Rheumatoid Arthritis

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Rheumatoid Arthritis

• Anand Lal, M.D.

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Rheumatoid Arthritis

• Chronic systemic inflammatory disease of unknown
  etiology
• Affects the Synovial Membranes of multiple joints
• Prevalence 1-2
• Female Male ratio 31
• Usual age of onset 20-40 years though individuals
  of any age group may be affected

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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.

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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

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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

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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
  extra-articular manifestations
• splenomegaly and lymphadenopathy can occur
• low grade fever, anorexia, weight loss, fatigue
  and weakness can occur

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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

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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

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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

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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., Feltys syndrome)
• the platelet count is often elevated in
  proportion to the degree of joint inflammation

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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

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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.

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Rheumatoid Arthritis

• 1987 American College of Rheumatology Revised
  criteria for the diagnosis of Rheumatoid
  Arthritis
• At least four of the following
• Morning stiffness gt 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

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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

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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

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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.

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Rheumatoid Arthritis

• Treatment
• goal of treatment
• reduce inflammation and pain,
• preservation of function, and
• prevention of deformity.

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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

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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.

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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

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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 7.5-15 mg once a week. The most common
  side effect is gastric irritation and stomatitis.
  Other side effects are hepatotoxicity,
  pancytopenia and interstitial pneumonitis.

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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
  anti-inflammatory benefit but are limited by
  their many side effects

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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

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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.

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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 Stills disease is
  characterized by fever and rash
• a juvenile form of ankylosing spondilitis