Hatem H Eleishi, MD Professor of Rheumatology, Cairo University Consultant Rheumatologist, Dr. Soliman Fakeeh Hospital

3. Rheumatoid Arthritis Wednesday, April 29th, 2009 Lecture 1 Rheumatoid Arthritis From the General Practitioner’s Perspective to the Basic Rheumatologist’s Perspective Hatem H Eleishi, MD Professor of Rheumatology, Cairo University Consultant Rheumatologist, Dr. SolimanFakeeh Hospital

4. IN THIS LECTURE WHAT MANY DOCTORS KNOW ABOUT RHEUMATOID ARTHRITIS WHAT MANY DOCTORS MIGHT NOT KNOW ABOUT RHEUMATOID ARTHRITIS

5. RHEUMATOID ARTHRITIS AS MANY DOCTORS KNOW IT

6. AN AUTOIMMUNE DISEASE THAT IS CHARACTERIZED BY: CLINICALLY: POLYARTHRITIS IN TIME, CRIPPLING JOINT DEFORMITIES LABORATORY: POSITIVE RF, HIGH ESR PLAIN RADIOLOGY: ARTICULAR EROSIONS MANAGEMENT: NO REAL TREATMENT; ONLY NSAIDs, MAY BE STEROIDS MTX WHICH IS VERY TOXIC

7. IN SHORT A CRIPPLING DISASTER THAT MORE OR LESS HAS NO TREATMENT

8. RHEUMATOID ARTHRITIS AS MANY DOCTORS MIGHT NOT KNOW IT PRESENTATION LABS IMAGING MANAGEMENT

9. ABOUT THE PRESENTATION OF RHEUMATOID ARTHRITIS TRUE: THE MOST COMMON PRESENTATION IS A SYMMETRICAL POLYARTHRITIS IN ADDITION TO A SYMMETRICAL POLYARTHRITIS WHICH IS SOMETIMES RATHER SUBTLE, WE HAVE OTHER PRESENTATIONS TOO;

10. WE HAVE THE RELUCTANT RA THE STUTTERING RA THE ACHES ALL OVER RA THE DISGUISED RA THE PUFFY RA

11. PRESENTATION 1 OF 5 A 42-YEAR OLD MALE WITH RECCURRENT ATTACKS OF PAIN AND SWELLING OF A WRIST OR A SHOULDER OR AN ANKLE FOR 2 YEARS. DURATION OF EACH ATTACK:3-7 DAYS ATTACK FREE PERIOD:2-3 MONHTS THE RELUCTANT RA OR PALINDROMIC RHEUMATISM

12. PRESENTATION 2 OF 5 2003: A 33-YEAR OLD FEMALE PRESENTED WITH INFLAMMATORY MONOARTHRITIS OF THE RIGHT WRIST PLAIN FILM OF HER HANDS: NORMAL MRI: EFFUSION, SYNOVIAL THICKENING, BONE MARROW EDEMA EARLY 2003: SHE STARTED TO COMPLAIN OF PAIN AND MS OF HER RIGHT WRIST LATE 2003: PAIN AND SWELLING OF THE ELBOWS, KNEES, ANKLES S T U T T E R I N G RA ANY POLYARTHRITIS CAN INITIALLY START AS A MONOARTHRITIS

13. RA RA RA ON TOP OF OA OR DISGUISED RA FEMALE; 48Y-OLD OA KNEES / HANDS LATELY PAIN NOCTURNAL PAINS REC EFFUSIONS PLAINS: OA ESR 50 RF +VE SYNOVIONALYSIS: INFLAMMATORY SF PRESENTATION 3 OF 5

14. PRESENTATION 4 OF 5 Mona, a 32-year old female, presented with diffuse aches all over of 3 months’ duration. She had a MS of 10-60 minutes and nocturnal pain sometimes. She was afraid she might have cancer or rheumatoid arthritis but had been reassured by her family doctor that she didn’t have cancer and that her RF test was negative.

15. Examination revealed a very anxious patient with inconsistent tenderness over several small joints of the hands but also over the trunk as well as the flesh of the forearms and legs. Investigations: ESR 21 CBC, liver, kidney, electrolytes: normal RF; ANA: negative Hepatitis serology: negative A plain film of the hands and feet were normal

16. A Tc99 bone scan was done DIFFUSE ACHES ALL OVER RA OR FIBROMYALGIC RA

17. Early rheumatoid arthritis can sometimes be a vague diagnosis Bone scan helps to settle the diagnosis in such situations

18. PRESENTATION 5 OF 5 Abu-Ismail, a 59-year old male, presented with gradual onset of pain and swelling of his hands with NP and MS of 4 hours Examination: diffuse swelling (puffinness) of the dorsum of both hands; tenderness of the MCPs, and wrists LABS: ESR 70; Hb 11gm%; RF: Negative RS3PE REMITTING SYMMETRICAL SERONEGATIVE SYNOVITIS WITH PITTING EDEMA OR PUFFY RA

