Management of Rheumatoid Arthritis

1. Morning stiffness 2. Arthritis in at least three joint Areas*

Morning stiffness in and around the joints, lasting at least 1 hour before maximal improvement at any time inthe disease course. Soft tissue swelling or fluid observed by a physician, with swelling at current examination or deformity and a documented history of swelling. Swelling of wrist, MCP, or PIP with swelling at current examination or deformity and a documented history of swelling. Simultaneous involvement of the same joint areas (defined in 2) on both sides of the body (bilateral involvement of PIPs, MCPs, or MTPs is acceptable without absolute symmetry) with swelling at current examination or deformity and a documented history of swelling. Over bony prominences or extensor surfaces, or in periarticular regions Detected by a method positive in less than 5% normal controls at current examination or documented to have been positive in the past by any assay method. Typical of RA on posteroanterior hand and wrist radiographs which must include erosions or unequivocal bony decalcification localized to or most marked adjacent to the involved joints (osteoarthritis changesalone do not qualify).

3.Arthritis of
hands 4. Symmetric arthritis

5. Rheumatoid nodules 6.Rheumatoid factor 7. Radiographic changes

*Note: At least four criteria must be fulfilled for classification as RA.

Autoimmune/Genetic factors?

Other factors
Silica Dust Exposure Increased risk for RA in smokers Infections?-(EBV) Dietary Factors? red meat ? intake of fruit and oily fish may protect against RA (Mediterranean diet)

?Interactions between genes and environment

and stochastic factor contributions

Other nutrient factors

Lower intakes of vitamin C, fruit and
vegetables (high consumption of the antioxidants cryptoxanthin and zeaxanthin) increased the risk of inflammatory polyarthritis

Articular and Peri-articular Manifestations

Duration of signs and symptoms at more than 3
months was the strongest predictor of RA Duration of signs and symptoms at more than 3 months was the strongest predictor of RA Slow, insidious disease onset (70%) Intermediate onset (20%) Sudden acute onset (10%) Complain of pain, stiffness, and swelling of their peripheral joints

Clinical Findings
Examination of the joints reveals tenderness to
palpation, synovial thickening, joint effusion, redness and warmth May show decreased range of motion, ankylosis, and subluxation Upper limb (50%) multiple joints affected (30%) hand only (25%)

Clinical Findings
Symmetrical joints involvement (85%) Joints most commonly affected areThe proximal interphalangeal (PIP) and

metacarpophalangeal (MCP) joints of the hands and wrists, followed by The metatarsophalangeal (MTP) joints of the feet, ankles, and shoulders.

Radiograph of the left

hand. Soft tissue swelling is present around the MCP joints and wrist with diffuse narrowing of MCP, PIP, and radiocarpal joint spaces. Erosions are seen at the first CMC joint and distal ulna. Periarticular osteopenia surrounds all of the articulations.

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Radiograph of the left

wrist reveals soft-tissue swelling with narrowing about the radial carpal joint associated with early reactive sclerosis involving the radial articular surface. There is widening of the distal radialulnar joint and cysts are present within the carpal navicular and distal ulna.

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An MRI of the left wrist of

the same patient multiple bony erosions in the ulna, lunate, triquetrum, and distal radius. Complete loss of articular cartilage is with slight ulnar shift Exuberant synovial proliferation with inflamed synovium is seen to enter the large erosion within the distal ulna, illustrating the extensive synovitis that is missed on conventional radiography

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Diffuse swelling of the hand with

polyarthritis of the MCPs, PIPs, and wrists seen in remitting seronegative symmetric synovitis with pitting edema

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Extra-Articular Manifestations
Rheumatoid Nodules Anemia of chronic
disease, lymphadenopathy Vasculitissensorimotor neuropathy, nail-fold infarcts, leg ulcers, purpura, and digital gangrene

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Treatment of Early Arthritis

Nonsteroidal Anti-Inflammatory Drugs- do not
alter the course of the arthritis and its outcome GlucocorticoidsDisease-Modifying Antirheumatic Drugs Methotrexate- favorable riskbenefit ratio, is (as in established RA) regarded to be the drug of first choice hydroxychloroquine or sulfasalazine

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QOL assessment
Mobility Self-care Usual activities Pain/discomfort Anxiety/depression

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Specific drugs: Methotrexate

Anti folic acid- inhibition of proliferation of cells
responsible for synovial inflammation Decreases markers of inflammation, including the erythrocyte sedimentation rate and c-reactive protein (CRP) Adverse Effects-low-dose weekly-7.5 to 10 mg anorexia, nausea, vomiting, and diarrhea(10%) Hematologic-leukopenia (3%) ? cirrhosis and liver failure (1/1000) acute interstitial pneumonitis 18

MTX is currently considered a first-line agent in the treatment of RA, and the anchor drug for combination therapy with other DMARDs and biologic agents. It has become the standard of care and the most widely used drug in the treatment of RA.

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Leflunomide
A second choice DMARD to be used after
methotrexate has a long half-life (2 wks) dose:20 mg daily lefl unomide, sulfasalazine, and methotrexate reduced radiologic progression

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Other Drugs
Antimalarials Sulfasalazine Tetracyclines Gold Salts D-penicillamine Azathioprine Cyclosporine

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