rheumatoid arthritis

Rheumatoid Arthritis Anand Lal, M.D. Rheumatoid Arthritis • Chronic systemic inflammatory disease of unknown etiology • Affects the Synovial Membranes of multiple joints • Prevalence 1-2% • Female : Male ratio 3:1 • Usual age of onset 20-40 years though individuals of any age group may be affected Rheumatoid Arthritis • Pathologic finding: chronic synovitis with pannus formation. The pannus erodes cartilage, bone, ligament and tendons. In the acute phase effusion and other manifestations of inflammation are evident; in the later stages ankylosis of the joint may set in. In both the acute and chronic phase, there may be widespread inflammation of the tissues around the joint that can lead to significant joint destruction. Rheumatoid Arthritis • Clinical presentation – usually presents insidiously; – prodromal syndrome of malaise, weight loss and vague periarticular pain and stiffness may be seen – less commonly, the onset is acute, triggered by a stressful situation such as infection, trauma, emotional strain or in the postpartum period. – the joint involvement is characteristically symmetric with associated stiffness, warmth tenderness and pain Rheumatoid Arthritis • Clinical Features – the stiffness is characteristically worse in the morning and improves during the day; its duration is a useful indicator of the activity of the disease. The stiffness may recur especially after strenuous activity. – the usual joints affected by rheumatoid arthritis are the metacarpophalangeal jts, the PIP jts, the wrists, knees, ankles and toes. – Entrapment syndromes may occur especially carpal tunnel syndrome Rheumatoid Arthritis • 20% of patients with rheumatoid arthritis will have subcutaneous nodules, usually seen over bony prominences but also observed in bursa and tendon sheaths; these nearly always occur in seropositive patients as do most other extraarticular manifestations • splenomegaly and lymphadenopathy can occur • low grade fever, anorexia, weight loss, fatigue and weakness can occur Rheumatoid Arthritis • After months to years, deformities can occur; the most common are – ulnar deviation of the fingers – swan neck deformity, which is hyperextension of the distal interphalangeal joint and flexion of the proximal interphalangeal joint – boutonniere deformity, which is flexion of the distal interphalangeal joint and extension of the proximal interphalangeal joint – valgus deformity of the knee Rheumatoid Arthritis • Dryness of the eyes, mouth and other mucus membranes is found, especially in advanced disease • Pericarditis and pleuritis can occur but are usually clinically silent • aortitis can occur as a late complication, usually associated with vasculitis; rupture of the aorta can lead to aortic regurgitation Rheumatoid Arthritis • Labs – Rheumatoid factor, an IgM antibody is seen in the sera of 75% of patients with rheumatoid arthritis. High titers of rheumatoid factor are associated with severe disease. – Rheumatoid factor is also found in other diseases like syphilis, sarcoidosis, infective endocarditis, TB, leprosy, parasitic infections; in advanced age and in asymptomatic relatives of patients with rheumatoid disease. – Antinuclear antibody are seen in 20% of patients with rheumatoid arthritis, though their titer is lower than in SLE Rheumatoid Arthritis • Labs – The ESR is elevated both in the acute and chronic phases of the disease – a moderate anemia is often present which is usually hypochromic normocytic – the white count is normal or slightly increased but leukopenia may occur, often in presence of splenomegaly (e.g., Felty’s syndrome) – the platelet count is often elevated in proportion to the degree of joint inflammation Rheumatoid Arthritis • Labs – joint fluid examination is valuable. The fluid is translucent to opaque and has between 3000 and 50,000 WBCs /microL. There are 50% or more polymorphonuclear leukocytes. The culture is negative. • X-ray – of all the laboratory tests, x-ray changes are most specific for rheumatoid arthritis. However, they are not sensitive and usually are negative during the first 6 months of the disease Rheumatoid Arthritis • X-rays – the earliest changes occur in the wrist or feet and consist of soft tissue swelling and juxta-articular demineralization. Later, diagnostic changes consisting of joint space narrowing and erosions develop. The erosions are first seen at the ulnar styloid and at the juxta-articular margin, where the bony surface is not protected by cartilage. Diagnostic changes also occur in the cervical spine with C1-2 subluxation, but this can take several years to develop. Rheumatoid Arthritis • 1987 American College of Rheumatology Revised criteria for the diagnosis of Rheumatoid Arthritis: – At least four of the following • • • • Morning stiffness > 1hour Synovitis