Rheumatoid Arthritis

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• Rheumatoid Arthritis
• Systemic chronic inflammatory disease
• Mainly affects synovial joints
• Variable expression
• Prevalence about 3
• Worldwide distribution
• Femalemale ratio 31
• Peak age of onset 25-50 years

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Rheumatoid Arthritis

• Unknown etiology
• Genetics
• Environmental
• Possible infectious component
• Autoimmune disorder

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• THE PATHOLOGY OF RA
• Serositis
• 1. