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*this material is free to be used in any educational procedure, downloaded , copied or shared once used without any content modification.*

Rheumatoid Arthritis

( الروماتويدي المفصل (التهاب

Definition:● Rheumatoid arthritis (RA)Is a chronic, systemic inflammatory disorder that may affect many

tissues and organs, but principally attacks synovial joints. او نسيج من اكثر يصيب ان الممكن من مزمن التهاب عن عبارة الروماتويدى المفاصل التهاب

الزاللية المفاصل يهاجم ما غالبا) ولكنه عضو

● Rheumatoid arthritis (RA) is an autoimmune disease.الذاتية المناعة امراض مرضمن انه

● autoimmune diseases are illnesses that occur when the body's tissues are mistakenly attacked by their own immune system.

المناعى جهازه بواسطة خطئا) الجسم ي8هاجم عندما تحدث الذاتية المناعة امراض

● While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms. However, rheumatoid arthritis is typically a progressive illness that has the potential to cause joint destruction and functional disability.

اى تظهر ان دون طويلة لفترة المرض المريض يحمل انا الممكن من انه اى مزمن المرض هذاقد متطور نفسالوقت فى لكنه اعراضو

الوظيفة فى وقصور المفاصل تدمير الى يؤدى

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● The pathology of the disease process often leads to the destruction of articular cartilage and ankylosis of the joints. المفاصل تصلب و الغضاريف تدمير الى المرض هذا يؤدى قد

Rheumatoid arthritis can also produce diffuse inflammation in the lungs, pericardium, pleura, and sclera, and also nodular lesions, most common in subcutaneous tissue.

==============================================================

Causes :

Although the cause of rheumatoid arthritis is unknown

● autoimmunity plays a pivotal role in both its chronicity and progression, and RA is considered a systemic autoimmune disease.

● The disease involves abnormal B cell–T cell interaction, with presentation of antigens by B cells to T cells .

B-cells & T-cells وهى المناعية الخاليا بين طبيعى غير تفاعل المرض يتضمن

● Inflammation is then driven either by B cell or T cell products stimulating release of TNF and other cytokines. تسبب المناعية الخاليا من النواتج بعض خروج التفاعل هذا عن يبنتج

االلتهاب حدوث

● If TNF release is stimulated by B cell products in the form of RF or ACPA -containing immune complexes, through activation of immunoglobulin Fc receptors, then RA can be seen as a form of Type III hypersensitivity.

ال Antigenده ACPAال مع األلتهاب taregetبيتحد حدوث ويسبب الزاللى الغشاء فى بتاعهال ال TNFاما tumor necrosis factorفده

ال ال RFو reumatoid factorده

ال من تخرج دى الحاجات بيعمل B-cellsلما انواع type III hypersensitivityده من نوع ده ووال المضادة األجسام بإن بيتميز المفرطة معين Antigenالحساسية موقع فى موجودين بيكونوا

ال و المضادة األجسام تركيز على فتتوقف حدتها تدمير Agو زلد التركيز زاد ما كل المكانو هذاالمفاصل

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● If TNF release is stimulated by T cell products such as interleukin-17 it might be considered closer to type IV hypersensitivity

ال من خرجت دى المواد ان حالة فى ) type V)delayed hypersensitivityيحصل T-cellsاما

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*this material is free to be used in any educational procedure, downloaded , copied or shared once used without any content modification.*● The debate on the relative roles of immune complexes and T cell products in inflammation in

RA has continued for 30 years. There is little doubt that both B and T cells are essential to the disease.

ال بتفرزها اللى المواد على معتمد بيفضل بيحصل اللى ال B-cellsااللتهاب سنة 30لمدة T-cellsوال الخاليا كال تكون ان فى شك هناك لكن المرض B-cells & T-cellsو لحدوث اساسيين

● As with most autoimmune diseases, it is important to distinguish between the cause(s) that trigger the process, and those that may permit it to persist and progress.

التى العوامل و المرض حدوث سبب بين نفرق ان و البد الذاتية المناعة امراض معظم فى كماالمرض تطور و استمرار على تساعد

1-Possible infectious triggers:

● Some infectious organisms suspected of triggering rheumatoid arthritis include: Mycoplasma, Erysipelothrix, parvovirus B19 and rubella, but these associations have never been supported in epidemiological studies. Nor has convincing evidence been presented for other types of triggers such as food allergies.

● Epidemiological studies have confirmed a potential association between RA and two herpesvirus infections: Epstein - Barr virus (EBV) and Human Herpes Virus 6 (HHV-6).

بين محتمل ارتباط وجود الوبائية الدراسات أكدت ونوعين RAوقدبار : ( من ابشتاين فيروس هربس الهربس) EBVالتهابات (6وفيروس

HHV - 6.(

● Individuals with RA are more likely to exhibit an abnormal immune response to the Epstein-Barr virus.

