Professional Documents
Culture Documents
Acknowledgements
• Dr. Andrew Thompson, rheumatologist at
SJHC and developer of the UWO
rheumatology medical school program
Objectives
• Gain a basic understanding of Rheumatoid
Arthritis
• Understand the presentation of
Rheumatoid Arthritis (Inflammatory
Arthritis)
• Understand the current treatment
paradigm and medications used
Case Presentation
• 43 yo woman, has been healthy apart from:
– C-Section for
– Mild depression
• Her current medications are
– Sertraline 100 mg per day (depression)
– Naproxen 500 mg twice a day (recent joint
pain)
Case Presentation
• 4 months ago developed pain in the left
knee with some mild swelling.
– The episode lasted a few days and then went
away.
Case Presentation
• About a week later the right knee began to
swell and become sore
• Then both wrists began to swell and
become sore. She also noticed some
soreness in her feet.
• About two weeks later her hands started to
stiffen up and she couldn’t get her rings
on.
Case Presentation
• She feels stiff when she wakes up in the
morning and this stiffness lasts for at least
3 hours
• She has no energy and has missed the
last week of work
• Her sleep is difficult because she is
uncomfortable
• She isn’t running because it “hurts too
much”
Differential Diagnosis
INFLAMMATORY POLYARTHRITIS
1. Infection
2. Rheumatoid Arthritis
3. Seronegative Arthritis (Psoriatic)
4. Connective Tissue Disease (SLE etc)
5. Associated with another Systemic
Disease
Who gets RA?
• ANYONE CAN GET RA
– From babies to the very old
• Common Age to Start: 20’s to 50’s
• Sex: Females more common than males
3:1
How does RA start?
• RA usually starts off slowly (insidious) over
weeks to months and progresses (70%)
• It can come on overnight (acute) but this is
rare (10%)
• It can come on over a few weeks
(subacute – 20%)
• Palindromic Presentation
– RACECAR, RADAR, MOM, DAD
How does RA start?
• Initially, most patients notice stiffness of
the joints which seems more pronounced
in the morning
• Some fatigue
• Some pain
What Joints are affected?
• RA usually begins as an oligoarticular
process (<5 joints) and progresses to
polyarticular involvmement
• Has a predilection for the small joints of
the hands and feet!
Small Joints of the Hand
What Joints are affected?
How are the Joints Affected
• Joints are usually
– Swollen
– Warm
Cooking
Dressing
Cleaning Pleasure
Bathing
Grooming
Shopping
Rheumatoid Arthritis is …
1. Usually insidious in onset
2. Adds joints over time
3. Has a predilection for the small joints of the
hands and feet
4. Joints become warm and swollen but not red
5. Morning stiffness is greater than 1 hour
6. Patients are often tired and don’t sleep properly
7. Can result in significant disability very quickly
Doesn’t just affect the joints
EXTRA-ARTICULAR
MANIFESTATIONS
Xerophthalmia (Dry Eyes)
Xerostomia (Dry Mouth)
Raynaud’s Phenomenon
Carpal Tunnel Syndrome
Pleural Effusion
Rheumatoid Nodules
Rheumatoid Nodules
Rheumatoid Vasculitis
Extra-Articular Manifestations
• Sicca Features: Xerostomia &
Xerophthalmia
• Raynaud’s Phenomenon
• Neuropathy: Carpal Tunnel Syndrome
• Rheumatoid Nodules
• Pleural Effusions
• Rheumatoid Vasculitis
Tests, Tests, Tests
INVESTIGATING A
PATIENT WITH
SUSPECTED RA
CASE SUMMARY
• Has a 4 month history of an inflammatory
polyarthritis
• Nothing else on history or physical
examination to suggest an associated
connective tissue disorder or seronegative
spondyloarthropathy.
INFLAMMATION
• Complete Blood Count (CBC)
– Hemoglobin: May be anemic (normocytic)
– WBC: Should be normal
– Platelets: May be normal to elevated
• Erythrocyte Sedimentation Rate (ESR)
• C-Reactive Protein (CRP)
ORGAN FUNCTION
TO MAKE SURE MEDS WILL BE SAFE
• Renal Function
– Creatinine + Urinalysis
• Liver Enzymes
– AST, ALT, ALP, ALB
– Hepatitis B & C Testing
• Consider baseline Chest X-Ray
ANTIBODIES
• Rheumatoid Factor
• Anti-Nuclear Antibody
Rheumatoid Factor
IgG Molecule
Autoantibodies
Fc Portion (IgM) directed
against the Fc
Fragment of IgG
An Antibody to an
IgM Molecule
Antibody
Antigen Binding Their Role in RA
Groove is not understood
Rheumatoid Factor
Rheumatic Disease Non- Rheumatic Disease
• Sjogren’s syndrome • Normal Aging
• Rheumatoid Arthritis • Infection
• SLE – Hepatitis B & C
• MCTD – SBE
– Tb
• Myositis
– HIV
• Cryoglobulinemia • Sarcoidosis
• Idiopathic Pulmonary
Fibrosis
Rheumatoid Factor (RF)
• Question: What Percentage of New Onset
RA will have a positive RF?
• Answer: 30-50%
• Question: What Percentage of Established
RA will have a positive RF?
• Answer: 70-85%
SO TREAT IT EARLY
Disability in Early RA
• Inflammation
– Swollen
– Stiff
– Sore
– Warm
• Fatigue
• Potentially
Reversible
Disability in RA
• Most of the disability in RA is a result of
the INITIAL burden of disease
• People get disabled because of:
– Inadequate control
– Lack of response
– Compliance
• GOAL: control the disease early on!
A Fire in the Joints
If there’s a fire in
the kitchen do you
wait until it
spreads to the
living room or do
you try and put it
out?
Clinical Course of RA
Severity of Arthritis
4
Type 1
3
Type 2
2 Type 3
1
0
0 0.5 1 2 3 4 6 8 16
Years
Trans-Membrane
Bound TNF
Macrophage
Soluble TNF
TNF Receptor
How Are the Effects
of TNF Naturally
Balanced?
Any Cell
Trans-Membrane
Bound TNF
Soluble TNF
Strategies for Monoclonal Antibody (Infliximab & Adalimumab)
Reducing
Effects of TNF
Trans-Membrane
Bound TNF
Macrophage
Soluble TNF
Infliximab (Remicade®) &
Adalimumab (Humira®)
• Chimeric (murine & human) monoclonal
antibody directed against TNF-α
Strategies for Soluble Receptor Decoy (Etanercept)
Reducing
Effects of TNF
Trans-Membrane
Bound TNF
Macrophage
Soluble TNF
Etanercept (Enbrel®)
•Infection
–Common (Bacterial)
–Opportunistic (Tb, Histo)
• Demyelinating Disorders
• Malignancy
• Worsening CHF
• Blood Counts
Do they work?
• Resounding YES!
• Outcome measured by ACR20
– 20% reduction in swollen & tender joints
– Plus 20% reduction in at least 3 of the
following:
• Patient VAS pain
• Physician global VAS
• Patient global VAS
• HAQ
• ESR or CRP
SUMMARY
• Rheumatoid Arthritis is a chronic
potentially debilitating illness
• Early treatment can have a PROFOUND
effect on this disease
• Treatment is multidisciplinary