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Rheumatoid ArthritisRheumatoid Arthritis
Dr Jaya RavindranDr Jaya RavindranConsultant RheumatologistConsultant Rheumatologist
Walsgrave HospitalWalsgrave Hospital
RHEUMATOID ARTHRITISRHEUMATOID ARTHRITISBackgroundBackground
Chronic erosive symmetrical arthritis (extra-articular Chronic erosive symmetrical arthritis (extra-articular features)features)
1% population 1% population
2-3X more common in women2-3X more common in women
Peak age onset 3rd to 5th decade Peak age onset 3rd to 5th decade (Macgregor et al 1998 in Klippel and Dieppe Rheumatology)(Macgregor et al 1998 in Klippel and Dieppe Rheumatology)
Erosions occur early in disease Erosions occur early in disease
(Fuchs et al 1989 J Rheumatol)(Fuchs et al 1989 J Rheumatol)
RHEUMATOID ARTHRITISRHEUMATOID ARTHRITIS
BackgroundBackground
Functional decline - 10 years work disability 40-60% Functional decline - 10 years work disability 40-60% o (Jantti et al 1999 Rheumatol)(Jantti et al 1999 Rheumatol)
Premature mortality comparable to coronary artery disease Premature mortality comparable to coronary artery disease and Hodgkin’s lymphoma and Hodgkin’s lymphoma
o (Pincus et al 1994 Ann Intern Med)(Pincus et al 1994 Ann Intern Med)
Economic burden £1.3 billion /year in UKEconomic burden £1.3 billion /year in UK
Early treatment works and RA responds better, earlier Early treatment works and RA responds better, earlier o (Munroe et al 1998 Ann Rheum Dis) (Munroe et al 1998 Ann Rheum Dis)
REFER EARLY!REFER EARLY!
Who and when to refer (In theory)Who and when to refer (In theory)
ARA 1987 Revised Criteria for the classification of Rheumatoid ARA 1987 Revised Criteria for the classification of Rheumatoid arthritisarthritis
At least 4 criteria must be filledAt least 4 criteria must be filled
1.1. Morning stiffness Morning stiffness > 1 hour > 6 weeks > 1 hour > 6 weeks
2.2. Arthritis of 3 or more jointsArthritis of 3 or more joints PIP, MCP, wrist elbow, knee, ankle, PIP, MCP, wrist elbow, knee, ankle, MTP > 6 weeks MTP > 6 weeks
3.3. Arthritis of hand jointsArthritis of hand joints wrist, PIP, MCP > 6 weekswrist, PIP, MCP > 6 weeks
4.4. Symmetric arthritisSymmetric arthritis at least one area > 6 weeksat least one area > 6 weeks
5.5. Rheumatoid nodulesRheumatoid nodules6.6. Positive Rheumatoid factorPositive Rheumatoid factor7.7. Radiographic changesRadiographic changes
REFER EARLY!REFER EARLY!
In practiceIn practice
Anyone with > 3 inflamed joints with symptoms > 6 weeksAnyone with > 3 inflamed joints with symptoms > 6 weeks
At presentation At presentation
o rheumatoid factor negative in 60%rheumatoid factor negative in 60%o normal x-rays in 50%normal x-rays in 50%o no acute phase in 60% no acute phase in 60%
o (Green et al 2002 Collected reports on the Rheumatic diseases)(Green et al 2002 Collected reports on the Rheumatic diseases)
Atypical presentations - polymyalgic, palindromic, Atypical presentations - polymyalgic, palindromic, monoarthritis monoarthritis
Useful Baseline InvestigationsUseful Baseline Investigations ESR/PV/CRPESR/PV/CRP
FBCFBC
U&E/LFTU&E/LFT
RhF (CCP)RhF (CCP) ANAANA Urine dipUrine dip
Radiology (Hands and Feet)Radiology (Hands and Feet)
(Synovial fluid analysis)(Synovial fluid analysis)
Clinical spectrumClinical spectrum
ArticularArticular
PIP, MCP, wrists, elbows, shoulders, knees, PIP, MCP, wrists, elbows, shoulders, knees, ankles, MTPankles, MTP
C-SpineC-Spine DIP usually sparedDIP usually spared
Early changesEarly changeso fusiform swelling PIP, MCP and wrist swellingfusiform swelling PIP, MCP and wrist swelling
Clinical Clinical spectrumspectrum
ArticularArticular Later deformitiesLater deformities
o Swan neck & BoutonniereSwan neck & Boutonniereo Z-shaped thumbZ-shaped thumbo Ulnar deviation (MCP)Ulnar deviation (MCP)o Volar subluxation (wrist)Volar subluxation (wrist)
Later deformitiesLater deformitieso Hammer, overlapping and claw toesHammer, overlapping and claw toeso Splayfoot, valgus deviation (MTP)Splayfoot, valgus deviation (MTP)o MTP head subluxationMTP head subluxationo pes planus, valgus hindfootpes planus, valgus hindfoot
Clinical Clinical spectrumspectrum
C/spineC/spine
o atlantoaxial subluxationatlantoaxial subluxationo subaxial diseasesubaxial diseaseo MyelopathyMyelopathy
Tenosynovitis and tendon ruptureTenosynovitis and tendon rupture
Extra-articularExtra-articular
40% patients40% patients Sero-positiveSero-positive NodulesNodules
