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Rheumatoid Arthritis Systemic chronic inflammatory disease Mainly affects synovial joints Variable expression Prevalence about 3% Worldwide distribution.

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Presentation on theme: "Rheumatoid Arthritis Systemic chronic inflammatory disease Mainly affects synovial joints Variable expression Prevalence about 3% Worldwide distribution."— Presentation transcript:

1 Rheumatoid Arthritis Systemic chronic inflammatory disease Mainly affects synovial joints Variable expression Prevalence about 3% Worldwide distribution Female:male ratio 3:1 Peak age of onset: years

2 Rheumatoid Arthritis Unknown etiology –Genetics –Environmental –Possible infectious component Autoimmune disorder

3 THE PATHOLOGY OF RA Serositis 1. Synovitis Joints Tendon sheaths Bursae Nodules Vasculitis

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5 Signs and Symptoms Joint inflammation –Tender, warm swollen joints –Symmetrical pattern Pain and stiffness Symptoms in other parts of the body –Nodules –Anemia Fatigue, occasional fever, malaise

6 JOINT INVOLVEMENT ON PRESENTATION OF RA Polyarticular 75% Monoarticular 25% Small joints Knee 50% of hands and feet 60% Large joints 30% Shoulder } Wrist } Large and Hip } 50% Small joints 10% Ankle } Elbow }

7 Articular features seen in the Rheumatoid Hand WRIST: PIPs: SynovitisSynovitis Prominent ulnar styloidFixed flexion or extension Subluxation and collapse of deformities carpus(Swan neck or boutonniere Radial deviation deformity) MCPs: THUMBS: SynovitisSynovitis Ulnar deviation‘Z’ deformity Subluxation

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11 Joint Destruction

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13 Extra-articular manifestations General –fever, lymphadenopathy, weight loss, fatigue Dermatologic –palmar erythema, nodules, vasculitis Ocular –episcleritis/scleritis, scleromalacia perforans, choroid and retinal nodules

14 Extra-articular manifestations Cardiac –pericarditis, myocarditis, coronary vasculitis, nodules on valves Neuromuscular –entrapment neuropathy, peripheral neuropathy, mononeuritis multiplex Hematologic –Felty’s syndrome, large granular lymphocyte syndrome, lymphomas

15 Extra-articular manifestations Pulmonary –pleuritis, nodules, interstitial lung disease, bronchiolitis obliterans, arteritis, effusions Others –Sjogren’s syndrome, amyloidosis

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22 Investigations: Hematology : CBC, ESR Biochemistry : LFT, Renal profile Serology : RF, Anti-CCP Radiography : Joints, Spines,Chest

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24 Treatment Goals Relieve pain Reduce inflammation Prevent/slow joint damage Improve functioning and quality of life

25 Treatment Approaches Lifestyle modifications Rest Physical and occupational therapy Medications Surgery

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27 Rationale for the Early Treatment of R.A. Erosions develop early in the disease course Destruction is irreversible Disease activity is strongly associated with joint destruction later in the disease course Early treatment can slow down radiographic progress Disease activity must be suppressed maximally in its early stages to prevent destruction and preserve function

28 Drug Treatments Nonsteroidal anti-inflammatory drugs (NSAIDs) Disease-modifying antirheumatic drugs (DMARDs) Biologic response modifiers Corticosteroids

29 Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Traditional NSAIDs Aspirin Ibuprofen Ketoprofen Naproxen COX-2 Inhibitors Celecoxib Rofecoxib

30 Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) To relieve pain and inflammation Use in combination with a DMARD Gastrointestinal side effects

31 Disease-Modifying Antirheumatic Drugs (DMARDs) Hydroxychloroquine Sulfasalazine Methotrexate Leflunomide Gold Azathioprine

32 Disease-Modifying Antirheumatic Drugs (DMARDs) Control symptoms No immediate analgesic effects Can delay progression of the disease (prevent/slow joint and cartilage damage and destruction) Effects generally not seen until a few weeks to months

33 DMARDs hydroxychloroquine –mild non-erosive disease –combinations –200 mg bid –eye exams

34 DMARDs Sulfasalazine –1 gm bid - tid –CBC, LFTs –onset months Methotrexate –most commonly used drug –fast acting (4-6 weeks) –po, SQ - weekly –CBC, LFTs

35 DMARDs IM Gold –slow onset (3-6 months) –weekly then monthly injections –CBC, UA before each injection Oral Gold –less effective –slow acting (4-6 months) –daily –CBC, UA

36 Biologic Response Modifiers Etanercept Infliximab Anakinra

37 Biologic Response Modifiers Etanercept and infliximab target tumor necrosis factor alpha (TNF-  ) Anakinra targets interleukin-1 receptor

38 OSTEOARTHRITIS

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41 MULTIFACTORAL ETIOLOGY OF OA ● Joint instability ●Age ●Hormonal factors ●Trauma ●Altered biochemistry ●Inflammation ●Genetic predisposition ●? Others

42 SYMPTOMS AND SIGNS OF OA Pain – worse on use of joint Stiffness – mild after immobility Loss of movement Pain on movement/restricted range Tenderness (articular or periarticular) Bony swelling Soft tissue swelling Joint crepitus

43 RADIOLOGICAL FEATURES OF OA Narrowing of joint space Osteophytosis Altered bone contour Bone sclerosis and cysts Periarticular calcification Soft-tissue swelling

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49 MANAGEMENT OF OSTEOARTHTITIS Confirm diagnosis Initial Therapy : Pysiotherapy Wt loss Local therapy Paracetamol

50 MANAGEMENT OF OSTEOARTHTITIS cont Second-line approach: NSAIDS Intra-articular therapy: steroids,hyalurinate Opioids ?glucosamines Arthroscopy Surgery

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