rheumatoid arthritis dr ahad azami. rheumatoid arthritis systemic systemic chronic chronic...
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Rheumatoid ArthritisRheumatoid Arthritis
Dr ahad azamiDr ahad azami
Rheumatoid ArthritisRheumatoid Arthritis
SystemicSystemic
ChronicChronic
InflammatoryInflammatory
Primarily targets the synovium of diarthrodial jointsPrimarily targets the synovium of diarthrodial joints
Etiology likely combination genetic and Etiology likely combination genetic and
environmentalenvironmental
Diarthrodial JointDiarthrodial Joint
Rheumatoid ArthritisRheumatoid Arthritis
Female: male 3:1Female: male 3:1
44thth-6-6thth decades of life decades of life
Symmetric polyarthritis Symmetric polyarthritis
Extra-articular manifestationsExtra-articular manifestations Subcutaneous nodules/lung nodulesSubcutaneous nodules/lung nodules ScleritisScleritis VasculitisVasculitis Felty’s syndromeFelty’s syndrome
Stages of RA PathogenesisStages of RA Pathogenesis
StageStage SymptomsSymptoms FindingsFindings
1.1. AntigenAntigen NoneNone None None PresentationPresentation Normal X-rayNormal X-ray
to T Cellsto T Cells
2.2. T and B CellT and B Cell Malaise, Mild,Malaise, Mild, Swelling or PainSwelling or PainProliferation,Proliferation, Joint StiffnessJoint Stiffness of Small Jointsof Small JointsAngiogenesisAngiogenesis SwellingSwelling Wrists, KneesWrists, Kneesin Synoviumin Synovium Normal, X-rayNormal, X-ray
ACR
Stages of RA Pathogenesis Stages of RA Pathogenesis (Continued)(Continued)
StageStage SymptomsSymptoms FindingsFindings
3.3. SFPMNSFPMN Joint Pain,Joint Pain, Warm, SwollenWarm, SwollenAccumulationAccumulation SwellingSwelling Joints, Inc SFJoints, Inc SFSynovial CellSynovial Cell AM Stiffness,AM Stiffness, Soft TissueSoft TissueProliferationProliferation Malaise,Malaise, Proliferation,Proliferation,
WeaknessWeakness Limited ROM,Limited ROM,Nodules, SoftNodules, SoftTissue Tissue
SwellingSwellingon X-rayon X-ray
ACR
Stages of RA Pathogenesis Stages of RA Pathogenesis (continued)(continued)
StageStage Symptoms Symptoms FindingsFindings
4.4. PannusPannus Same as Same as Same asSame as
Invasion,Invasion, Stage 3 Stage 3 Stage 3Stage 3
ChondrocyteChondrocyte PeriarticularPeriarticular
Activation,Activation, Osteopenia,Osteopenia,
EnzymeEnzyme Proliferative Proliferative
ActivationActivation Pannus on MRIPannus on MRI
ACR
Stages of RA Pathogenesis Stages of RA Pathogenesis (continued)(continued)
StageStage Symptoms Symptoms FindingsFindings
5.5. SubchondralSubchondral Same as Same as Same as stage 3Same as stage 3Bone Erosion,Bone Erosion, Stage 3 Stage 3 Plus InstabilityPlus InstabilityPannusPannus Plus Loss Plus Loss FlexionFlexionInvasion ofInvasion of of Function of Function Contractures,Contractures,Cartilage Cartilage Deformity Deformity Extra-ArticularExtra-ArticularStretchedStretched Disease, EarlyDisease, EarlyLigamentsLigaments Erosions and JointErosions and Joint
Space Space NarrowingNarrowing
on X-Rayon X-Ray
ACR
Synovium in RASynovium in RA
PIP SwellingPIP Swelling
Ulnar Deviation, MCP Swelling, Ulnar Deviation, MCP Swelling, Left Wrist SwellingLeft Wrist Swelling
Joints involved in RAJoints involved in RA
Joints involved in RAJoints involved in RA
Don’t forget the cervical spine!! Instability Don’t forget the cervical spine!! Instability there can lead to impingement of the spinal there can lead to impingement of the spinal cordcord
Thoracolumbar, sacroiliac, and distal Thoracolumbar, sacroiliac, and distal interphalangeal joints of the hand are not interphalangeal joints of the hand are not involvedinvolved
