Rheumatoid Arthritis 1

RHEUMATOID ARTHRITIS
DR SEIF JUMA ABAS

MD
Contents
• Introduction
• Epidemiology
• Etiology
• Clinical features
• Diagnosis
• Management
• Complications
Introduction
• Rheumatoid disease, is a heterogeneous,
multisystem auto-inflammatory disorder of
unknown etiology
• It manifests chiefly as synovitis, however,
extra-articular involvement is common
• The disease is associated with significant
disability and premature mortality
Epidemiology
• Incidence worldwide ranges from 0.2-5.3%
• Women are more affected than men
(3.4/100,000 vs 1.4/100,000)
• Incidence in men declines after age 45
• In women, incidence increases after age 45,
plateaus then declines at age 75
Clinical features
• A typical onset of insidious pain, stiffness, and
symmetrical swelling of small joints is only one
of several presenting patterns.
• Up to one-third of patients may have a
subacute onset with symptoms of fatigue,
malaise, weight loss, myalgias, morning
stiffness, and joint pain without overt signs of
swelling or radiological evidence of joint
erosions
Clinical features…
• Rheumatoid arthritis is symmetric synovitis of
the small joints of the hands, wrists, and feet
• Symmetry, however, develops later in the
disease course
• A mono- or bilateral arthropathy of the
shoulder or wrist, may account for up to 30–
40% of initial presentations; 5% of initial
presentations involve the knee
Clinical features…
• Any synovial joint can become involved in RA
The hands, wrists, elbows, shoulders, and
knees are involved most commonly, followed
by the hip and temporo-mandibular joints
Swan neck deformity
Boutonniere deformity
Ulnar deviation
Piano hands
Diagnosis
• As no diagnostic test exists for RA its
identification relies on the clinical picture
supplemented by laboratory and radiological
investigations
• Fewer than one-third of unselected patients
with positive rheumatoid factor will have RA
Differential diagnosis
1. Gout / pseudogout
2. Osteoarthritis
3. Reactive arthritis
4. Rheumatic fever
Management
• The current approach to the management of RA
advocates for “treatment to target”.
• Patients should be evaluated (and medications
adjusted) monthly until remission (i.e., the absence
of synovitis) or low disease activity is achieved.
• The Disease Activity Score (DAS) is a composite score
using the Ritchie Articular Index (0–78), a swollen
joint count (0–44 joints), ESR, and patient global
assessment of disease activity using a 100 mm visual
analogue scale.
NSAIDs
• Most patients will either periodically or
continuously be taking NSAIDs. These agents
offer reliable, even if sometimes limited, relief
of pain, swelling, and stiffness, improving
quality of life in the majority of cases. These
drugs do not, however, alter the natural
history of RA.
• Adverse effects are, however, common and
sometimes life-threatening
Glucocorticoids
• IM and oral steroids are very effective in active RA,
reducing active disease in an acute crisis or while waiting
for a DMARD to take effect.
• Local steroid injections are of value in symptom control
both early in the disease and in an acute flare. The effect
on joint recovery may be dramatic but short lived, with
little impact on the overall process of RA, and should not
be repeated any more than once every 3 months.
• High-dose systemic administration may reduce overall
disease activity in the short-term but adverse effects
preclude its uninhibited use and it is best preserved for
refractory RA and severe extra-articular complications.
Disease Modifying Anti-Rheumatic Drugs
(DMARDs)
• All patients with active disease should be offered a
DMARD early. The rationale is to prevent or reduce
joint destruction.
• Guidelines now recommend that the majority of
patients with newly diagnosed RA should be
started on DMARD therapy within 3 months of
diagnosis.
• Toxicity is an important concern and this should
always be discussed with patients.
• These agents are also slow-acting, sometimes
taking up to 6–9 months to have maximal effect
DMARDS
1. Methotrexate
2. Leflunomide
3. Hydroxychloroquine
4. Sulfasalazine
1. Methotrexate
• Methotrexate (MTX 10–30 mg) is given weekly
by mouth or SQ or IM injection.
• Toxicity, particularly stomatitis, GI disturbance,
and alopecia, may be reduced by the addition
of folic acid daily, without loss of therapeutic
effect.
• All patients taking methotrexate should
receive 1–5 mg of folic acid to reduce toxicity
2. Leflunomide
• Leflunomide (LEF 10–20 mg PO q.i.d) is effective
for the treatment of moderately active
rheumatoid arthritis
• GI side effects, including diarrhea, nausea, and
• Transaminitis, may all occur
• Patients with pre-existing liver disease should not
be treated with Leflunomide, and it should be
used with caution in combination with other
drugs that are also associated with hepatotoxicity
3. Hydroxychloroquine
• Hydroxychloroquine (HCQ 400 mg PO q.i.d)
• Retinal toxicity and maculopathy with HCQ are
rare. The risk increases with abnormal liver or
kidney function, after a cumulative dose of
800 g, and in patients aged 70 years and over.
The eyes should be checked formally by an
ophthalmologist yearly and the patient
informed to report any visual disturbances.
4. Sulfasalazine
• Sulfasalazine (SSZ 1.0–1.5 g po bid)
• Sulfasalazine has been used successfully in
pregnancy.
• Sulfasalazine may cause leukopenia,
pancytopenia, hemolysis, and aplastic anemia.
• Sulfasalazine can rarely cause a hypersensitivity
reaction characterized by liver function test
abnormalities, lymphadenopathy, and rash.
• Spermatogenesis can be affected by SSZ, but it is
reversible.
Biologic agents
• Biologic DMARDs are drugs that are directed against
specific components of the immune system.
• Broadly speaking, these drugs fall into three major
groups:
•Cytokine-directed strategies (anti-TNF- A , anti-IL6)
•T-cell directed strategies (CTLA4-Ig)
• B-cell directed strategies (anti-CD20)
• Overall, these agents are associated with a roughly
equal increased rate of serious infection
BIOLOGICAL DMARDS
1. TNF modulatory agents (Etanercept,
infliximab, adalimumab, golimumab,
certolizumab)
2. Abatacept (CTLA4-Ig)
3. Rituximab
4. Tocilizumab
Disease Progression
• RA is extremely heterogeneous with regard to
severity and progression.
• Permanent remission can occur but is rare
once joint damage has started.
Complications
• Without adequate treatment, life expectancy is
reduced by approximately 7 years in men and 3
years in women.
• This is mainly due to cardiovascular disease,
infections, respiratory disease, and RA itself.
• Atlantoaxial (C1-C2) subluxation (partial
dislocation) is a known complication of RA, and
may present with pain radiating towards the
occiput, spastic quadriparesis, or sensory findings.

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RHEUMATOID ARTHRITIS

DR SEIF JUMA ABAS

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