إبشتاين لفيروس طبيعية غير مناعية استجابة لديهم الروماتويدى باأللتهاب المصابون األفرادبار

● Psychological factors physical and emotional effects or stress could be a trigger for the disease.

● Continued abnormal immune response.

==============================================================

Propapility:

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*this material is free to be used in any educational procedure, downloaded , copied or shared once used without any content modification.*● About 1% of the world's population is affected by rheumatoid arthritis.● women three times more often than men. من اكثر مرات ثالث لالصابة عرضة النساء

الرجال● Onset is most frequent between the ages of 40 and 50, but people of any age

can be affected. ===============================================================

Symptoms:

● Stiffness(تصلب): The joint does not move as well as it once did. Its range of motion (the extent to which the appendage of the joint, such as the arm, leg, or finger, can move in different directions) may be reduced. Typically, stiffness is most noticeable in the morning and improves later in the day.

حركة . معدل الحركة يحاول مرة ألول كأنه يتحرك ال المفصل . يالحظ التصلب هذا يقل سوف األتجاهات مختلف فى المفصل

اليوم اثناء ويتحسن الصباح فى خاصة

● Inflammation: Redness, tenderness, and warmth are the hallmarks of inflammation.

● Swelling: The area around the affected joint is swollen and puffy.

منتفخة تصبح بالمفصل المحيطة المنطقةNodules: These are hard bumps that appear on or near the joint. They often are found near the elbows. . انها المفصل من بالقرب أو على تظهر التي الصلبة البروز هي هذه

المرفقين من بالقرب وجدت ما .غالباThey are most noticeable on the part of the joint that juts out when the joint is flexed.

يتمدد المفصل لما لبرة بيطلع الى المفصل جزء على وضوحا اكثر تكون البروز هذه● Pain: Pain in rheumatoid arthritis has several sources. Pain can

come from inflammation or swelling of the joint and surrounding tissues or from working the joint too hard. The intensity of the pain varies by the individual.

و ا المفاصل وانتفاخ التهاب إما اسباب عدة له الروماتويد فى األلمشخصآلخر تختلفمن األلم شدة و شاق عمل فى المفاصل اجهاد

These symptoms may keep you from being able to carry out your normal activities. General symptoms include the following:

● malaise (a "blah" feeling), ضيق

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*this material is free to be used in any educational procedure, downloaded , copied or shared once used without any content modification.*● fever,حمى

● fatigue,تعب

● loss of appetite, الشهية فقدان

● weight loss, الوزن فقدان

● myalgias (muscle aches), and بالعضالت آالم

● weakness or loss of energy. ضعف

Additional symptoms of rheumatoid arthritis include:

● Eye problems األحساس مثل بالعيون مشاكلبالجفاف

● Nodules under the skin الجلد فى بروزات

● Pale skin شاحب جلد

● Redness and inflammation of the skin احمرارالجلد والتهاب

● Swollen glands الغدد انتفاخ

==========================================================

Diagnosis:

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*this material is free to be used in any educational procedure, downloaded , copied or shared once used without any content modification.*1- Imaging X-Ray of the hand & feet .

2-Blood tests* Rheumatoid Factor :When RA is clinically suspected, immunological studies are required, such as testing for the presence of rheumatoid factor (RF, a non-specific antibody)BUT about 15% of patients. During the first year of illness, rheumatoid factor is more likely to be negative.

* Erythrocyte sedimentation rate (ESR) :when increased confirms the presence of an inflammatory condition .

* C-reactive protein (CRP) :Increased when the disease is active but it’s not specific .

* Other tests : Increased in : Alkaline phosphatase & Platelet count.Decreased in serum albumin .Normochromic,normocytic anaemia.

* The synovial fluid : yellow, watery , turbid due to high white blood cell count & has low glucose content .

Treatment :

Lifestyle modification and analgesics are the mainstay of treatment.

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*this material is free to be used in any educational procedure, downloaded , copied or shared once used without any content modification.*1- Lifestyle modification :

Exercise● Physical therapy has been shown to significantly improve function, decrease pain, and delay

need for surgical intervention الجراحى .in advanced cases التدخل● Exercise helps maintain joint and overall movement. Ask your health care provider to

recommend an appropriate home exercise routine. Water exercises, such as swimming, are especially helpful.

● Exercise prescribed by a physical therapist has been shown to be more effective than medications in treating osteoarthritis of the knee.

Other lifestyle recommendations include:

● Applying heat and cold● Eating a healthy, balanced diet● Getting rest● Losing weight if you are overweight● Protecting the joints

2- Medication :

● Analgesic Drugs :

A- Paracetamol● Paracetamol is the first line treatment for OA.