Extra-articular SymptomsExtra-articular Symptoms
Patients that are more likely to get are:Patients that are more likely to get are:
RF+RF+
HLA DR4+HLA DR4+
Male Male
Corneal MeltCorneal Melt
NodulesNodules
Pulmonary NodulesPulmonary Nodules
Felty’s SyndromeFelty’s Syndrome
Seropositive Rheumatoid ArthritisSeropositive Rheumatoid Arthritis SplenomegalySplenomegaly GranulocytopeniaGranulocytopenia
ACR
Large Granular LymphocytesLarge Granular Lymphocytes
LabsLabs
Can also see nonspecific abnormalitiesCan also see nonspecific abnormalities
High sedimentation rateHigh sedimentation rate
AnemiaAnemia
HypergammaglobulinemiaHypergammaglobulinemia
ThrombocytosisThrombocytosis
Rheumatoid FactorRheumatoid Factor
Antibodies that recognize Fc portion of Antibodies that recognize Fc portion of IgGIgG
Can be IgM, IgG, IgA, IgECan be IgM, IgG, IgA, IgE
85% of patients with RA over the first 2 85% of patients with RA over the first 2 years become RF+years become RF+
Anti-ccpAnti-ccp
Radiographic FeaturesRadiographic Features
Peri-articular osteoporosisPeri-articular osteoporosis Uniform joint space narrowingUniform joint space narrowing Marginal erosionsMarginal erosions Soft tissue swellingSoft tissue swelling Subluxations Subluxations Symmetric Symmetric CystsCysts
Synovial FluidSynovial Fluid
InflammatoryInflammatory
WBCs 5000-50,000WBCs 5000-50,000
≥ ≥ 50% neutrophils50% neutrophils
No crystalsNo crystals
Negative CulturesNegative Cultures
Noninflammatory on leftNoninflammatory on leftInflammatory on rightInflammatory on right
ACR CriteriaACR Criteria
Morning Stiffness ≥1 hourMorning Stiffness ≥1 hour
Soft tissue swelling of ≥ 3 joints observed by Soft tissue swelling of ≥ 3 joints observed by
physicianphysician
Swelling of proximal interphalangeal (PIP), Swelling of proximal interphalangeal (PIP),
metacarpophalangeal (MCP), or wrist jointsmetacarpophalangeal (MCP), or wrist joints
These signs and symptoms must be present ≥ 6 weeksThese signs and symptoms must be present ≥ 6 weeks
ACR Criteria ContinuedACR Criteria Continued
Symmetric Arthritis present for ≥ 6 weeksSymmetric Arthritis present for ≥ 6 weeks Subcutaneous nodulesSubcutaneous nodules Positive Rheumatoid FactorPositive Rheumatoid Factor Radiographic Erosions or periarticular Radiographic Erosions or periarticular
osteopenia in hand or wrist jointsosteopenia in hand or wrist joints
Must have ≥4 criteria to meet diagnosis of RA
Criteria for Progression of RACriteria for Progression of RA
Stage I – Stage I – EarlyEarlyNo Destructive ChangesNo Destructive Changes
Osteoporosis on X-RayOsteoporosis on X-Ray
Stage II – Stage II – ModerateModerateOsteoporosis and Slight Subchondral Bone or Osteoporosis and Slight Subchondral Bone or Cartilage DestructionCartilage Destruction
No Joint Deformaties, Mobility May be LimitedNo Joint Deformaties, Mobility May be Limited Adjacent Muscle AtrophyAdjacent Muscle Atrophy
Nodules or Tenosynovitis May be PresentNodules or Tenosynovitis May be PresentACR
Criteria for Progression of RA Criteria for Progression of RA (continued)(continued)
Stage III – Stage III – SevereSevere
Osteoporosis and ErosionsOsteoporosis and Erosions
Deformity Without AnkylosisDeformity Without Ankylosis
Extensive Muscle AtrophyExtensive Muscle Atrophy
Nodules and TenosynovitisNodules and Tenosynovitis
Stage IV – Stage IV – TerminalTerminal
Fibrous or Bony AnkylosisFibrous or Bony Ankylosis
Features of Stage IIIFeatures of Stage III
ACR
ManagementManagement
