Rheumatoid Arthritis

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Rheumatoid Arthritis
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RhA

• Chronic progressive and debilitating
• Rapidly advancing research, mechanism leading to
  joint damage and arthritis, revealing targets for
  therapy

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history

• Typically femalegtmales
• Short history of few weeks to 2-3/12
• c/o joint and muscle pain, fatigue
• Shorter history of joint swelling-(puffy fingers,
  rings getting tighter) hands and wrist swelling.
• Occasional systemic features-wt loss, appetite
  loss, pyrexia. These need to be Ix to exclude
  other conditions

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Joint pain

• Pain worse in the morning
• Gets better as the day goes on
• Worse with resting, better with gentle
  mobilisation
• Associated with marked early morning
  stiffnessgt1hr. Need to differentiate this from
  actual joint pain.
• Pts with PMR have predominant EMS compared to
  joint pain

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Pain

• NSAIDs far more effective than simple analgesics,
  and codeine based analgesia.

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Signs

• Synovitis- warm, tender and soft tissue swelling
• Symmetrical disease
• Affect small joints before larger weight bearing
  joints.
• Signs can be masked by both NSAIDs and steroids
  making diagnoses difficult

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Signs

• Early disease-B/L index and middle mcps going on
  to affect pips
• B/L little mcps going to pips.
• B/L wrists then elbows and ankles.
• Tender shoulders, elbows and pain elicited on
  squeezing mtps.

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Investigations

• Elevated inflammatory markers-both crp and esr.
  This will give an indication of an inflammatory
  process. May only be marginally elevated compared
  to large inflamed OA knee. The mass of synovial
  tissue inflamed is proportional to the
  inflammatory markers
• Note amount of adipose tissue also associated
  with elevated esr

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Investigations

• FBC normochromic normocytic anaemia, low wcc and
  plats may indicate a lupus cross-over disease
  entity.
• LFTs- exclude synovitis secondary to hepatitis
• UEs-ensure safe to continue prescribing NSAIDs
  /-DMARDS.

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Rheumatoid factor

• Should not be used as a screening tool.
• Positive in 5-10 of the normal population,
  higher as the population ages.
• Frequently positive in elderly patients with
  normal aches and pains but no inflammatory
  arthropathy
• Up to 20 of patients with RhA are sero-negative.

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Rheumatoid Factor

• Only check RF if patient has inflammatory type
  pain with elevated inflammatory markers and
  evidence of synovitis
• Patients with non-inflammatory pain and a
  positive RF will need other causes excluded

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Non-rheumatological RF

• Malignancies-lymphoma
• Tb, syphillis, leprosy, viral infection (incl hep
  b and c)
• Interstitial pulmonary fibroses
• Silicoses
• Asbestoses
• Primary billiary cirrhoses

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Other Investigations

• Anti-CCP(cyclic cytrullinated protein) only
  available for requesting from rheumatology
  department. Not a screening tool
• More specific for RhA than RF. 98 specificity
  for RhA.
• 30 of RF-ve rheumatoids are ccpve. They behave
  as sero-positive rheumatoids with aggressive,
  nodular and extra-articular disease.
• Ccpve smokers with rheumatoid disease have a
  worse disease outcome compared to non-smokers

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• LFTs-if abnormal and in the presence of
  synovitis. Will need to exclude viral
  hepatitis-frequently presents with synovitis.
  Need normal LFTs prior to commencing any DMARDs
• CXR-Occasional paraneoplastic syndrome presenting
  with synovitis secondary to bronchial ca. ensure
  normal baseline CXR prior to commencing DMARDs
  esp MTX in smokers
• Exclude Rh lung disease with pneumonitis,
  nodules, effusion and pleural thickening

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Other investigations

• Bone mineral density-if patients on steroids,
  heavy alcohol intake, smoker, low body mass index
• XR hand and feet-as a baseline. Used to asses
  erosive disease-marker of aggressive and
  progressive disease with poorer outcome if
  present at baseline
• Used for comparison in patients suspected of
  radiological progression

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GP management

• Simple analgesics prn?regular
• Add in NSAIDs prn?regular
• NSAIDs-reduce pain, swelling and stiffness
• Add in proton pump inhibitor.
• Avoid steroids as 1)mask signs, which delays
  diagnoses and hence treatment, 2)excludes
  patients from drug trials, 3)difficult to wean
  patients off steroids

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Gp management

• Smoking cessation-advice and help. Smokers have a
  worse disease outcome esp sero-positive, is an
  added risk factor in addition to RhA for
  cardiovascular disease
• Weight reduction-joint protection, improved
  mobility reduction in joint pain
• Healthy diet-incl calcium and vit D
• Exercise-improves muscle strength and tone, esp
  atrophic muscle secondary to arthritis

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Referral aids

• New history of joint pain and soft-tissue
  swelling. Especially in small joints of hand and
  feet
• Larger joint inflammatory arthropathy typically
  reactive arthropathy, crystal arthropathy,
  seronegative arthropathy which will also need
  referring
• Refer if associated with significant early
  morning stiffnessgt1hr

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Referral aids

• Symptoms worse in the morning compared to later
  in the day
• Elevated inflammatory markers
• If sero-positive, but should only be requested in
  the correct clinical setting

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Secondary care management

• DMARD commenced at time of diagnoses after all
  investigations and patient counselling
• Usual dmards-sulphasalazine, methotrexate and
  leflunomide
• If high RF titre, and/or anave, commenced
  methotrexate
• If mild symptoms and signs with RF-ve and pt
  frail and elderly, consider hydroxycholoroquine

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Secondary care management

• If no improvement and DAS 28 score
  persistentlygt5.1 after 3/12 on dmards then
  commence anti-tnf a
• Criteria for tnfa das 28 gt/ 5.1, failed or
  intolerant to mtx one other dmard
• Exclude Tb with cxr and mantoux, CCF stage 4,
  carcinoma, demyelinating disease and check
  baseline ANA. If ve monitor for symptoms and
  signs of drug induced lupus

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Secondary care management

• Rituximab-anti CD20 (B-cell). Tends to be
  effective in diseases with pathological
  antibodies eg rheumatoid arthritis (RF, ccp),
  CTDs- eg lupus (ana), sjogrens (ro, la),
  vasculitis (ana, anca)

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Mangement-Flare

• Exclude infection causing flare
• If evidence of ?esr/crp with synovitis and
  stiffness and no symptoms/signs suggestive of
  septic arthritis or septicaemia-im depomedrone
  80-120mg. Could try short course of oral steroids
  (starting at 10-20mg) for 1wk, weaning dose down
  rapidly

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Questions?
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