Rheumatoid Arthritis

1. Rheumatoid Arthritis

2. Acknowledgements • Dr. Andrew Thompson, rheumatologist at SJHC and developer of the UWO rheumatology medical school program

3. Objectives • Gain a basic understanding of Rheumatoid Arthritis • Understand the presentation of Rheumatoid Arthritis (Inflammatory Arthritis) • Understand the current treatment paradigm and medications used

4. Case Presentation • 43 yo woman, has been healthy apart from: • C-Section for • Mild depression • Her current medications are • Sertraline 100 mg per day (depression) • Naproxen 500 mg twice a day (recent joint pain)

5. Case Presentation • 4 months ago developed pain in the left knee with some mild swelling. • The episode lasted a few days and then went away.

6. Case Presentation • About a week later the right knee began to swell and become sore • Then both wrists began to swell and become sore. She also noticed some soreness in her feet. • About two weeks later her hands started to stiffen up and she couldn’t get her rings on.

8. Case Presentation • She feels stiff when she wakes up in the morning and this stiffness lasts for at least 3 hours • She has no energy and has missed the last week of work • Her sleep is difficult because she is uncomfortable • She isn’t running because it “hurts too much”

9. Differential Diagnosis INFLAMMATORY POLYARTHRITIS • Infection • Rheumatoid Arthritis • Seronegative Arthritis (Psoriatic) • Connective Tissue Disease (SLE etc) • Associated with another Systemic Disease

10. Who gets RA? • ANYONE CAN GET RA • From babies to the very old • Common Age to Start: 20’s to 50’s • Sex: Females more common than males 3:1

11. How does RA start? • RA usually starts off slowly (insidious) over weeks to months and progresses (70%) • It can come on overnight (acute) but this is rare (10%) • It can come on over a few weeks (subacute – 20%) • Palindromic Presentation • RACECAR, RADAR, MOM, DAD

12. How does RA start? • Initially, most patients notice stiffness of the joints which seems more pronounced in the morning • Some fatigue • Some pain

13. What Joints are affected? • RA usually begins as an oligoarticular process (<5 joints) and progresses to polyarticular involvmement • Has a predilection for the small joints of the hands and feet!

14. Small Joints of the Hand

15. What Joints are affected?

16. How are the Joints Affected • Joints are usually • Swollen • Warm • NOT RED (might be a bit purple)

17. NO REDNESS!

18. Morning Stiffness • Prominent Feature • Greater than 60 minutes of morning stiffness (Patients minimize) • Some patients have difficulty answering the question because they are stiff all day • “How long does it take until you are the best you are going to be?”

19. Morning Stiffness • Inflammatory fluid increases in and around the joint • As patients get moving the fluid gets resorbed • Stiffness can occur after rest “gelling”

20. Constitutional Features • Fever – Unusual • Weight Loss – Can be seen with severe polyarticular disease (again not common) • Anorexia – Unusual • Fatigue – VERY COMMON • Sleep Disturbance – VERY COMMON • Musculoskeletal Reasons • Neurologic Reasons – Carpal Tunnel • Psychological Reasons – Worry about illness, finances, job, family etc.

21. Functional Status • In the Rheumatology Clinic we use a Health Assessment Questionnaire (HAQ) • Dressing, Bathing, Grooming • Cooking, Cleaning, Shopping • Mobility – Walking and Standing • Working • Social Activities & Sports • Rank the Functional Status (IMPORTANT) • Mild, Moderate, or Severe

22. Work Cooking Cleaning Pleasure Dressing Bathing Grooming Shopping

23. Rheumatoid Arthritis is … • Usually insidious in onset • Adds joints over time • Has a predilection for the small joints of the hands and feet • Joints become warm and swollen but not red • Morning stiffness is greater than 1 hour • Patients are often tired and don’t sleep properly • Can result in significant disability very quickly

24. Doesn’t just affect the joints EXTRA-ARTICULAR MANIFESTATIONS

25. Xerophthalmia (Dry Eyes)

26. Xerostomia (Dry Mouth)

27. Raynaud’s Phenomenon

28. Carpal Tunnel Syndrome

29. Pleural Effusion

30. Rheumatoid Nodules

31. Rheumatoid Nodules

32. Rheumatoid Vasculitis

33. Extra-Articular Manifestations • Sicca Features: Xerostomia & Xerophthalmia • Raynaud’s Phenomenon • Neuropathy: Carpal Tunnel Syndrome • Rheumatoid Nodules • Pleural Effusions • Rheumatoid Vasculitis

34. Tests, Tests, Tests INVESTIGATING A PATIENT WITH SUSPECTED RA

35. CASE SUMMARY • Has a 4 month history of an inflammatory polyarthritis • Nothing else on history or physical examination to suggest an associated connective tissue disorder or seronegative spondyloarthropathy.

36. INFLAMMATION • Complete Blood Count (CBC) • Hemoglobin: May be anemic (normocytic) • WBC: Should be normal • Platelets: May be normal to elevated • Erythrocyte Sedimentation Rate (ESR) • C-Reactive Protein (CRP)

37. ORGAN FUNCTION TO MAKE SURE MEDS WILL BE SAFE • Renal Function • Creatinine + Urinalysis • Liver Enzymes • AST, ALT, ALP, ALB • Hepatitis B & C Testing • Consider baseline Chest X-Ray

38. ANTIBODIES • Rheumatoid Factor • Anti-Nuclear Antibody

39. Rheumatoid Factor IgG Molecule Fc Portion Autoantibodies (IgM) directed against the Fc Fragment of IgG An Antibody to an Antibody Their Role in RA is not understood IgM Molecule Antigen Binding Groove

40. Rheumatoid Factor • Non- Rheumatic Disease • Normal Aging • Infection • Hepatitis B & C • SBE • Tb • HIV • Sarcoidosis • Idiopathic Pulmonary Fibrosis Rheumatic Disease • Sjogren’s syndrome • Rheumatoid Arthritis • SLE • MCTD • Myositis • Cryoglobulinemia

41. Rheumatoid Factor (RF) • Question: What Percentage of New Onset RA will have a positive RF? • Answer: 30-50% • Question: What Percentage of Established RA will have a positive RF? • Answer: 70-85% NOT USEFUL FOR DIAGNOSIS OF RA

42. Pearls about RF in RA • Asymptomatic people with a positive RF are unlikely to go on to develop RA • The higher the value the greater the likelihood of rheumatic disease • USEFUL for PROGNOSIS • Patients who are RF +ve are more likely to have aggressive disesase • NOT USEFUL to FOLLOW TITRES • Not predictive of flare • Not predictive of improvement

43. RADIOGRAPHIC FINDINGS IN RA

44. Periarticular OsteopeniaJoint Space NarrowingErosionsMal-Alignment

46. SYNOVIAL FINDINGS IN RA

47. Rheumatoid Synovium • A non-suppurative (no pus) inflammatory infiltrate in the synovium • Due to the aggregation of lymphocytes and plasma cells

48. Rheumatoid Synovium

49. PRINCIPLES OF TREATMENT

50. The Big Bang 90% of the joints involved in RA are affected within the first year SO TREAT IT EARLY