Focused on relieving pain and preventing Focused on relieving pain and preventing damage/disabilitydamage/disability
Patient education about the disease is keyPatient education about the disease is key Physical Therapy for stretching and range of motion Physical Therapy for stretching and range of motion
exercisesexercises Occupational Therapy for splints and adaptive Occupational Therapy for splints and adaptive
devicesdevices SurgerySurgery
Rheumatoid Arthritis: Rheumatoid Arthritis: Classification of FunctionClassification of Function
Class I:Class I: No LimitationsNo Limitations
Class II:Class II: Adequate for Normal Activities DespiteAdequate for Normal Activities Despite
Joint Discomfort of Limitation of MovementJoint Discomfort of Limitation of Movement
Class III: Class III: Inadequate for Most Self-Care andInadequate for Most Self-Care and
Occupational ActivitiesOccupational Activities
Class IV: Class IV: Largely or Wholly Unable to Manage Self-Largely or Wholly Unable to Manage Self-
Care; Restricted to Bed or ChairCare; Restricted to Bed or Chair
ACR
MedicinesMedicines
Non-Steroidal anti-inflammatories (NSAIDS) Non-Steroidal anti-inflammatories (NSAIDS) for symptom controlfor symptom control
Prednisone for quick control of joint Prednisone for quick control of joint inflammation but cannot use long term due to inflammation but cannot use long term due to side effectsside effects
Osteoporosis, cataracts, weight gain, insulin Osteoporosis, cataracts, weight gain, insulin resistance, dyslipidemiasresistance, dyslipidemias
Disease Modifying Anti-Disease Modifying Anti-rheumatic Agentsrheumatic Agents
Drugs that actually control the disease and not Drugs that actually control the disease and not just treat symptomsjust treat symptoms
Should be used early on in patientsShould be used early on in patients
Erosions can develop in the joints of patients Erosions can develop in the joints of patients within the first two years of diseasewithin the first two years of disease
Disease Modifying Anti-Disease Modifying Anti-rheumatic Agentsrheumatic Agents
Hydroxychloroquine-for mild disease, takes a Hydroxychloroquine-for mild disease, takes a long time to reach steady state, very benign in long time to reach steady state, very benign in side effect profileside effect profile
Sulfasalazine-for mild disease, toxicities Sulfasalazine-for mild disease, toxicities include GI upsetinclude GI upset
Azathioprine-for moderate disease, not as Azathioprine-for moderate disease, not as modifying as other drugs, cytopeniasmodifying as other drugs, cytopenias
Disease Modifying Anti-Disease Modifying Anti-rheumatic Agentsrheumatic Agents
Methotrexate-moderate to severe disease, very Methotrexate-moderate to severe disease, very successful in preventing erosions, liver successful in preventing erosions, liver toxicitiestoxicities
Anti-TNFAnti-TNFαα agents-used for mod-severe agents-used for mod-severe disease, but moving up as first line drug, TB disease, but moving up as first line drug, TB reactivation a concern reactivation a concern
PrognosisPrognosis
RA can shorten the life span 3-18 yearsRA can shorten the life span 3-18 years
Most die from cardiovascular disease, infection or Most die from cardiovascular disease, infection or lymphoproliferative disorderslymphoproliferative disorders
Overall RA patients are much better off than at any Overall RA patients are much better off than at any other time in history due to ongoing research and new other time in history due to ongoing research and new meds!!meds!!