2. History When was it diagnosed? Presenting features: Vague generalised symptoms Fatigue Anorexia Musculoskeletal pains Oligoarticular arthritis Severe constitutional symptoms Acute arthritis Morning stiffness (>1 hour) Initial treatment Disease progression and joint involvement(lumber spine – never involved and the distal interphalangeal joints are rarely involved) Alterations of treatment over time and any complications encountered?
3. RA - Non-articular features Skin: Raynaud’s phenomenon, leg ulcers Eyes: dry eyes and mouth: Sjogren’s syndrome, scleritis, episcleritis, scleromalaciaperforans, cataracts (caused by steriods); iritis does not occur Cricoaryteroid joint disease (sore throat, hoarseness or neck pain); recurrent headaches at the base of the skull or arm tingling from C1-2 subluxation (obtain a lateral flexion cervical spine X-ray) Lungs: dyspnea owing to diffuse interstitial fibrosis or pleural effusion, pain as a result of pleuritis.
4. RA - Non-articular features Heart – chest pain (pericarditis), valve disease (from rheumatoid nodules), increased atherosclerosis Renal – drug use, amyloid disease (all rare) Nervous system – peripheral neuropathy, mononeuritis multiplex, cord compression (cervical spine involvement, C1-2 subluxationor rheumatoid nodules), entrapment neuropathy (carpal tunnel syndrome) Blood – anemia of chronic disease, iron deficiency anaemia(blood loss), folate deficiency (diet), Felty’s syndrome (RA with leucopenia and splenomegaly, and non-healing leg ulcers) Systemic – fever, weight loss, fatigue Vasculitis – digital arteritis, ulcers, mononeuritis multiplex, pyodermagangrenosum.
5. RA – drug complications Aspirin – pain or nausea, gastric erosions or peptic ulcers bleeding, tinnitus. NSAIDs – ulcertation, renal impairment, increased CVS risks Methotrexate – hepatic, pulmonary toxicity; low WBC counts, thrombocytopenia (not to drink alcohol when taking methotrexate); alternative: leflunomide (diarrhoea, liver toxicity, alopecia) Penicillamine (e.g. nephrotic syndrome, thrombocytopenia, rashes, mouth ulcers, alternation in taste, SLE, polymyositis, myasthenia gravis, Goodpasture’s syndrome or pulmonary infiltration) Cyclosporin – monitor renal function and BP Hydroxychloroquine (nausea, pigmentation, bull’s eye retinopathy – need regular ophthalmological review) Sulfasalazine (rash, nausea, haemotological abnormalities, abnormal LFTs, reversible oligospecima) Anti-TNF monoclonal antibody (increased risk of infections including reactivation of TB, positive ANA, lymphoma, demyelination) Steroids
6. RA – current status Major current problem – decreased hand function, parasthesia, severe pain Current activity of the disease: Number of joints involvedwith active synovitis The severity and duration of early morning stiffness (very important) Functional ability Changes in weight and the degree of systemic ill-health Severity: early appearance of rheumatoid nodules/insidious onset/constitutional symptoms.
7. RA – other history PMHx: Peptic ulceration Drug reactions or renal disease Social background: Ability to cope at home Ability to climb steps Independence in daily activities Fine movement Work environment Availability of support services Family history of rheumatoid arthritis
9. DDx – deforming symmetrical chronic polyarthropathy RA Psoriatic arthropathy or other seronegativespondyloarthropathies Chronic tophaceous gout(rarely symmetrical) Primary generalised osteoarthritis
10. DDx– arthritis + nodules RA (seropositive) SLE (rare) Rheumatic fever (Jaccoud’s arthritis) – very rare Amyloidarthropathy (associated with multiple myeloma)
11. RA - Investigations To support the diagnosis (mainly a clinical diagnosis) Serological tests: RF Anti-citrullinated cyclic peptide (anti-CCP) More specific (97%) Associated with a more severe disease course and erosive disease X-ray of the involved joints: Soft-tissue swelling Joint space narrowing Juxta-articular osteoporosis Joint erosions
12. RA – investigations to assess disease activity ESR, CRP (DDxfor increased inflammatory markers: active disease, amyloidosis, infection, Sjogren’s syndrome) Hb – the severity of normochromicanaemia usually correlates with activity Anti-CCP, and RF titres The presence of progressive erosions on serial x-ray films
13. RA - treatment Education: palliative not curative, side effects of treatment Physiotherapy, including exercise and splinting of the joints to prevent deformity. Occupational therapy
14. RA - Drug treatment Aim: reduce pain and inflammation (aspirin, NSAIDs/COX-2 inhibitors), prevent disease progression. (side effects: increase cardiovascular risks, peptic ulcer/bleeding, worsens renal function) Early use of Disease-modifying anti-rheumatic drugs (DMARDs) is recommended in patients with active progressive disease (esp. with joint destruction) Methotrexate, sulfasalazine, hydroxychloroquine, cyclosporin, leflunomide, azathioprine, penicillamine and gold (oral or injected). Evidence of healing of bone erosions. Monitoring: FBE, Urine: proteinuria, LFTs (for methotrexate), eye check (visual fields for hydroxychloroquine)
15. RA – Drug treatment Methotrexate: First choice (better tolerated than other DMARDs) Start with a low dose (once weekly, 10mg – 25mg, oral or IM) May sometimes cause increased number of nodules!!! Can be given alone or in combination of hydroxychloroquine and sulfasalazine. To decrease the S/E (mouth ulcer), folic acid is usually given at the same time Other S/E: rash. Monitoring: FBE (leucopenia, thrombocytopenia) LFTs (transaminases increase) Interstitial lung disease (it should not be given to patients with G6PD deficiency)
16. RA – Drug treatment (alternatives) Leflunomide: (pyrimidine antagonist – inhibits the proliferation of T cells) Cyclosporin + methotrexate Cytokine-targeted monoclonal antibodies (anti-TNF, IL-1 receptor antagonists) Directed against TNF (infliximab, adalimumab) Against the TNF receptor (eternacept, given as s/c injections or as an infusion – infliximab) Good for symptoms control, reduce disease progression, development of erosions. S/E: increased risks of infection (TB), lymphoma. Gold (parenteral): a test dose first (5-10mg), then 50mg weekly, until 1000 mg is reached, then decrease the frequency of the injections over several months to 50mg once a month. Oral gold: less effective. Gold is now used much less often, having been superseded by the above regimens. Monitoring regularly for proteinuria and bone marrow depression (leucopenia, thrombocytopenia), which are indicators for cessation of therapy. D-penicillamine use is restricted by complications of renal toxicity and bone marrow suppression. Local steroids injections – helpful for acute involvement of a joint and may give prolonged relief from pain and swelling and improve function. The main indications for steroid use: Vasculitis complications of RA (where high doses are needed) Severe progressive disease, until suppressive treatment with another slow-acting antirheumatic drug becomes effective. Chronic low-dose treatment (may be justifiable in the elderly) Surgery: Hip, shoulder, knee replacement Arthroplasty and relief of contractures
17. RA - prognosis Variable A small group have no permanent joint problems 10 years after Dx ½ have a disability that interferes with work by this time. Life-expectancy: reduced by up to 7 years as a result of the increased risk of GI bleeding, infection, and atherosclerosis.
