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    Rheumatoid Arthritis

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    Nisya Andesita H
    Rheumatoid arthritis is a chronic inflammatory disease that commonly causes symmetric polyarthritis of the hands and feet. It is characterized by inflammation of the synovial membranes in multiple joints that can lead to joint damage over time. Key diagnostic criteria include involvement of 3 or more joint areas, symptoms lasting over 6 weeks, and presence of rheumatoid factor or anti-CCP antibodies. Treatment involves early use of disease-modifying antirheumatic drugs like methotrexate with tumor necrosis factor inhibitors added for more severe cases.

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    Rheumatoid Arthritis

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    Nisya Andesita H
    53 views28 pages
    Rheumatoid arthritis is a chronic inflammatory disease that commonly causes symmetric polyarthritis of the hands and feet. It is characterized by inflammation of the synovial membranes in multiple joints that can lead to joint damage over time. Key diagnostic criteria include involvement of 3 or more joint areas, symptoms lasting over 6 weeks, and presence of rheumatoid factor or anti-CCP antibodies. Treatment involves early use of disease-modifying antirheumatic drugs like methotrexate with tumor necrosis factor inhibitors added for more severe cases.

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    Rheumatoid arthritis is a chronic inflammatory disease that commonly causes symmetric polyarthritis of the hands and feet. It is characterized by inflammation of the synovial membranes in multiple joints that can lead to joint damage over time. Key diagnostic criteria include involvement of 3 or more joint areas, symptoms lasting over 6 weeks, and presence of rheumatoid factor or anti-CCP antibodies. Treatment involves early use of disease-modifying antirheumatic drugs like methotrexate with tumor necrosis factor inhibitors added for more severe cases.

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    Download as ppt, pdf, or txt
    53 views28 pages

    Rheumatoid Arthritis

    Uploaded by

    Nisya Andesita H
    Rheumatoid arthritis is a chronic inflammatory disease that commonly causes symmetric polyarthritis of the hands and feet. It is characterized by inflammation of the synovial membranes in multiple joints that can lead to joint damage over time. Key diagnostic criteria include involvement of 3 or more joint areas, symptoms lasting over 6 weeks, and presence of rheumatoid factor or anti-CCP antibodies. Treatment involves early use of disease-modifying antirheumatic drugs like methotrexate with tumor necrosis factor inhibitors added for more severe cases.

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    Presented by: Praharsha R.

    Menon PGY 2
    03/18/2010

    Key Features
    Symmetric, inflammatory polyarthritis
    Autoimmune Females > Males

    Symptoms > 6 wks


    Morning stiffness > 1 hr > 3 joints involved

    Spares:

    Thoracolumbar spine DIP of fingers

    www.cks.nhs.uk/.../rheumatoid_arthritis_arc

    Nodules: S/C or periosteal, at pressure points

    Rheumatoid factor :

    Ab : recognizes Fc portion of IgG +: implies c/c inflammation 70 % + at onset, 85% + in first 2 yrs Associated with more severe disease, extra-articular manifestations, mortality

    Rheumatoid Nodule

    Stage I: Acute: synovial thickening; confined to joint capsule

    Stage II: Persistent inflammation c/c pain, joint damage

    Stage III: Inflammation and damage limiting joint function

    Stage IV: Permanent joint damage and deformity disability

    Extra-articular features
    General fever, lymphadenopathy, weight loss, fatigue Dermatologic palmar erythema, nodules, vasculitis Ocular episcleritis/scleritis, scleromalacia perforans, choroid and retinal nodules Cardiac pericarditis, myocarditis, coronary vasculitis, nodules on valves

    Neuromuscular entrapment neuropathy, peripheral neuropathy, mononeuritis multiplex Hematologic Feltys syndrome, large granular lymphocyte syndrome, lymphomas Pulmonary pleuritis, nodules, interstitial lung disease, bronchiolitis obliterans, arteritis, effusions Others Sjogrens syndrome, amyloidosis

    Diagnosis
    Score >/= 6 : diagnosis
    Joint Involvement Serology Duration of synovitis Acute phase reactants

    MITCHEL L. ZOLER; FEBRUARY 1 5 , 2 0 1 0 FAMILY PRACTICE NEWS

    Joint Involvement
    1 medium-large joint (0 points)
    2-10 medium-large joints (1 point) 1-3 small joints (2 points)

    4-10 small joints (3 points)


    More than 10 small joints (5 points)

