Presented by: Praharsha R.

Menon PGY 2
03/18/2010

Key Features
Symmetric, inflammatory polyarthritis
Autoimmune Females > Males

Symptoms > 6 wks

Morning stiffness > 1 hr > 3 joints involved

Spares:

Thoracolumbar spine DIP of fingers

www.cks.nhs.uk/.../rheumatoid_arthritis_arc

 Nodules: S/C or periosteal, at pressure points

Rheumatoid factor :

Ab : recognizes Fc portion of IgG +: implies c/c inflammation 70 % + at onset, 85% + in first 2 yrs Associated with more severe disease, extra-articular manifestations, mortality

Rheumatoid Nodule

Stage I: Acute: synovial thickening; confined to joint capsule

Stage II: Persistent inflammation c/c pain, joint damage

Stage III: Inflammation and damage limiting joint function

Stage IV: Permanent joint damage and deformity disability

Extra-articular features
General fever, lymphadenopathy, weight loss, fatigue Dermatologic palmar erythema, nodules, vasculitis Ocular episcleritis/scleritis, scleromalacia perforans, choroid and retinal nodules Cardiac pericarditis, myocarditis, coronary vasculitis, nodules on valves

 Neuromuscular entrapment neuropathy, peripheral neuropathy, mononeuritis multiplex Hematologic Feltys syndrome, large granular lymphocyte syndrome, lymphomas Pulmonary pleuritis, nodules, interstitial lung disease, bronchiolitis obliterans, arteritis, effusions Others Sjogrens syndrome, amyloidosis

Diagnosis
Score >/= 6 : diagnosis
Joint Involvement Serology Duration of synovitis Acute phase reactants

MITCHEL L. ZOLER; FEBRUARY 1 5 , 2 0 1 0 FAMILY PRACTICE NEWS

Joint Involvement
1 medium-large joint (0 points)
2-10 medium-large joints (1 point) 1-3 small joints (2 points)

4-10 small joints (3 points)

More than 10 small joints (5 points)

Serology
RF neg, Anti CCP neg (0 points)
RF +/ Anti CCP + at low titer (2 points) RF +/ Anti CCP + at high titer (3 points) Low titer: > upper lmt. of normal, upto 3x upper lmt

of normal High titer: > 3 x upper lmt. of normal

Duration of synovitis
< 6 weeks: 0 points >/= 6 weeks: 1 point

Acute phase reactants:

CRP and ESR normal : 0 points Abnormal CRP or abnormal ESR : 1 point

Clinical course
Type 1 = Self-limited: 5%

to 20%
Type 2 = Minimally

progressive:5% to 20%

Type 3 = Progressive: 60% to 90%

Bloodwork
CBC: AOCD

Thrombocytosis Leukopenia in Feltys syndrome

ESR CRP RF Other: based on Differential diagnosis

Radiologic progression

Differential Diagnosis
Spondyloarthropathies
CTDs Gout CPPD Viral infections Fibromyalgia Lyme disease Rheumatic fever

Treatment guidelines
Confirm the diagnosis
Determine where the patient stands in the spectrum of

disease When damage begins early, start aggressive treatment early Use the safest treatment plan that matches the aggressiveness of the disease Monitor treatment for adverse effects Monitor disease activity, revise Rx as needed

Medications:
NSAIDs
Steroids DMARDs:

Biologic: anti- TNF, Abatacept, Etanercept, Rituximab, Infliximab, Adalimumab Non- biologic: Methotrexate, Leflunamide, Sulfasalazine, Hydroxychloroquine, Minocycline, Gold

The 2008 ACR Recommendations for Rheumatoid Arthritis Treatment

Initiate: MTX/ Lef. in most patients Mod. to high D/S activity: MTX +HCQ

Mod. to high D/S activity + poor prognosis: MTX+HCQ+SSZ (if inadequate response consider Rituximab and Abatacept)
High D/S activity + sx < 3 mo.s: anti- TNF +MTX (pt. w/o prior DMARD treatment)

Adverse Effects of DMARDs

Drug HCQ SSZ Gold MTX AZA PcN Cy CSA TNF* Lef* Hem + + ++ + ++ ++ +++ + ++ Liver + + + + ++ ++ Lung + + ++ + Renal ++ ++ +++ Infect Ca Other Eye GI Sx Rash ++ ? Mucositis ++ + Pancreas - SLE, MG +++ +++ Cystitis ++ + HTN ? ? Local ? ?

*Long-term data not available.

Adapted from Paget. Primer on Rheum Dis. 11th edition. 1997:168.

Contraindications
MTX, Lef., or biologic DMARDs (Enbrel, Remicade,

Humira, Orencia, or Rituxan): active bacterial infection, active VZV infection, active or latent TB, or acute or chronic Hep B or Hep C TNF blockers: heart failure, lymphoma, multiple sclerosis or other demyelinating disorders Pregnancy and lactation: MTX, Lef., Minocycline

Baseline evaluation
MTX, Lef, Min, SSZ, HCQ, all biologic agents:

CBC, Liver transaminases, Crn In addition: Ophthal. Exam for HCQ; Hep B and C testing for Lef, MTX

Monitoring:
Therap. agents HCQ <3 months None after baseline 36 months None >6 months None

Leflunomide Methotrexate Minocycline Sulfasalazine

24 weeks 24 weeks None after baseline 24 weeks

812 weeks 812 weeks None 812 weeks

12 weeks 12 weeks None 12 weeks

Summary: Evidence- based rating of recommendations

Patients with rheumatoid arthritis should be treated ASAP

with DMARDs to control symptoms and delay disease progression. A Patients with persistent inflammatory joint disease (> 6-8 weeks) already receiving analgesics or NSAIDs should be considered for rheumatology referral, preferably within 12 weeks. C Combination therapy may be more effective than treatment with one drug alone. A Exercise is beneficial for aerobic capacity and muscle strength with no detrimental effects on disease activity or pain levels. C
Rindfleisch J.A.: American Family Physician; Sep 15, 2005

References
Saag K.G., Teng G.G. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic diseasemodifying antirheumatic drugs in rheumatoid arthritis . Arthritis &Rheumatism2008; Vol. 59, No. 6 : p 762-784) Rindfleisch J.A. Diagnosis and Management of Rheumatoid Arthritis.

the American Family Physician; September 15, 2005 ; Volume 72, Number 6

Family Practice News Feb 15, 2010 www.medscape.com