Rheumatoid arthritis

28/4/2011 Uaepong Limpapanasit, MD

Introduction
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Characterised by
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Persistent synovitis involve peripheral joint in a symmetric distribution Systemic inflammation Autoantibodies : rheumatoid factor and citrullinated peptide

Epidemiology
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Frequency
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0.5-1.0% of adults in developed countries. Female : Male = 3: 1 Prevalence rises with age Onset most frequent during 4th 5th decades

Etiology
Unknown l Possible infectious agents
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Mycoplasma EBV CMV Parvovirus Rubella

Etiology
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Genetics
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50% of risk of developing RA is attributable to genetic factors. 10% of pt have an affected 1st degree relative HLA-DRB1 and DR4 alleles major genetic risk factor These HLA alleles share a similar amino acids sequence known as the shared epitope l Autoimmune l Risk & severity of RA l Anti-CCP +ve l Smoking : increase risk RA

Etiology
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Environmental risk factors

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Smoking doubles risk of developing ACPApositive disease. Other potential risk factors include
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alcohol intake coffee intake vitamin D status oral contraceptive use low socioeconomic status

Pathophysiology
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3 phases
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Nonspecific inflammation l Initiated by unknown stimulus l Accumulation of macrophages and other mononuclear cells within the synovium Activation & differentiation of memory CD4+ T cells l Overproduction & overexpression of TNF, IL-1, IL-6 Tissue injury & chronic inflammation l Polyclonal B cell stimulation auto-Ab complement activation Chronic Synovitis l Systemic manifestations fatique, fever, acute-phase protein

Pathophysiology
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Chronic synovitis
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Overproduction of proinflammatory cytokines is believed to be led predominantly by macrophage-like synoviocytes. Fibroblast-like synoviocytes show abnormal behaviour in rheumatoid arthritis. l leads to fibroblasts invading cartilage, correlates with joint destruction. l can spread between joints, suggesting how polyarthritis might develop. Osteoclast activation as a key process leading to bone erosion.

Clinical manifestations
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Onset
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2/3 insidiously with fatique, anorexia, weakness before synovitis becomes apparent Progressive symmetrical polyarthritis
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Articular disease
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Pain, swelling, tenderness, warmth, Limit ROM Morning stiffness > 1 hr

PIP, MCP, wrist, elbow, knee, forefoot, ankle, subtalar joints Upper cervical spine atlantoaxial subluxation

Clinical manifestations
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Bakers cyst : extension of inflamed synovium into the popliteal space Characteristic changes of hand
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Z deformity Swan-neck deformity Boutonniere deformity Piano key deformity

Septic arthritis superimpose

Clinical manifestations
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Extraarticular
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40 % of pt , often with RF & Anti-CCP +ve Rheumatoid nodules : usually sero +ve l Periarticular surface, extensor surface, pressure area Constitutional symptoms : fever, wt. loss, fatique Ocular : scleritis, episcleritis, keratoconjuctivitis sicca Pulmonary l interstitial fibrosis, pleuropulmonary nodule, pleural effusion(classically low glucose) l Caplans syndrome(pneumoconiosis +pulmonary nodule)

Clinical manifestations
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Pulmonary hypertension : rarely

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Cardiac : pericarditis, myocarditis Hemato : ACD , Feltys syndrome(RA + neutropenia + splenomegaly), DLBCL Renal : GN(MGN, mesangial, MPGN) Rheumatoid vasculitis
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Polyneuropathy, mononeuritis multiplex, palpable purpura, dermal necrosis, visceral gangrene

Other : nerve entrapment, Weakness & atrophy of skeletal muscle, osteoporosis

Laboratory finding
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Serology
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RF : non-specific l 5 % of healthy person l 10-20% of age > 65 l Other disease : SLE, Sjogren, Chronic liver disease, Sarcoidosis, IPF, infectious mononucleosis, HBV, TB , leprosy, syphilis, SBE l Can be prognostic sigificant Anti-CCP : better specific than RF l Associated with HLA-B1 alleles l 1.5 % of normal individual l Confirm Dx and predict Prognosis

Laboratory finding
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CBC : anemia of chronic inflammation, elevate plt Acute phase reactant : assoc. radiographic damage & long-term functional disability
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ESR : increase in nearly all pt with RA CRP, Ceruloplasmin : also elevate

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Synovial fluid : wbc 5-50000, PMN predominate X-Ray

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Early : soft tissue swelling, joint effusion Late : juxtaarticular osteopenia, narrow joint space, marginal bone erosion, deformities

Two typical erosions are sufficient for Dx

Diagnosis
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The American College of Rheumatology (ACR) 1987 criteria

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poor sensitivity and specificity for early inflammatory arthritis as having rheumatoid Effective treatment in early arthritis averts or delays patients fulfilling these 1987 criteria two criteriaerosive joint damage and extraarticular diseaseare late changes prevented by modern treatment.