● Mechanism of action : it exerts its analgesic action by raising the threshold of response to pain stimuli by interfering with their relay from the thalamus to the cortex, other forms of sensations however remain completely unaffected.

● Precautions: it should be given with care to patients with impaired kidney or liver & to patients with alcohol dependence.

● Dose: 1 tab. / 4-6 hours.● N.B: 1) Can be safely used during pregnancy

2) Can be safely used with patients receiving anti-coagulants

3) Acetaminophen : is a metabolite of Paracetamol which has the same

properties & action

● N.B : Paracetamol ( Acetaminophen ) is not related to Non-Steroidal Anti-inflammatory Drugs but, it’s Analgesic Anti-pyretic Drug.

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Cetal Panadol Extra Paramol

* *

*

Perfalgan Abimol Pyral

**

*

B- NSAIDs● Mechanism of action : Most NSAIDs act as non-selective inhibitors of the enzyme

cyclooxygenase (COX), inhibiting both the cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) isoenzymes. COX catalyzes the formation of prostaglandins and thromboxane from arachidonic acid. Prostaglandins act as messenger molecules in the process of inflammation.

● If paracetamol does not control your pain, non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can be used instead.

● Common side effects of NSAIDs include:

1-indigestion2-stomach ulcer

● N.B : PPIs help to prevent stomach ulcers and internal bleeding by reducing the production of stomach acid.

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*this material is free to be used in any educational procedure, downloaded , copied or shared once used without any content modification.*● N.B : ٍASelective COX-2 inhibitors are not suitable for pregnant women or those with a history of

heart problems.1-Ibuprofen

Brufen Marcofen Megafen (ibuprfen + Paracetamol)

*

* *

2-Aceclofenac :

Amoflam Bristaflam Fenac

*

* *

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3-Diclofenac :

Rheumafen (diclofenac Na) Dolfin (diclofenac Na & K) Voltareen (diclofenac Na)

*

*

*

Cataflam (dicolfenac K) Catafast (diclofenac K) Neurofenac (diclofenac Na + Vit.B complex)

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*

* *

4-Indomethacin :

Indomethacin

*

5-Ketoprofen :

Biprofenid Ketofan Ketolgin

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* **

6-Naproxen :

Naprofen 500

*

7-Piroxicam :

Felden

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*

8-Tolmetin :

Rumatol 200 , 400 Tolmet DS 400

* *

9- Selective Cox II inhibitors :

Arythrex (celecoxib) Celebrex (celecoxib) Mobic (meloxicam)

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*

**

Mobitil (meloxicam) Rheuxicam (lornoxicam) Xefo (lornoxicam)

* *

*

10-Other Anti-inflamatory drugs :

Diacerein (diacerein) Nimalox (nimesulide) Sulide (nimesulide)

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*

*

*

Ponstan fort (mefenamic acid) Analfan (galfenine) Nabutone (nabumetone)

*

*

*

● Disease-modifyning antirheumatic drugs (DMARDs) :

They are used to reduce signs & symptoms & retard structural damage of the joint التدمير يؤخرللمفصل .( erosions & joint space narrowing ) الشكلى

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*this material is free to be used in any educational procedure, downloaded , copied or shared once used without any content modification.*1) Lefunamide

Apetoid (leflunomide) Arthfree (leflunomide) Avara

N.B. : Leflunamide, has antiproliferative effect on B-cells

2) Sulphasalazine

Salazopyrin 500

3)Methotrexate

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Methotrexate

4) Penicillamine

It decreases RF & interfering with DNA synthesis .

Artamine Retadel Rheumaton

4) Cyclosporin

5) Hydroxychloroquine

Plaquenil Hydroquine

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6)Azathioprine

Azathioprine Herceptin Immuless Imuran

9) Corticosteroids

● HydroCortisone

Sigmacortin Solu-Cortef Hostacortin

● Prednisolone

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Hostacortil-H Predilone Predsol Xilone

● Methyl Prednisolone

Depomedrol MPA Urbasone

● Betamethasone

Betasone Betafos Diprofos

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● Dexamethasone

Deltasone Dexamethasone Dexazone Fortecortin

Epidron Orazone Oradexone

● Triamicnolone & other CS

Kenacort-A Ultralan

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● Synacthen

● Dexamethasone & Chroropheniamine maleate

Apidone Dexaphen Phenadone Vendexine

3- Complementary medicine التكميلي :الطب

Many alternative medicines are purporting يزعم to decrease pain associated with arthritis.

● Glucosamine & Chondroitin sulphate Combinations :

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Glucosamine involved in the manufacture of glycosaminoglycan, which forms cartilage tissue in the body; also present in tendons & ligaments.

Dose: one cap. 3 times daily.

