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

2. 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)

3. 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)

4. How do you diagnose RA ?

5. 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

6. 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

7. Investigations?

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

9. Articular presentation?

10. 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

11. Early RA

12. 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

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

16. How do you diagnose atlanto-axial subluxation?

18. Extra-articular RA?

21. 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

22. 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

23. Management of RA?

24. 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

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

26. 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

27. 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

28. 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

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

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

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