dyspnoea
    • MTX, SSZ, gold
biologics
Biologics
  • TNF alpha blockade
  • NICE guidelines
  • Infections esp TB
  • ?Malignancy
  • Others eg MS,CCF
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