Dorofen Elasticin Genuphil

** *

Glucosamine Glucosamine-Comp Move Free

*

* *

● Methyl Sulphonyl Methane (MSM) :

Natural source of sulphur needed by joints & muscle to gaurd يحمى against pain & cramps.

It may relieve pain similar to nonsteroidal anti-inflammatory drugs

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Joifit 500 MSM 1000 Nitora

*

**

● Omega-3 fatty acid :

Essential fatty acids are molecules that cannot be synthesized by the human body but are vital مهمين for normal metabolism. One of the two families of these essential fatty acids is the omega-3 fatty acids.

Omega 3

*

● Anti-oxidants Vitamins ( Vit. A, C, E ) األكسدة مضادة فيتامينات● Acupuncture بالوخز العالج● Mud Pack Therapy بالطين : العالج

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*this material is free to be used in any educational procedure, downloaded , copied or shared once used without any content modification.*Mud pack therapy has been suggested to temporarily relieve pain in patients with osteoarthritis of the knees الركب. According to researchers, treatment with mineral-rich mud compresses, can be used to augment conventional medical therapy التقليدي الطبي .in these patients العالج

4-Surgery :

If the above management is ineffective, joint replacement surgery المفاصل استبدال or جراحةresurfacing may be required in advanced cases.

Severe cases of OA might need surgery to replace or repair damaged joints. Surgical options include:

● Arthroscopic surgery بالمنظار .torn and damaged cartilage تقليم to trim الجراحة● Changing the alignment of a bone to relieve stress الضغط .on the bone or joint لتقليل● Surgical fusion of bones, usually in the spine الفقرى (مفصلى arthrodesis) العمود● Total or partial replacement of the damaged joint with an artificial joint صناعى knee) مفصل

replacement, hip replacement, shoulder replacement, ankle replacement, elbow replacement)

5-Braces & Splints الجبائر و : الدعائم

● Splints and braces can sometimes support weakened joints الضعيفة المفاصل Some .تدعمprevent the joint from moving; others allow some movement.

● You should use a brace only when your doctor recommends one.● Using a brace the wrong way للدعامة الخاظىء ,can cause joint damage, stiffness األستخدام

and pain.

Complications :● Adverse reactions to drugs used for treatment لالدوية الجانبية األعراض● Anemia● Bleeding gastric ulcers● Chronic pain● Immobility and disability● Instability of neck bones● Joint deformity and destruction● Rheumatoid vasculitis, a type of inflammation of the blood vessels, which can lead to atherosclerosis,

stroke, heart attack, and other cardiac conditions.● Skin ulcerations and infections

● Decreased ability to perform everyday activities, such as personal hygiene, or cooking● Decreased ability to walk● Surgical complications

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Advices for patient :1. – . تحتوي ال ثيابا اشتري مثال اليومية المهام تسهل أدوات استعمل لمفاصلك األذى تسبب التي النشاطات تجنب

لفتحها قوة الى تحتاج ال معلبة أغذية واستعمل أزرار، .على

2. االمر األصابع على الضغط تقليل وبالتالي األشياء، لرفع واألقوى، األكبر والمفاصل العضالت استعمال حاولاأللم يقلل .الذي

تتحرك .3 أن بدون طويلة لفترات تنام أو تجلس .ال

العضالت .4 لتقوية المستطاع قدر البدنية النشاطات ببعض القيام .حاول

به .5 تقوم الذي النشاط عن توقف بااللم تشعر وعندما لجسمك .استمع

المرض .6 تحديات لمواجهة واألصدقاء األهل مساعدة .اطلب

االلم .7 ونوبات االعراض لتخفيف والدوائية الطبيعية المسكنات استخدم

8. , , الكاملة , والحبوب والمكسرات الطازجة والفواكه بالخضروات الغني الغذاء .تناول

9. , , , , , والطماطم , والفلفل والباذنجان والبطاطس بانواعه والسمن والبيض الدسمة اللحوم اكل عن .االمتناع

10. فيتامين .A, B تناول

11. , , , البانتوثينيك , وحمض والكلسيوم والمنجنيز والنحاس الزنك معادن .تناول

12. يوميا الماء من كاف قدر بشرب االهتمام

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*this material is free to be used in any educational procedure, downloaded , copied or shared once used without any content modification.*13. , الكبيرة المفاصل التهاب او الركبة في خشونة من تعاني كنت :اذا

, , خارجيا ويدلك سمسم زيت في نعناع او كافور يذاب

14. يوميا الزنجبيل منقوع من كوب تناول على الحرص

Refrences:ttp://www.bettermedicine.com/article/rheumatoid-arthritis/symptomshttp :// en . wikipedia . org / wiki / Rheumatoid _ arthritis http :// www . bettermedicine . com / article / rheumatoid - arthritis / treatments

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