1. Rheumatoid Arthritis Anila Malik GPVTS

2. Aims To cover the following: What is RA? Diagnostic criteria and clinical features Rheumatoid Factor Investigations When to refer? Management of RA

3. Rheumatoid Arthritis Chronic systemic inflammatory disease characterised by symmetrical joint involvement. Typically affects the small joints of the hands and the feet. There are around 400 000 people with RA with approximately 12000 new diagnoses per year in the Uk. Affects 3 times as many women as men. Total costs in the Uk has been estimated between 3.8 and 4.75£ billion/year

4. Onset InsidiousAcutePalindromic

5. ACR RA Criteria 1987 Morning stiffness >6/52 in and around joints lasting> 1hr/day Arthritis of three or more joint areas involved simultaneously Arthritis of at least one area in a wrist, MC or PIP joints Symmetrical arthritis Rheumatoid nodules Positive serum RF Radiological changes typical of RA on hand and wrist xrays

6. NICE Guidelines NICE recommends clinical diagnosis of RA is more important than meeting all the criteria listed in ACR RA classification. The rationale for this is the need to treat a persistent synovitis quickly in order to try and stop irreversible damage to joints.

7. When To Refer Small joints of the hands or feet are affected More than one joint is involved There has been delay of 3months or longer between onset of symptoms and seeking medical advice. Also refer persistent synovitis of undetermined cause whose bloods show normal acute phase response and negative rheumatoid factor.

8. Clinical Features Poly-arthritisFatigue Diffuse musculoskeletal pain Swelling Morning stiffness Functional loss

9. Rheumatoid Factor NICE recommends RF blood test in patients with suspected history and examination. RFs are antibodies against the Fc portion of immunoglobulin G. Not specific for RA Detected in acute and chronic infections

10. RF RF is positive in 60-70% of patient with RA and the reminder stay negative throughout the disease. RF is abnormal in 5% of the normal population and up to 25% in the elderly.

11. Other Investigations FBC, Inflammatory markers, Liver and renal function is required before initiating any treatment. NICE recommends anti-cyclic citrullinated peptide (CCP) measurement in patients who are negative for RF.

12. Radiology Plain Film xray: peri articular swelling, erosions, osteoporosis, cysts, subluxation joint space narrowing, ankylosis reactive sclerosis and osteophytes. MRI and USS show inflammation of synovial membrane and erosions.

13. Monitoring Disease Activity Monthly CRP and Disease Activity Score (DAS28) until treatment has controlled the disease to a pre-determined level agreed between the patient and the clinician. DAS28 – consists of following parameters: Number of tender joints Number of tender joints Number of swollen joints Number of swollen joints inflammatory markers (ESR or CRP) inflammatory markers (ESR or CRP) Patient’s assessment of disease activity Patient’s assessment of disease activity Cases in remission score 5.1

14. Management Main Goals: 1. Pain relief 2. Reduction of joint inflammation and damage 3. Control of systemic disease 4. Maintaining function and supporting 5. Patient education

15. Non Pharmacological All patients with RA should have access to a multidisciplinary team for periodic assessment of the disease and its effect on their lives. This includes a named specialist rheumatology nurse who is responsible for co-ordinating their care. Patients should also have access to specialist physiotherapist, occupational therapist, podiatrist and to behavioural therapists.

16. Pharmacological Combination therapy of Disease modifying anti- rheumatic drugs is the first line treatment in the newly diagnosed active RA. Offer short-term glucocorticoids (oral intramuscular and intra-articular) to rapidly improve symptoms. Biological therapy is recommended in case of unsuccessful trials of two DMARDs with a disease score of 5.1 on two occassions.

17. Analgesia NICE recommends the following analgesia for symptom control: Paracetamol Paracetamol codeine codeine compound analgesics compound analgesics NSAIDS/COX – 2 inhibitors (lowest effective dose for the shortest possible time. NSAIDS/COX – 2 inhibitors (lowest effective dose for the shortest possible time. If the above analgesics are not providing adequate pain relief then review disease modifying or biological drug regime

18. General Measures Vaccination 1. annual influenza and one off penumococcal vaccination. 2. Live vaccines are contraindicated if treated with immunosuppressive agents. Patient education and self help 1. ARC patient information leaflets 2. The National Rheumatoid Arthritis Society

19. Health Screening CVS Depression – NICE depression screening Qs Osteoporosis Neurology – sudden loss of function in lower limbs should prompt exclusion of cervical cord myelopathy.

20. Thankyou! Thankyou!