1 / 31

Rheumatoid Arthritis

Rheumatoid Arthritis. Dr Jaya Ravindran Consultant Rheumatologist Walsgrave Hospital. RHEUMATOID ARTHRITIS. Background Chronic erosive symmetrical arthritis (extra-articular features) 1% population 2-3X more common in women Peak age onset 3rd to 5th decade

mike_john
Download Presentation

Rheumatoid Arthritis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Rheumatoid Arthritis Dr Jaya Ravindran Consultant Rheumatologist Walsgrave Hospital

  2. RHEUMATOID ARTHRITIS Background • Chronic erosive symmetrical arthritis (extra-articular features) • 1% population • 2-3X more common in women • Peak age onset 3rd to 5th decade (Macgregor et al 1998 in Klippel and Dieppe Rheumatology) • Erosions occur early in disease (Fuchs et al 1989 J Rheumatol)

  3. RHEUMATOID ARTHRITIS Background • Functional decline - 10 years work disability 40-60% • (Jantti et al 1999 Rheumatol) • Premature mortality comparable to coronary artery disease and Hodgkin’s lymphoma • (Pincus et al 1994 Ann Intern Med) • Economic burden £1.3 billion /year in UK • Early treatment works and RA responds better, earlier • (Munroe et al 1998 Ann Rheum Dis)

  4. How do you diagnose RA ?

  5. REFER EARLY! Who and when to refer (In theory) • ARA 1987 Revised Criteria for the classification of Rheumatoid arthritis • At least 4 criteria must be filled • Morning stiffness > 1 hour > 6 weeks • Arthritis of 3 or more joints PIP, MCP, wrist elbow, knee, ankle, MTP > 6 weeks • Arthritis of hand joints wrist, PIP, MCP > 6 weeks • Symmetric arthritis at least one area > 6 weeks • Rheumatoid nodules • Positive Rheumatoid factor • Radiographic changes

  6. REFER EARLY! In practice • Anyone with > 3 inflamed joints with symptoms > 6 weeks • At presentation • rheumatoid factor negative in 60% • normal x-rays in 50% • no acute phase in 60% • (Green et al 2002 Collected reports on the Rheumatic diseases) • Atypical presentations - polymyalgic, palindromic, monoarthritis

  7. Investigations?

  8. Useful Baseline Investigations • ESR/PV/CRP • FBC • U&E/LFT • RhF (CCP) • ANA • Urine dip • Radiology (Hands and Feet) • (Synovial fluid analysis)

  9. Articular presentation?

  10. Clinical spectrum Articular • PIP, MCP, wrists, elbows, shoulders, knees, ankles, MTP • C-Spine • DIP usually spared • Early changes • fusiform swelling PIP, MCP and wrist swelling

  11. Early RA

  12. Clinical spectrum Articular • Later deformities • Swan neck & Boutonniere • Z-shaped thumb • Ulnar deviation (MCP) • Volar subluxation (wrist) • Later deformities • Hammer, overlapping and claw toes • Splayfoot, valgus deviation (MTP) • MTP head subluxation • pes planus, valgus hindfoot

  13. Clinical spectrum • C/spine • atlantoaxial subluxation • subaxial disease • Myelopathy • Tenosynovitis and tendon rupture

  14. How do you diagnose atlanto-axial subluxation?

  15. Extra-articular RA?

  16. Extra-articular • 40% patients • Sero-positive • Nodules • Systemic • weight loss, low-grade fever, lymphadenopathy, fatigue • Ocular • Keratoconjunctivitis sicca • scleritis (scleromalacia perforans) • episcleritis • Pulmonary • Alveolitis and lung fibrosis, • nodules • pleural effusions • BOOP • Caplans

  17. Extra-articular • Cardiac • Carditis, conduction disturbances, coronary arteritis • Vasculitis • ischaemia and infarction (eg leg ulcers, mononeuritis multiplex) • Felty’s syndrome • Amyloidosis • nephrotic syndrome, cardiac, malabsorption • Anaemia • chronic disease & drugs • Osteoporosis

  18. Management of RA?

  19. Management of RA Multidisciplinary • Effective in RA • Vliet Vlieland et al 1997 Br J Rheumatol • GP, rheumatologist, nurse specialist, PT, OT, podiatrist, orthotist, surgery • Education - team, leaflets, resources from organisation/support groups • OT – activities of daily living, equipment and adaptations, splinting • PT – dynamic exercise therapy and hydrotherapy • Podiatry and orthotics – insoles, shoes, intervention for callosities

  20. Management of RA Surgery • Joint arthroplasty • Tendon repair • Synovectomy • C/spine stabilisation

  21. DMARDs (adapted from BSR 2000 and ARC 2002 guidelines) • Monotherapy used in majority of patients • Combination therapy and use of steroids • evidence less clear-cut and perhaps reserved for poor responders/aggressive disease • Steroids - bridge therapy’ • Onset of action 6 weeks to few months • Monitoring – “joint” responsibilty • GP / Rheumatologist / patient • local / national guidelines / shared cared monitoring cards • trends important

  22. Toxicity Bone marrow toxicity • Thrombocytopenia, leucopenia or pancytopenia • WBC<4 (neut<2) • Plts<150 • Sorethoat, mouth ulcers, flu-like illnesses, bleeding, bruising • Isolated anaemia very rare and tends to be due to other causes. • Methotrexate, sulphasalazine, gold, azathioprine, penicillamine, cyclosporin, leflunomide, cyclophosphamide, chlorambucil

  23. Toxicity Liver toxicity • Raised ALP common in active RA and by itself does not usually suggest liver toxicity • >2 X increase in AST or ALT or unexplained falling albumin • Methotrexate, sulphasalazine, azathioprine, cyclosporin, leflunomide

  24. Toxicity Renal toxicity and hypertension • >1+ blood and/or protein • quantify proteinuria (gold, penicillamine) • >30% rise in creatinine (cyclosporin) • hypertension (leflunomide, cyclosporin)

  25. Toxicity Other • Mucocutaneous and GI • Pulmonary – dry cough and dyspnoea • MTX, SSZ, gold

  26. Biologics • TNF alpha blockade • NICE guidelines • Infections esp TB • ?Malignancy • Others eg MS,CCF

More Related