    Serology
    RF neg, Anti CCP neg (0 points)
    RF +/ Anti CCP + at low titer (2 points) RF +/ Anti CCP + at high titer (3 points) Low titer: > upper lmt. of normal, upto 3x upper lmt

    of normal High titer: > 3 x upper lmt. of normal

    Duration of synovitis
    < 6 weeks: 0 points >/= 6 weeks: 1 point

    Acute phase reactants:


    CRP and ESR normal : 0 points Abnormal CRP or abnormal ESR : 1 point

    Clinical course
    Type 1 = Self-limited: 5%

    to 20%
    Type 2 = Minimally

    progressive:5% to 20%

    Type 3 = Progressive: 60% to 90%

    Bloodwork
    CBC: AOCD

    Thrombocytosis Leukopenia in Feltys syndrome


    ESR CRP RF Other: based on Differential diagnosis

    Radiologic progression

    Differential Diagnosis
    Spondyloarthropathies
    CTDs Gout CPPD Viral infections Fibromyalgia Lyme disease Rheumatic fever

    Treatment guidelines
    Confirm the diagnosis
    Determine where the patient stands in the spectrum of

    disease When damage begins early, start aggressive treatment early Use the safest treatment plan that matches the aggressiveness of the disease Monitor treatment for adverse effects Monitor disease activity, revise Rx as needed

    Medications:
    NSAIDs
    Steroids DMARDs:

    Biologic: anti- TNF, Abatacept, Etanercept, Rituximab, Infliximab, Adalimumab Non- biologic: Methotrexate, Leflunamide, Sulfasalazine, Hydroxychloroquine, Minocycline, Gold

    The 2008 ACR Recommendations for Rheumatoid Arthritis Treatment


    Initiate: MTX/ Lef. in most patients Mod. to high D/S activity: MTX +HCQ

    Mod. to high D/S activity + poor prognosis: MTX+HCQ+SSZ (if inadequate response consider Rituximab and Abatacept)
    High D/S activity + sx < 3 mo.s: anti- TNF +MTX (pt. w/o prior DMARD treatment)

    Adverse Effects of DMARDs


    Drug HCQ SSZ Gold MTX AZA PcN Cy CSA TNF* Lef* Hem + + ++ + ++ ++ +++ + ++ Liver + + + + ++ ++ Lung + + ++ + Renal ++ ++ +++ Infect Ca Other Eye GI Sx Rash ++ ? Mucositis ++ + Pancreas - SLE, MG +++ +++ Cystitis ++ + HTN ? ? Local ? ?

    *Long-term data not available.

    Adapted from Paget. Primer on Rheum Dis. 11th edition. 1997:168.

    Contraindications
    MTX, Lef., or biologic DMARDs (Enbrel, Remicade,

    Humira, Orencia, or Rituxan): active bacterial infection, active VZV infection, active or latent TB, or acute or chronic Hep B or Hep C TNF blockers: heart failure, lymphoma, multiple sclerosis or other demyelinating disorders Pregnancy and lactation: MTX, Lef., Minocycline

    Baseline evaluation
    MTX, Lef, Min, SSZ, HCQ, all biologic agents:

    CBC, Liver transaminases, Crn In addition: Ophthal. Exam for HCQ; Hep B and C testing for Lef, MTX

    Monitoring:
    Therap. agents HCQ <3 months None after baseline 36 months None >6 months None

    Leflunomide Methotrexate Minocycline Sulfasalazine

    24 weeks 24 weeks None after baseline 24 weeks

    812 weeks 812 weeks None 812 weeks

    12 weeks 12 weeks None 12 weeks

    Summary: Evidence- based rating of recommendations


    Patients with rheumatoid arthritis should be treated ASAP

    with DMARDs to control symptoms and delay disease progression. A Patients with persistent inflammatory joint disease (> 6-8 weeks) already receiving analgesics or NSAIDs should be considered for rheumatology referral, preferably within 12 weeks. C Combination therapy may be more effective than treatment with one drug alone. A Exercise is beneficial for aerobic capacity and muscle strength with no detrimental effects on disease activity or pain levels. C
    Rindfleisch J.A.: American Family Physician; Sep 15, 2005

    References
    Saag K.G., Teng G.G. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic diseasemodifying antirheumatic drugs in rheumatoid arthritis . Arthritis &Rheumatism2008; Vol. 59, No. 6 : p 762-784) Rindfleisch J.A. Diagnosis and Management of Rheumatoid Arthritis.

    the American Family Physician; September 15, 2005 ; Volume 72, Number 6

    Family Practice News Feb 15, 2010 www.medscape.com

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