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Rheumatoid Arthritis

Rheumatoid Arthritis. RhA. Chronic progressive and debilitating Rapidly advancing research, mechanism leading to joint damage and arthritis, revealing targets for therapy. history. Typically female>males Short history of few weeks to 2-3/12 c/o joint and muscle pain, fatigue

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Rheumatoid Arthritis

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  1. Rheumatoid Arthritis

  2. RhA • Chronic progressive and debilitating • Rapidly advancing research, mechanism leading to joint damage and arthritis, revealing targets for therapy

  3. history • Typically female>males • Short history of few weeks to 2-3/12 • c/o joint and muscle pain, fatigue • Shorter history of joint swelling-(puffy fingers, rings getting tighter) hands and wrist swelling. • Occasional systemic features-wt loss, appetite loss, pyrexia. These need to be Ix to exclude other conditions

  4. Joint pain • Pain worse in the morning • Gets better as the day goes on • Worse with resting, better with gentle mobilisation • Associated with marked early morning stiffness>1hr. Need to differentiate this from actual joint pain. • Pts with PMR have predominant EMS compared to joint pain

  5. Pain • NSAIDs far more effective than simple analgesics, and codeine based analgesia.

  6. Signs • Synovitis- warm, tender and soft tissue swelling • Symmetrical disease • Affect small joints before larger weight bearing joints. • Signs can be masked by both NSAIDs and steroids making diagnoses difficult

  7. Signs • Early disease-B/L index and middle mcps going on to affect pips • B/L little mcps going to pips. • B/L wrists then elbows and ankles. • Tender shoulders, elbows and pain elicited on squeezing mtps.

  8. Investigations • Elevated inflammatory markers-both crp and esr. This will give an indication of an inflammatory process. May only be marginally elevated compared to large inflamed OA knee. The mass of synovial tissue inflamed is proportional to the inflammatory markers • Note: amount of adipose tissue also associated with elevated esr

  9. Investigations • FBC: normochromic normocytic anaemia, low wcc and plats may indicate a lupus cross-over disease entity. • LFTs- exclude synovitis secondary to hepatitis • U+Es-ensure safe to continue prescribing NSAIDs +/-DMARDS.

  10. Rheumatoid factor • Should not be used as a screening tool. • Positive in 5-10% of the normal population, higher as the population ages. • Frequently positive in elderly patients with “normal” aches and pains but no inflammatory arthropathy • Up to 20% of patients with RhA are sero-negative.

  11. Rheumatoid Factor • Only check RF if patient has inflammatory type pain with elevated inflammatory markers and evidence of synovitis • Patients with non-inflammatory pain and a positive RF will need other causes excluded

  12. Non-rheumatological RF • Malignancies-lymphoma • Tb, syphillis, leprosy, viral infection (incl hep b and c) • Interstitial pulmonary fibroses • Silicoses • Asbestoses • Primary billiary cirrhoses

  13. Other Investigations • Anti-CCP(cyclic cytrullinated protein): only available for requesting from rheumatology department. Not a screening tool • More specific for RhA than RF. 98% specificity for RhA. • 30% of RF-ve rheumatoids are ccp+ve. They behave as sero-positive rheumatoids with aggressive, nodular and extra-articular disease. • Ccp+ve smokers with rheumatoid disease have a worse disease outcome compared to non-smokers

  14. LFTs-if abnormal and in the presence of synovitis. Will need to exclude viral hepatitis-frequently presents with synovitis. Need normal LFTs prior to commencing any DMARDs • CXR-Occasional paraneoplastic syndrome presenting with synovitis secondary to bronchial ca. ensure normal baseline CXR prior to commencing DMARDs esp MTX in smokers • Exclude Rh lung disease with pneumonitis, nodules, effusion and pleural thickening

  15. Other investigations • Bone mineral density-if patients on steroids, heavy alcohol intake, smoker, low body mass index • XR hand and feet-as a baseline. Used to asses erosive disease-marker of aggressive and progressive disease with poorer outcome if present at baseline • Used for comparison in patients suspected of radiological progression

  16. GP management • Simple analgesics prn→regular • Add in NSAIDs prn→regular • NSAIDs-reduce pain, swelling and stiffness • Add in proton pump inhibitor. • Avoid steroids as 1)mask signs, which delays diagnoses and hence treatment, 2)excludes patients from drug trials, 3)difficult to wean patients off steroids

  17. Gp management • Smoking cessation-advice and help. Smokers have a worse disease outcome esp sero-positive, is an added risk factor in addition to RhA for cardiovascular disease • Weight reduction-joint protection, improved mobility reduction in joint pain • Healthy diet-incl calcium and vit D • Exercise-improves muscle strength and tone, esp atrophic muscle secondary to arthritis

  18. Referral aids • New history of joint pain and soft-tissue swelling. Especially in small joints of hand and feet • Larger joint inflammatory arthropathy typically reactive arthropathy, crystal arthropathy, seronegative arthropathy which will also need referring • Refer if associated with significant early morning stiffness>1hr

  19. Referral aids • Symptoms worse in the morning compared to later in the day • Elevated inflammatory markers • If sero-positive, but should only be requested in the correct clinical setting

  20. Secondary care management • DMARD commenced at time of diagnoses after all investigations and patient counselling • Usual dmards-sulphasalazine, methotrexate and leflunomide • If high RF titre, and/or ana+ve, commenced methotrexate • If mild symptoms and signs with RF-ve and pt frail and elderly, consider hydroxycholoroquine

  21. Secondary care management • If no improvement and DAS 28 score persistently>5.1 after 3/12 on dmards then commence anti-tnf α • Criteria for tnfα: das 28 >/= 5.1, failed or intolerant to mtx + one other dmard • Exclude Tb with cxr and mantoux, CCF stage 4, carcinoma, demyelinating disease and check baseline ANA. If +ve monitor for symptoms and signs of drug induced lupus

  22. Secondary care management • Rituximab-anti CD20 (B-cell). Tends to be effective in diseases with pathological antibodies eg rheumatoid arthritis (RF, ccp), CTDs- eg lupus (ana), sjogrens (ro, la), vasculitis (ana, anca)

  23. Exclude infection causing flare If evidence of ↑esr/crp with synovitis and stiffness and no symptoms/signs suggestive of septic arthritis or septicaemia-im depomedrone 80-120mg. Could try short course of oral steroids (starting at 10-20mg) for 1wk, weaning dose down rapidly Mangement-Flare

  24. Questions?

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