Dr Jaya Ravindran Consultant Rheumatologist Walsgrave Hospital Rheumatoid Arthritis Dr Jaya Ravindran Consultant Rheumatologist Walsgrave Hospital

RHEUMATOID ARTHRITIS Background Chronic erosive symmetrical arthritis (extra-articular features) 1% population 2-3X more common in women Peak age onset 3rd to 5th decade (Macgregor et al 1998 in Klippel and Dieppe Rheumatology) Erosions occur early in disease (Fuchs et al 1989 J Rheumatol)

RHEUMATOID ARTHRITIS Background Functional decline - 10 years work disability 40-60% (Jantti et al 1999 Rheumatol) Premature mortality comparable to coronary artery disease and Hodgkin’s lymphoma (Pincus et al 1994 Ann Intern Med) Economic burden £1.3 billion /year in UK Early treatment works and RA responds better, earlier (Munroe et al 1998 Ann Rheum Dis)

How do you diagnose RA ?

REFER EARLY! Who and when to refer (In theory) ARA 1987 Revised Criteria for the classification of Rheumatoid arthritis At least 4 criteria must be filled Morning stiffness > 1 hour > 6 weeks Arthritis of 3 or more joints PIP, MCP, wrist elbow, knee, ankle, MTP > 6 weeks Arthritis of hand joints wrist, PIP, MCP > 6 weeks Symmetric arthritis at least one area > 6 weeks Rheumatoid nodules Positive Rheumatoid factor Radiographic changes

REFER EARLY! In practice Anyone with > 3 inflamed joints with symptoms > 6 weeks At presentation rheumatoid factor negative in 60% normal x-rays in 50% no acute phase in 60% (Green et al 2002 Collected reports on the Rheumatic diseases) Atypical presentations - polymyalgic, palindromic, monoarthritis

Investigations?

Useful Baseline Investigations ESR/PV/CRP FBC U&E/LFT RhF (CCP) ANA Urine dip Radiology (Hands and Feet) (Synovial fluid analysis)

Articular presentation?

Clinical spectrum Articular PIP, MCP, wrists, elbows, shoulders, knees, ankles, MTP C-Spine DIP usually spared Early changes fusiform swelling PIP, MCP and wrist swelling

Early RA

Clinical spectrum Articular Later deformities Swan neck & Boutonniere Z-shaped thumb Ulnar deviation (MCP) Volar subluxation (wrist) Hammer, overlapping and claw toes Splayfoot, valgus deviation (MTP) MTP head subluxation pes planus, valgus hindfoot

Clinical spectrum C/spine Tenosynovitis and tendon rupture atlantoaxial subluxation subaxial disease Myelopathy Tenosynovitis and tendon rupture

How do you diagnose atlanto-axial subluxation?

Extra-articular RA?

Extra-articular 40% patients Sero-positive Nodules Systemic Ocular weight loss, low-grade fever, lymphadenopathy, fatigue Ocular Keratoconjunctivitis sicca scleritis (scleromalacia perforans) episcleritis Pulmonary Alveolitis and lung fibrosis, nodules pleural effusions BOOP Caplans

Extra-articular Cardiac Vasculitis Felty’s syndrome Amyloidosis Carditis, conduction disturbances, coronary arteritis Vasculitis ischaemia and infarction (eg leg ulcers, mononeuritis multiplex) Felty’s syndrome Amyloidosis nephrotic syndrome, cardiac, malabsorption Anaemia chronic disease & drugs Osteoporosis

Management of RA?

Management of RA Multidisciplinary Effective in RA Vliet Vlieland et al 1997 Br J Rheumatol GP, rheumatologist, nurse specialist, PT, OT, podiatrist, orthotist, surgery Education - team, leaflets, resources from organisation/support groups OT – activities of daily living, equipment and adaptations, splinting PT – dynamic exercise therapy and hydrotherapy Podiatry and orthotics – insoles, shoes, intervention for callosities

Management of RA Surgery Joint arthroplasty Tendon repair Synovectomy C/spine stabilisation

DMARDs (adapted from BSR 2000 and ARC 2002 guidelines) Monotherapy used in majority of patients Combination therapy and use of steroids evidence less clear-cut and perhaps reserved for poor responders/aggressive disease Steroids - bridge therapy’ Onset of action 6 weeks to few months Monitoring – “joint” responsibilty GP / Rheumatologist / patient local / national guidelines / shared cared monitoring cards trends important

Toxicity Bone marrow toxicity Thrombocytopenia, leucopenia or pancytopenia WBC<4 (neut<2) Plts<150 Sorethoat, mouth ulcers, flu-like illnesses, bleeding, bruising Isolated anaemia very rare and tends to be due to other causes. Methotrexate, sulphasalazine, gold, azathioprine, penicillamine, cyclosporin, leflunomide, cyclophosphamide, chlorambucil

Toxicity Liver toxicity Raised ALP common in active RA and by itself does not usually suggest liver toxicity >2 X increase in AST or ALT or unexplained falling albumin Methotrexate, sulphasalazine, azathioprine, cyclosporin, leflunomide

Toxicity Renal toxicity and hypertension >1+ blood and/or protein quantify proteinuria (gold, penicillamine) >30% rise in creatinine (cyclosporin) hypertension (leflunomide, cyclosporin)

Toxicity Other Mucocutaneous and GI Pulmonary – dry cough and dyspnoea MTX, SSZ, gold

Biologics TNF alpha blockade NICE guidelines Infections esp TB ?Malignancy Others eg MS,CCF