Systemic Systemic weight loss, low-grade fever, lymphadenopathy, fatigueweight loss, low-grade fever, lymphadenopathy, fatigue
OcularOcular Keratoconjunctivitis siccaKeratoconjunctivitis sicca scleritis (scleromalacia perforans)scleritis (scleromalacia perforans) episcleritisepiscleritis
PulmonaryPulmonary Alveolitis and lung fibrosis, Alveolitis and lung fibrosis, nodules nodules pleural effusionspleural effusions BOOPBOOP CaplansCaplans
Extra-articularExtra-articular
CardiacCardiac Carditis, conduction disturbances, coronary arteritisCarditis, conduction disturbances, coronary arteritis
VasculitisVasculitis ischaemia and infarction (eg leg ulcers, mononeuritis ischaemia and infarction (eg leg ulcers, mononeuritis
multiplex)multiplex)
Felty’s syndromeFelty’s syndrome
AmyloidosisAmyloidosis nephrotic syndrome, cardiac, malabsorption nephrotic syndrome, cardiac, malabsorption
AnaemiaAnaemia chronic disease & drugschronic disease & drugs
OsteoporosisOsteoporosis
Management of RAManagement of RA
Multidisciplinary Multidisciplinary Effective in RA Effective in RA
Vliet Vlieland et al 1997 Br J RheumatolVliet Vlieland et al 1997 Br J Rheumatol
GP, rheumatologist, nurse specialist, PT, OT, podiatrist, orthotist, GP, rheumatologist, nurse specialist, PT, OT, podiatrist, orthotist, surgerysurgery
Education - Education - team, leaflets, resources from organisation/support team, leaflets, resources from organisation/support groupsgroups
OTOT – activities of daily living, equipment and adaptations, splinting – activities of daily living, equipment and adaptations, splinting
PT – PT – dynamic exercise therapy and hydrotherapydynamic exercise therapy and hydrotherapy
Podiatry and orthoticsPodiatry and orthotics – insoles, shoes, intervention for callosities – insoles, shoes, intervention for callosities
Management of RAManagement of RA
SurgerySurgery
Joint arthroplastyJoint arthroplasty
Tendon repairTendon repair
SynovectomySynovectomy
C/spine stabilisationC/spine stabilisation
DMARDs DMARDs (adapted from BSR 2000 and ARC 2002 (adapted from BSR 2000 and ARC 2002
guidelines)guidelines) Monotherapy used in majority of patientsMonotherapy used in majority of patients
Combination therapy and use of steroidsCombination therapy and use of steroids evidence less clear-cut and perhaps reserved for poor evidence less clear-cut and perhaps reserved for poor
responders/aggressive diseaseresponders/aggressive disease Steroids - bridge therapy’Steroids - bridge therapy’
Onset of action 6 weeks to few monthsOnset of action 6 weeks to few months
Monitoring – “joint” responsibilty Monitoring – “joint” responsibilty GP / Rheumatologist / patientGP / Rheumatologist / patient local / national guidelines / shared cared monitoring cardslocal / national guidelines / shared cared monitoring cards trends importanttrends important
ToxicityToxicity
Bone marrow toxicityBone marrow toxicity Thrombocytopenia, leucopenia or pancytopenia Thrombocytopenia, leucopenia or pancytopenia
WBC<4 (neut<2)WBC<4 (neut<2) Plts<150Plts<150
Sorethoat, mouth ulcers, flu-like illnesses, bleeding, Sorethoat, mouth ulcers, flu-like illnesses, bleeding, bruising bruising
Isolated anaemia very rare and tends to be due to other Isolated anaemia very rare and tends to be due to other causes. causes.
Methotrexate, sulphasalazine, gold, azathioprine, Methotrexate, sulphasalazine, gold, azathioprine, penicillamine, cyclosporin, leflunomide, penicillamine, cyclosporin, leflunomide, cyclophosphamide, chlorambucilcyclophosphamide, chlorambucil
ToxicityToxicity
Liver toxicityLiver toxicity
Raised ALP common in active RA and by itself Raised ALP common in active RA and by itself does not usually suggest liver toxicitydoes not usually suggest liver toxicity
>2 X increase in AST or ALT or unexplained falling >2 X increase in AST or ALT or unexplained falling albuminalbumin
Methotrexate, sulphasalazine, azathioprine, cyclosporin, Methotrexate, sulphasalazine, azathioprine, cyclosporin, leflunomideleflunomide
ToxicityToxicity
Renal toxicity and hypertensionRenal toxicity and hypertension
>1+ blood and/or protein>1+ blood and/or protein
quantify proteinuria (gold, penicillamine)quantify proteinuria (gold, penicillamine)
>30% rise in creatinine (cyclosporin)>30% rise in creatinine (cyclosporin)
hypertension (leflunomide, cyclosporin)hypertension (leflunomide, cyclosporin)
ToxicityToxicity
OtherOther
Mucocutaneous and GIMucocutaneous and GI
Pulmonary – dry cough and dyspnoeaPulmonary – dry cough and dyspnoea MTX, SSZ, goldMTX, SSZ, gold