Rheumatoid Arthritis - PowerPoint

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					Rheumatoid Arthritis
Systemic disease
Primarily Presents as Arthritis
Other Organs can be involved
Etiology not clear probably
Multifactor involved

Can affect ant age
Peak 30-55
Women affected 2-3 times > men
Worldwide affect 1%
Annual incidence about 30/100,000
Prevalence in women > 65 years old 5%
Joint and surrounding
Basic Changes

Chronic synovial inflammation
Joint infiltration by inflammatory cells
Inflammation mechanism

Increasing the production of
 proinflammatory cytokines
Increasing cell migration by activating
 cellular adhesion molecules
Increasing tissue destruction by matrix-
 degrading proteinases
Constitutional symptoms
and signs of systemic
rheumatoid arthritis
Weight loss
Excessive sweating
Low-grade fevers
Morning stiffness
Laboratory features of
rheumatoid arthritis

   Anemia
   Eosinophilia
   Thrombocytosis
   Increased levels of alkaline phosphatase,
 aspartate amino-transferase, and -
 Decreased albumin and prealbumin
 Elevated erythrocyte sedimentation rate
 Elevated C-reactive protein

Rheumatoid factors are antibodies directed
 against the Fc portion of IgG
RF-positive patients with RA may
 experience more aggressive and erosive
 joint disease and extraarticular
 manifestations than those who are RF-
            RF positive conditions
                                     Frequency of
Condition                               RF, percent
Aging (>age 60)                      5 to 25

Bacterial endocarditis*              25 to 50
Hepatitis B or hepatitis C*          20 to 75
Tuberculosis                                      8
Syphilis*                            Up to 13
Parasitic diseases                   20 to 90
Leprosy*                             5 to 58
Viral infection*                     15 to 65
RF positive Pulmonary disease

                                     of RF,
Frequency of RF, percent             percent

Sarcoidosis                       3 to 33

Interstitial pulmonary fibrosis   10 to 50

Silicosis                         30 to 50

Asbestosis                                   30
Other diseases RF positive

Primary biliary cirrhosis      45 to 70

Malignancy                     5 to 25

After multiple immunizations   10 to 15
Anti-cyclic citrullinated peptide
(CCP) antibodies

are as sensitive as, and more specific than,
 IgM rheumatoid factors
may predict the eventual development into
 RA when found in undifferentiated arthritis
are a marker of erosive disease in RA
may be detected in healthy individuals
 years before onset of clinical RA

Typical clinical presentation
RF presence /absence does not make or
 exclude diagnosis but positive RF :more
 extrarticular manifestations and more
Exclude other diseases that may mimic RA
History taking and Exam in RA
   Discussing main points
   Joint pain localized
   Duration since onset
   Past similar history
   Swelling?
   Stiffness ?
   Joint affected small (hands), large
   Skin rash DD of arthritis
   GI symptoms DD of arthritis
   Fever
   Eye symptoms
   Urinary symptoms
   Back pain
   Family history
   Document swelling , deformities, and functional disability
Early RA ,symmetrical synovitis
of MCPs,PIPs,no deformity
Early RA with soft tissue
swelling,involving PIPs Joints
Active severe RA,synovitis
Subluxation and of MCPs,RA
Swan neck and Boutonniere
Longstanding RA,ulnar
RA patient with CTS
Rupture tendon in RA patient
MTPs joints affected in RA feet
MCPs in hands
Soft tissue swelling around MCP
PIP joints,osteoporosis
Distal IP joints erosions
/destruction –psoriatic arthritis,
Ulna styloid erosion
Erosion of   5th   MTP
MTP joints with
Bone uptake in RA,carpal
bones,MCPs and PIPs
Deferential Diagnosis

Viral syndromes
Post Streptococcal/other infections
Psoriatic arthritis,reactive arthritis, and
 other systemic rheumatological diseases
Crystal arthropathy
Septic arthritis, and may coexist

Parvo Virus (B19)mimic RA last from
 months to years
Hepatitis C ,also RF positive
Hepatitis B
Other viruses
Bacterial infections(reactive0

Post streptoccocal
Lyme disease
  Psoriatic arthritis
Can be like RA and difficult to
 differentiate But you may see
Asymmetrical,affect DIP joints while RA
 usually symmetrical.and does not affect
Skin changes of psoriasis
Can affect SI joint and cause low back
 pain,while RA more likely to affect
 Cervical spine
dactylitis ,enthesiopathy in psoriatic
Subcutaneous nodules in RA

Look for Nodules Over Olecranon
 ,Achilles,Occiput and pressure areas
RF positive
More extrarticular manifestations
My worsen with treatment (methotrexate)
Surgery for very large nodules
But can be seen in other Rheumatic
 diseases (SLE,MCTD)
Subcutaneous nodules
Lung nodules in RA
ILD ,Cavitation
Major ocular manifestations

Keratoconjunctivitis sicca
Scleritis:painful and serious
Episcleritis,Superficial but
cause irritation
Scleromalacia :potential serious
Scleromalacia perforance
Marginal corneal disease,and
Vasculitis affecting small
terminal arterioles
Vasculitis and gangrene
Signs of spinal cord damage

