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Rheumatoid Arthritis Dr Jaya Ravindran Consultant Rheumatologist Walsgrave Hospital.

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Presentation on theme: "Rheumatoid Arthritis Dr Jaya Ravindran Consultant Rheumatologist Walsgrave Hospital."— Presentation transcript:

1 Rheumatoid Arthritis Dr Jaya Ravindran Consultant Rheumatologist Walsgrave Hospital

2 RHEUMATOID ARTHRITIS Background Chronic erosive symmetrical arthritis (extra-articular features) Chronic erosive symmetrical arthritis (extra-articular features) 1% population 1% population 2-3X more common in women 2-3X 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) Erosions occur early in disease Erosions occur early in disease (Fuchs et al 1989 J Rheumatol)

3 RHEUMATOID ARTHRITIS Background Functional decline - 10 years work disability 40-60% Functional decline - 10 years work disability 40-60% o (Jantti et al 1999 Rheumatol) Premature mortality comparable to coronary artery disease and Hodgkin’s lymphoma Premature mortality comparable to coronary artery disease and Hodgkin’s lymphoma o (Pincus et al 1994 Ann Intern Med) Economic burden £1.3 billion /year in UK Economic 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)

4 How do you diagnose RA ? 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 ARA 1987 Revised Criteria for the classification of Rheumatoid arthritis At least 4 criteria must be filled At least 4 criteria must be filled 1. Morning stiffness > 1 hour > 6 weeks 2. Arthritis of 3 or more jointsPIP, MCP, wrist elbow, knee, ankle, MTP > 6 weeks 3. Arthritis of hand jointswrist, PIP, MCP > 6 weeks 4. Symmetric arthritisat least one area > 6 weeks 5. Rheumatoid nodules 6. Positive Rheumatoid factor 7. Radiographic changes

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

7 Investigations? Investigations?

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

9 Articular presentation? Articular presentation?

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

11 Early RA

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

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15 Clinical spectrum C/spine C/spine o atlantoaxial subluxation o subaxial disease o Myelopathy Tenosynovitis and tendon rupture Tenosynovitis and tendon rupture

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

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18 Extra-articular RA?

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

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

23 Management of RA? Management of RA?

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

25 Management of RA Surgery Joint arthroplasty Joint arthroplasty Tendon repair Tendon repair Synovectomy Synovectomy C/spine stabilisation C/spine stabilisation

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

27 Toxicity Bone marrow toxicity Thrombocytopenia, leucopenia or pancytopenia Thrombocytopenia, leucopenia or pancytopenia WBC<4 (neut<2) WBC<4 (neut<2) Plts<150 Plts<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 causes. Isolated anaemia very rare and tends to be due to other causes. Methotrexate, sulphasalazine, gold, azathioprine, penicillamine, cyclosporin, leflunomide, cyclophosphamide, chlorambucil Methotrexate, sulphasalazine, gold, azathioprine, penicillamine, cyclosporin, leflunomide, cyclophosphamide, chlorambucil

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

29 Toxicity Renal 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)

30 Toxicity Other Mucocutaneous and GI Mucocutaneous and GI Pulmonary – dry cough and dyspnoea Pulmonary – dry cough and dyspnoea  MTX, SSZ, gold

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


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