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)

How do you diagnose RA ?How do you diagnose RA ?

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

Investigations?Investigations?

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)

Articular presentation?Articular presentation?

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

Early RA

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

How do you diagnose atlanto-axial How do you diagnose atlanto-axial subluxation?subluxation?

• Extra-articular RA?

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 multiplex)ischaemia and infarction (eg leg ulcers, mononeuritis multiplex)

Felty’s syndromeFelty’s syndrome

AmyloidosisAmyloidosis nephrotic syndrome, cardiac, malabsorption nephrotic syndrome, cardiac, malabsorption

AnaemiaAnaemia chronic disease & drugschronic disease & drugs

OsteoporosisOsteoporosis

Management of RA?Management of RA?

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

ToxicityToxicityBone 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, bruising Sorethoat, mouth ulcers, flu-like illnesses, bleeding, 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

BiologicsBiologics TNF alpha blockadeTNF alpha blockade NICE guidelinesNICE guidelines Infections esp TBInfections esp TB ?Malignancy?Malignancy Others eg MS,CCFOthers eg MS,CCF