Rheumatoid Arthritis Lecture PDF

Rheumatoid Arthritis Samar Tharwat Radwan Assistant Professor of Rheumatology and Immunology (Internal Medicine Department ) Musculoskeletal Ultrasound –EULAR Mansoura University –Horus University  At the end of the lecture ,the students should be able to Identify the clinical characterist...

Rheumatoid Arthritis Samar Tharwat Radwan Assistant Professor of Rheumatology and Immunology (Internal Medicine Department ) Musculoskeletal Ultrasound –EULAR Mansoura University –Horus University  At the end of the lecture ,the students should be able to Identify the clinical characteristics of rheumatoid arthritis Establish patient-centered management plans for the rheumatoid arthritis Recognize differential diagnosis with other types of arthritis ✓ Introduction ✓ Symptoms and Signs 1. Onset 2. Systemic symptoms 3. Distribution of involved joints 4. Morning stiffness 5. Articular manifestations 6.Extra-articular manifestations ✓ Laboratory Findings ✓ Imaging Studies ✓ Making the Diagnosis ✓ Differential Diagnosis ✓ Complications ✓ Treatment ✓ Adult-onset Still's disease Introduction RA is chronic, Primarily targets systemic the synovium autoimmune disease  Epidemiology Affect 1% of the adult population It may present at any age, but typically affects women in their late childbearing years Female: male: 3:1 Pathogenesis Pathology The primary pathology is inflammation of the synovial membrane, leading to synovitis and proliferation Results in loss of articular cartilage and erosion of juxtaarticular bone.  1. Onset Clinical 2. Systemic symptoms Findings 3. Distribution of involved joints 4. Morning stiffness 5. Articular manifestations 6.Extra-articular Manifestations  Insidious: weeks to months (The patient may 1. Onset hardly notice the disease onset). Fulminant: abrupt onset of pain and stiffness Palindromic rheumatism: episodic, self-limited attacks of polyarthritis Monoarthritis/oligoarthritis (atypical ) Polyarticular (typical presentation )  2. Systemic symptoms Fatigue Low-grade fevers (≤38°C) Weight loss  3. Distribution of involved joints PIP, MCP, MTP joints large joints occurring later Spares DIP joints May affect temporomandibular, cricoarytenoid, sternoclavicular joints May involve the upper part of the cervical spine particularly the C1–2 articulation  4. Morning stiffness Is a hallmark of inflammatory arthritis Worst upon arising in the morning or after prolonged periods of rest Stiffness in and around joints Lasts for hours Improves with activity , running warm water  5. Articular manifestations “pain, swelling, and stiffness “  The hands Synovial proliferation Swelling of MCP,PIP joints Late : ulnar deviation , swan neck deformities boutonnière (or buttonhole) deformities Wrists Early :synovial proliferation Late :Carpal tunnel syndrome  The feet MTP joints Subluxation of the toes at the MTP joints Skin ulceration  Large joints Involvement of large joints is common at late stage Symmetric fashion The cervical spine  6.Extra- articular manifestations Rheumatoid Nodules Rheumatoid Vasculitic Leg Ulcers Sjogren’s Syndrome  Lung Complications Interstitial Lung Disease Caplan Syndrome  CBC: Anemia of chronic disease White blood cell :↑,↓ (felty s.),→ Thrombocytosis: in active disease Laboratory Acute phase reactants: ESR , CRP Findings Autoantibodies: RF: against IgG Anti-CCP antibodies ANA (30%) ANCA (30%) Synovial fluid: WBCs 5000-50,000/mcL Differential of a positive rheumatoid factor  Juxta articular demineralization C. Imaging Studies joint-space narrowing Late :Bony erosions, deformities ,subluxation Musculoskeletal Ultrasound Synovitis Erosions Tenosynovitis MRI cervical spine Atlantoaxial subluxation  Making the Diagnosis No single finding on physical examination or laboratory testing is diagnostic of RA Differential Diagnosis of RA TREATMENT “Window of opportunity” in which aggressive treatment with disease-modifying antirheumatic drugs (DMARDs) leads to better long-term outcomes Treatment Glucocorticoids Nonsteroidal anti-inflammatory drugs (NSAIDs) Synthetic DMARDs Biologic DMARDs Janus Kinase (JAK) Inhibitors Glucocorticoids Low-dose glucocorticoids (eg, prednisone 5–10 mg daily Not appropriate as monotherapy for RA Intra-articular injections of glucocorticoids ( residual activity in large joints ) Nonsteroidal anti-inflammatory drugs (NSAIDs) Provide symptomatic relief Should not be used as the sole therapy for RA  Disease-Modifying Antirheumatic Drugs Optimal control of disease activity often requires combinations of different synthetic DMARDs or combinations of synthetic DMARDs and a biologic DMARD. Synthetic disease modifying antirheumatic drugs Methotrexate Hydroxychloroquine Sulfasalazine Leflunomide Minocycline  Methotrexate Single dose once a week (a maximum of 25 mg) Never on a daily basis Oral folate Monitoring of blood cell counts, liver transaminase levels, and serum creatinine every 3 months Contraindications: liver disease, renal impairment Toxicities :oral ulcers, nausea, hepatotoxicity, bone marrow suppression, and pneumonitis Hydroxychloroquine Antimalarials 200–400 mg daily Retinal toxicity Sulfasalazine 1–3 g daily Hypersensitivity Leflunomide 10–20 mg Diarrhea Hepatotoxicity Hypertension Teratogenic Biologic DMARDs Biologic Increased risk of infection DMARDs (tuberculosis, hepatitis B infection )  Small-molecule inhibitors Janus Tofacitinib, baricitinib, and Upadacitinib Kinase (JAK) Oral route of administration Inhibitors Increased risk of herpes zoster reactivation  Adult-Onset Still Disease Quotidian fever, greater than 39°C. Evanescent, salmon-colored macular rash often coincident with fever spikes Pharyngitis, polyarthralgia, lymphadenopathy, splenomegaly, and serositis. Common laboratory abnormalities include a leukocytosis, elevations of the acute phase reactants (erythrocyte sedimentation rate and C-reactive protein), and dramatic increases in the serum ferritin level. MCQ Rheumatoid arthritis is characterized by 1.Affect the distal interphalangeal joints 2.Frequently causes nephritis 3.Affects males mare than females 4.Atlantoaxial subluxation MCQ Rheumatoid arthritis is characterized by 1.Affect the distal interphalangeal joints 2.Frequently causes nephritis 3.Affects males mare than females 4.Atlantoaxial subluxation MCQ Long term use of hydroxycholoroquine may cause 1. Joint deformities 2. Retinal toxicity 3. Renal toxicity 4. Recurrent sinusitis MCQ Long term use of hydroxycholoroquine may cause 1. Joint deformities 2. Retinal toxicity 3. Renal toxicity 4. Recurrent sinusitis Short essay 1. Enumerate 4 drugs of disease modifying antirheumatic drugs and define characteristic complication of each one. 2. Define 4 extraarticular manifestations of rheumatoid arthritis