19. THE RELUCTANT RA THE STUTTERING RA THE ACHES ALL OVER RA THE SNEEKY RA THE PUFFY RA

20. RHEUMATOID ARTHRITIS AS MANY DOCTORS MIGHT NOT KNOW IT PRESENTATION LABS IMAGING MANAGEMENT

21. ABOUT THE LABORATORY INVESTIGATIONS IN RHEMATOID ARTHRITIS

22. POSITIVE RHEUMATOID FACTOR “THE RHEUMATOID CETRTIFICATE” THERE ARE CAUSES FOR A POSITIVE RF OTHER THAN RA SO YOU CANNOT RELY SOLELY ON A POSITIVE RF TO DIAGNOSE RA

23. NEGATIVE RHEUMATOID FACTOR RHEUMATOID FACTOR IS POSITIVE IN ONLY 70% OF PATIENTS AND NEGATIVE IN 30% SO A NEGATIVE RF DOESN’T RELIABLY EXCLUDE RA

24. ESR ESR IS NOT INVARIABLY ELEVATED IN RA

25. ABOUT THE IMAGING OF RHEUMATOID ARTHRITIS

26. NOT EVERY RHEUMATOID DISEASE IS NECESSARILY EROSIVE

27. BEFORE LOOKING FOR EROSIONS, LOOK FIRST FOR: JAO JSN

28. IN EARLY RA, PLAIN FILMS MAY BE NORMAL ANYWAY OTHER IMAGING MODALITIES MAY THEN BE NEEDED TO CONFIRM THE DIAGNOSIS

29. What is the most important thing that is needed to make the diagnosis of RA? A good lab An imaging center A chair A screening questionnaire for the population Knowing the family history of your patient Two doctors rather than one

30. HISTORY-TAKING IS THE MOST IMPORTANT STEP TO COME TO THE CORRECT DIAGNOSIS

31. THE JOURNALIST’S HISTORY THE POLICE OFFICER’S HISTORY THE GOOD DOCTOR’S HISTORY THERE ARE 3 TYPES OF HISTORY THAT COULD BE TAKEN FROM A PATIENT:

32. GOOD DOCTORS DO NOT DIAGNOSE DISEASES THEY JUST LEAVE DISEASES DIAGNOSE THEMSELVES

33. الأمراض مثل البشر ، لكل مرض ملامحه المميزة و طبائعه الخاصة التي يدرسها الطبيب ثم تزداد و تصقل معرفته بها بالممارسة و البحث و الإطلاع المستمر. يتعرف الطبيب على هذه الملامح المميزة في أثناء الحوار مع المريض وعلى هذا فإن أهم خطوة لتشخيص المرض هي: الإستماع الجيد إلى المريض و إلى إجاباته على أسئلة الطبيب

34. ماذا يحدث بالإستماع الجيد إلى المريض و إلى إجاباته على أسئلة الطبيب؟ يقع المريض في حفرة........ ماذا يفعل الطبيب في هذه الحالة؟ يسيبه يقع لوحده، ما يزقوش

35. ABOUT THE MANAGEMENT OF RHEUMATOID ARTHRITIS

36. MANAGEMENT OF RA COMPRISES: PATIENT EDUCATION AND INSTRUCTIONS MEDICAL TREATMENT REHABILITATION SURGICAL TREATMENT SOMETIMES

37. DON’T UNDERESTIMATE THE POWER OF TALKING TO YOUR PATIENT PATIENT EDUCATION

38. MEDICAL TREATMENT REHABILITATION NSAIDs AND PHYSIOTHERAPY Hydroxychloroquine, sulfasalazine, gold Methotrexate, lefulonamide Biological Agents Aim of medical treatment: Induction and maintenance of remission

39. Corticosteroids are not part of the medical treatment of RA except in very selected situations as: Intra-articular steroids Bridge therapy Severe systemic illness

40. Conclusions

41. THERE IS MUCH MORE ABOUT RHEUMATOID ARTHRITIS THAN JUST: A CRIPPLING JOINT DISEASE WITH A POSITIVE RF AND NO TREATMENT

42. PRESENTATION • A SYMMETRIC POLYARTHRITIS IS THE COMMONEST PRESENTATION, • BUT • THERE ARE OTHER NOT UNCOMMON PRESENTATIONS FOR RHEUMATOID ARTHRITIS AS WELL

43. PRESENTATION THE MOST IMPORTANT STEP TOWARDS A DIAGNOSIS OF RA IS A GOOD HISTORY TAKEN BY A GOOD DOCTOR

44. INVESTIGATIONS A POSITIVE RF DOESN’T NECESSARILY MEAN RA AND A NEGATIVE RF DOESN’T NECESSARILY MEAN NO RA

45. INVESTIGATIONS PLAIN FILMS IN EARLY RA MAY BE NORMAL

46. MANAGEMENT DOCTORS ARE MORE THAN JUST TABLETS

47. MANAGEMENT A MOST INDISPENSIBLE STEP IN THE MANGEMENT OF PATIENTS WITH RA IS PATIENT EDUCATION

48. MANAGEMENT CORTICOSTEROIDS HAVE NO PLACE IN THE TREATMENT OF RA EXCEPT IN VERY SPECIAL SITUATIONS

49. MANAGEMENT VARIOUS IMMUNOMODULATORS AND IMMUNOSUPPRESSIVES AND BIOLOGICAL AGENTS ARE AVAILIABLE FOR THE INDUCTION AND MAINTENANCE OF REMISSION IN PATIENTS WITH RHEUMATOID ARTHRITIS

50. Thank you