Diagnosis
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The 2010 ACR-EULAR classification criteria for rheumatoid arthritis

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revised new classification criteria for early arthritis assess joint involvement, autoantibody status, and acute-phase response and symptom duration

Clinical course

Persistent but fluctuating disease activity 15% of patients with early RA achieve remission Persistent synovitis > 12 wks increase likelihood of developing bone erosions > 80 % have evidence of disability or joint abnormalities after 10-12 yrs 50% have work disability within 10 yrs Median life expectancy shorten by 3-7 yrs 2.5 times increase in mortality rate (Limited to pt with more severe artricular diseases)

Clinical course
Mortality due to Infection, GIB, CVS death l Poor prognostic factors have
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high tender and swollen joint counts evidence of radiographic erosions elevated levels of RF and/or anti-CCP elevated ESR and/or CRP Other : Old age, female sex, genotype (HLA DRB1 shared epitope), worse physical functioning, smoking

Management
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Treatment of symptoms
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Simple analgesics
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reduce pain Both analgesic and anti-inflammation Inability to modify the long-term course of disease Gastrointestinal and cardiac toxic effects should be given with PPI for gastroprotection, with short-acting drugs administered for short periods to minimise risks

NSAIDs
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Management
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Low dose oral glucocorticoid

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< 7.5 mg/day of prednisolone oral Suppress inflammation Retard progression of bone erosion Intraarticular glucocorticoi provide transient symptomatic relief

Management
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Disease-modifying antirheumatic drugs (DMARDs)

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Mainstay of treatment for RA

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Reduce joint swelling and pain Decrease acute-phase markers Limit progressive joint damage and improve function

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Benefit usually delayed for weeks or months Should begin as soon as RA diagnosed

Management
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Non-biologic agents :
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Methotrexate is the 1st DMARDs administered Rapid onset of action & higher adherence 7.5-25 mg/week orally, Sc, IM Maximal improvement after 6 month of Rx SE : GI upset, Oral ulcer, hepatic fibrosis Folic acid decrease SE hydroxychloroquine, leflunomide, minocycline, and sulfasalazine Gold salt and cyclosporin are additional DMARDs; their use is limited by toxic effects

Management
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Biologic agents :
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TNF inhibitors : Etanercept, Infliximab, adalimumab, golimumab Control S&S, slow joint progression Risk reactivation of TB, Lymphoma, Anti-DNA Ab Recombinant IL-1 receptor antagonist : Anakinra Improve S&S, decrease disability, slow articular damage Clinical impact less than Anti-TNF

Management
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Anti CD20 : Rituximab Approved for anti-TNF failure Improve S&S, retard progress of bone damage T-cell co-stimulation modulator : Abatacept Improve S&S, retard progress of bone damage

Management
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Supportive treatment
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Exercise, joint protection, foot care, and psychological support Management of comorbidities is important include cardiac disease, bone disease, and depression Patients education is also of crucial importance.

Management
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Surgical treatment
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particularly joint replacement surgery, is vital to maintain function when joints fail, and collaboration with orthopaedic specialists is required.

Remission
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Current Definitions (American Rheumatism Association)

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5 or more must be fulfilled for at least 2 consecutive months: l Morning stiffness not exceeding 15 minutes l No fatigue l No joint pain (by history) l No joint tenderness or pain on motion l No soft tissue swelling in joints or tendon sheaths l ESR (W) < 30 mm/h (f); < 20 mm/h (m)

Clinical assessment
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DAS28 : 28-joints Disease Activity Score

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Assess
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28 swollen and 28 tender joints : hands, arms, shoulders and knees patients global assessment ESR

Recommendation
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Most patients should receive a DMARD or DMARD combinations as quickly as possible improves long-term outcomes and is costeffective Both intraarticular and oral/intramuscular glucocorticoids help minimize disease activity until other medications are sufficient MTX as the initial DMARDs Biologic agent in MTX failure or induction for remission in early RA

Management
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Treatment of early RA (less than six months)

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Treatment is influenced by the activity of the disease l Mild HCQ + SSZ l Moderate MTX, HCQ +SSZ l Severe MTX, TNF inhibitor, leflunomide Triple therapy with MTX, SSZ, and HCQ or Addition of a TNF inhibitor to MTX

Treatment of persistently active RA

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References
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David L Scott, Frederick Wolfe, Tom W J Huizinga; Rheumatoid arthritis; Lancet 2010; 376: 10941108 Harrison's Principles of Internal Medicine, 17e; Chapter 314. Rheumatoid Arthritis American College of Rheumatology 2008 Recommendations for the Use of Nonbiologic and Biologic Disease-Modifyin Antirheumatic Drugs in Rheumatoid Arthritis Peter H Schur, MD; General principles of management of rheumatoid arthritis; UpToDate 18.2