1. Rheumatoid Arthritis Dr M C du Plooy The Wits University DGMC

2. Introduction - Systemic disease -Progressive inflammatory immune mediated disorder. - Affects articular and extra articular structures - Joints pathology characterised by proliferation of synovial membrane - Chronic destructive polyarthritis

3. Epidemiology Worldwide distribution Incidence : 4 per 10,000 Prevalence : 1-3 % Female : Male ratio - 3:1 Older age groups - equal Children (UK) prevalence 1 per 1000 Incidence 1 per 10,000

4. Anatomy of synovial joint

5. Pathogenesis Synovial joints affected Synovial membrane -1 to 3 cells thick RA- proliferation of synovium - expanding layer of synovial cells - pannus formation ( granulation tissue )

6. Pathogenesis cont

7. PANNUS

8. Clinical Picture Systemic disease Articular features Extra articular features

9. Articular features Symmetrical Small joints hands and feet PIPJ MCPJ Wrists Elbows Shoulders Not DIPJ

10. Articular features cont Lower limbs Knees Ankles Midfoot – midtarsal joints Hip Other : Sternoclacicular joint TM Joint

11. Articular features -cont Cervical Spine esp C1 and C2 - radiculopathy - spinal cord involvement NOT thoracic or lumbar spine Cricoarytenoid joints : - throat pain - Hoarseness - Stridor

12. Typical deformities Hands : Swan neck deformities Boutonniere Z deformities thumb bent fork deformities Feet : Hallux valgus Cock up toes / hammer toes Overriding toes Subluxation of MTPJ Pes planus

13. Assessment RA Deformities that may occur with RA Synotenovitis Ulnar drift Swan neck deformity Boutonniere deformity

14. Subcutaneous nodules ( disappear and appear without warning)

15. Mutlans deformity (rapidly progressing RA) Hitch-hiker thumb Genu valgus

16. Hammer toes

17. Extra articular features Constitutional: - Fever / Weight loss / fatigue Skin ; - SC Nodules - Vasculitis - Palmar erythema Pulmonary : - Pleuritis - Pulm nodules - ILD - Bronciolitis obliterans - Pulmonary HPT : ILD / vasculitis of pulmonary vessels

18. cont Eyes : - Sjogrens syndrome - Episcleritis - Scleritis - scleromalacia perforans Haematological: - Anaemia : ACD / Fe deficiency / Folate def - Leucocytosis - Thrombocytosis

19. cont Renal : - Rarely directly - Amyloidosis or drugs CVS : Increased risk of IHD - Accelerated atherosclerosis - Corticosteroids - Vasculitis Other : MR / AR / TR RA is Independent risk factor for IHD

20. Cont Vasculitis - Leucocytoclastic vasculitis - Non healing ulcers eg Pyoderma gangrenosa - Neuropathy

21. cont Nervous system: Central NS: - brain not affected - spinal cord compression C/Spine Peripheral NS: - Peripheral neuropathy - Compression neuropathy eg CTS, TTS - Mononeuritis multiples eg wrist or foot drop

22. COMPLICATIONS MALIGNANCIES: Increased risk : - Altered immuno surveilance - Immunosuppressive drugs Types: - NHL - Nonmelanomatous skin cancers Lower risk: - Breast CA - Colon cancer ? NSAID Rx

23. cont INFECTIONS : Increased risk multifactorial : - Activity and severity of RA - GC use - Comorbidities eg DM, CCF - Joint replacement surgery

24. Investigations Blood tests RF Anti CCP ab FBC LFT ESR CRP ANA

25. Investigations - cont Imaging : - Xray : hands – AP only C/Spine - Ultrasound - MRI - Bone density Urine dipstix

26. Diagnosis ACR criteria 1987: - EMS > 1 hr - Arthritis in > joint areas - Small joints : PIPJ / MCPJ /wrists - Symmetric - Nodules - RF and/or Anti CCP positive - Xray changes eg typical erosions, PAOP 4/7 present > 6 weeks

27. Eular –ACR criteria 2010

28. Subcutaneous nodules ( disappear and appear without warning)

29. Poor prognostic features Smoking Number of swollen joints Socioeconomic status Level of education Lag time from onset sx to diagnosis to initiation of DMARD’s Sustained elevated acute phase reactants Anti CCP positivity High titers of RF and anti CCP ab Genetic background Erosions esp < 2 yrs

30. Management Non pharmacological : Pharmacological Surgical

31. Non Pharmacological - Multi disciplinary team OT PT Podiatry Biokinetics Psychologist Social worker

32. Joint Protection: Do’s and Don’t’s

33. Management -cont Pharmacological: Pain Relief : - Analgesics : - NSAIDS DMARD’s - Synthetic - Biologic

34. Mx -cont Synthetic DMARD’s Anti malarials Methotrexate Sulfasalazine Leflunomide Corticosteroids

35. Mx -cont Biologic DMARD’s: Cytokine Inhibitors : - Anti –TNF inhibitors : Infliximab; Adalumimab; Etanercept; Golimumab - Anti IL 6 ab ( Actemra ) T cell co stimulatory pathway modulator: Abatacept – Orencia B Cell inhibitors - Anti CD 20 inhibitor ( Rituximab ) Intracellular : Small molecules kinase inhibitors eg JAK kinase inhibitors

36. Management -cont DMARD’s - SLOW ACTING drugs - Explain to patients re A/E - Regular blood tests Corticosteroids: - Bridging period - Beneficial in first 6 months - Vit D and Ca prophylactically with CS > 1/12

37. Mx -cont Comorbid diseases: Depression Osteoporosis Traditional risk factors for IHD HPT; Dislipidaemia ; Smoking ; DM

38. Pregnancy Which drugs are safe to use ? Salazopyrin Hydroxycloroquin Azathioprine Prednisone

39. Mx - cont Surgical : Joint replacement Tenosynovectomy for nerve entrapment Decompression carpal tunnel Corrective arthrotomies of MTJ Stabilisation of C/Spine Tendon release and transfer Arthrodesis of esp ankle joint

40. Outcome measures Treat to target : What is the target ? - Remission (goal) Clinical remission Serological remission Radiographic remission - Low disease activity

41. cont How to measure ? Various tools : - SDAI - CDAI - DAS 28 score - HAQ

42. cont What parameter to be measured ? Duration of EMS Number of tender joints Number of swollen joints Patient global assessment Physicians global assessment Acute phase reactants Ultrasonography

43. Mortality and Morbidity Morbidity: Disease of > 10 yrs – 50 -80% unable to work Mortality: Causes of death : - IHD - Infections - Fractures with post op complications - Malignancies

44. THANK YOU