in three joints simultaneously Synovitis in wrist or hand MCP or PIP joints Symmetrical arthritis (some joint areas on both sides of the body) • Rheumatoid nodules • Serum rheumatoid factor • Radiographic changes typical of Rheumatoid Arthritis Rheumatoid Arthritis • Differential Diagnosis – Rheumatic fever: migratory arthritis, elevated ASO and dramatic response to Aspirin – Systemic Lupus Erythematosus: Butterfly rash, discoid lupus erythematous, photosensitivity, alopecia, high titers of Anti Ds-DNA, renal and CNS disease – Osteoarthritis: no constitutional manifestations and no evidence of joint inflammation – Gouty Arthritis: usually monoarticular initially but can become polyarticular in the later years Rheumatoid Arthritis • Differential Diagnosis – Pyogenic arthritis: usually monoarticular, fever and chills, abnormal joint fluid – Chronic Lyme disease: commonly monoarticular and associated with positive titers – Human Parvovirus infection: arthralgia more common than arthritis, rash may be present, serologic evidence of parvovirus B19 infection – Polymyalgia rheumatica is associated with proximal muscle weakness and stiffness Rheumatoid Arthritis • Differential Diagnosis – several cancers produce paraneoplastic syndromes including polyarthritis; e.g., hypertrophic pulmonary osteoarthropathy produced by lung and gastrointestinal cancers. Diffuse swelling of the palmar fascia has been associated with several cancers including ovarian cancer. Rheumatoid Arthritis • Treatment – goal of treatment • reduce inflammation and pain, • preservation of function, and • prevention of deformity. Rheumatoid Arthritis • Treatment – Nonpharmacologic treatment • • • • • • Education and emotional factors Physical and occupational therapies Systemic and articular rest Exercise Heat and cold Assistive devices like splints, canes, raised toilet seat and/or crutches or walker • Weight loss Rheumatoid Arthritis • Treatment – Nonsteroidal Anti-inflammatory agents like aspirin: usually given in a dose of 1 gram three to four times per day. If patients develop tinnitus, a common side effect, the dose should be reduced by .6-.9 grams every 3 days until the patient improves. Enteric coated aspirin and nonacetylated forms of aspirin like salsalate may be associated with less GI distress. GI irritation may also be reduced by taking the aspirin with meals or antacids. Rheumatoid Arthritis • Treatment – Other NSAIDs: Ibuprofen, naproxen, sulindac and other NSAIDs may also be effective though they are associated with a number of side effects including • GI irritation and peptic ulcers (misoprostol can reduce the incidence of peptic ulcers associated with NSAIDs) • Kidney damage • Liver damage Rheumatoid Arthritis • Treatment (Disease Modifying Agents (DMARDs) – Methotrexate: considered by many to be the drug of choice for RA. It produces a beneficial effect in 2-6 weeks and is given once weekly. The usual dose is 7.515 mg once a week. The most common side effect is gastric irritation and stomatitis. Other side effects are hepatotoxicity, pancytopenia and interstitial pneumonitis. Rheumatoid Arthritis • Treatment – Antimalarials such as hydroxychloroquine sulfate is effective in 25-50% of patients and in most cases after 3-6 months of therapy. It is reserved for mild disease. – Gold salts are used, especially in cases where patients are not responding to Methotrexate or in case of erosive disease. – Corticosteroids produce immediate and dramatic antiinflammatory benefit but are limited by their many side effects Rheumatoid Arthritis • Treatment – Sulfasalazine is a good second line agent for rheumatoid arthritis with an efficacy similar to gold and penicillamine. Side effects include neutropenia and thrombocytopenia. – Azathioprine is an antimetabolite which is reserved for use in case of severe cases. – Penicillamine Rheumatoid Arthritis • Prognosis – Patients can follow two divergent courses: 50-75% experience remission in 2 years (these patients are negative for rheumatoid factor and have good functional status even during disease activity). Conservative therapy is advised for this group. Patients who have severe disease have a worse prognosis, and on an average die 10-15 years earlier than people without RA. Since most of the joint damage occurs in the first two years, these patients should be started on a disease modifying agent early. Rheumatoid Arthritis • Juvenile chronic arthritis is similar to rheumatoid arthritis but is seen in children. Synovitis persisting for 6 weeks is essential to making this diagnosis. Four forms are recognized: – polyarticular form resembles adult RA – oligoarticular form affects young girls during peak ages of 2-4 – systemic onset disease or Still’s disease is characterized by fever and rash – a juvenile form of ankylosing spondilitis