Severe neck pain radiating to Occiput
Tingling or numbness in fingers and feet
Motor weakness
Urinary bladder dysfunction
Jumping legs
Posterior displacement of
odontoid process,normal
preodontoid space <3mm
Treatment Goals
Control symptoms
Prevent Progression
Preserve Function
Minimize side effects of treatment
Treat early to prevent joint damage and
Combination therapy works better
Educate patient about disease and
 Symptomatic relieve
 Be aware of side effects:GI toxicity,Fluid
  impairment,hepatic injury
 Use one your familiar with
 COX2 ,less GI toxicity but not 100% GI
  safe ,other side effects may be more
  common,not cardio protective consider add
  ASA if patient has CVS risks

 Very effective ,fast action,used both as
  local as intra-articular injection or
 1-Induction therapy, and to treat flares
 2- bridging therapy till other DMARDS
start to act
 Treat RA vasculitis with DMARDS
 Local injection (into joints or soft tissue)
Steroids side effects ,many

 Osteonecrosis
 Osteoporosis
 Hypertension,accelerated atherosclerosis
 Hyperglycemia
 Wt gain, Fluid retention,Cushenoid
 Adrenal suppression
 Skin thinning,easy bruising,acne like rash

 For mild disease and as part of multi drug
 Usual dose 200mg bid po
 Very safe
 Delayed onset of action :within 3 months
 Retinopathy is rare and only if dosage of >
  6mg/kg is used
 Eye exam q6months to screen for

 Antimetabolite when treating cancer
 Inhibition of inflammation in RA by
  increasing intracellular adenosine and
  inhibit cells that participate in
 Main DMARD for RA
 Used alone or in combination
 Safe if used and monitored appropriately
Methotrexate continue…

Usual starting dose 7.5-10mg given as
 single weekly dose,average dose 15-
 17.5mg,may need 20-25mg
Po absorption is less when dose is higher
 than 15mg ,better if given SQ
Onset of action about 4 weeks
Always give folate supplement to reduce
 adverse effects including stomatitis,hair
 loss,bone marrow suppression
MTX side effects continue..

Hepatic toxicity monitor liver
 transaminases and albumin q 2 months
Hypersensitivity peumonitis :stop MTX in
 case of unexplained cough or SOB
Bone marrow suppression
Other medications

Leflunmide: effective as single or in
 combination 10-20mg qd,may cause
Sulfsalazine :slow acting,helps in
 combination therapy, cause
 myelosuppression,rare heaptotoxicity
Azathioprine :cause
New agents

1-To Block TNF like infliximab, etanercept
2-Block IL1
3-Block IL 6
4-Block Co-stimulatory signal
New biological agents

 Effective as single or combined
 Expensive
 Injection only
 Side effects:local and systemic reaction to
  injection or infusion,opportunistic infection
  and sepsis,(test all for PPD),may trigger
  autoimmune antibodies.
Juvenile Rheumatoid Arthritis

Syndrome of several type of arthritis
Most common chronic disease in children
Incidence 6-19/100,000 and prevalence
Etiology :unknown ,evidence of altered
immunity but exact mechanism and cause no
ACR 1977 Criteria for JRA

Onset < 16 years of age
Persistent arthritis > 6 weeks
  Pauciarticular :< 5 joints
  Polyarticular :> 4 joints
  Systemic       : Fever and rash
Systemic onset JRA

Typical:< 5 Y old child with daily spiking
 fever often in the evenings associated with
 transient macular salmon-pink rash,non-
 pruritic,over trunk and extremities.Rash
 appear with fever and subside when fever
 subside.Temp will go back to normal or
 bellow normal in between episodes.
Arthritis onset may be delayed,typically
 symmetrical polyarthritis with wrists and
 ankles most commonly affected
Other features of systemic JRA

Generalized lymphadenopathy
Uveitis is uncommon
Elevated acute phase reactants
RF and ANA typically negative
Deferential Diagnosis

Infections and febrile illnesses
Other tumors of children
Other connective tissue diseases
Reaction to drugs
 Affect 5 or > joints, 2 main subtypes
 1-RF positive usually > 8 years old,more
  girls,more erosive and aggressive disease
  resemble adult RF+ RA,remission is rare
Uveitis is uncommon but often develop
  pulmonary disease,keratitis,vasculitis and
  Sjogren syndrome
 2-RF negative ,less systemic features,less
  aggressive arthritis,ANA+ 50%. Uveitis is
Pauciarticular JRA
 Early onset type:age 1-5,more girls,often
  ANA+,highest risk of eye involvement 30-
  50%,80% of whom has minimal or no
 Late onset:affects more boys,50%
  HLA+,affect large joints,spine,likely to
  have tendonitis,enthesitis,eye involvement
  less than early onset type
Irregular pupil due synechiae
between the lens and iris Also
hypopyon is seen
Systemic JRA rash
JRA affect growth,leg length
2nd toe is short ,2nd MT bone on
JRA affecting PIPs , MCPs and
wrist joints

Steroids:systemic and intra-articular
TNF blocking

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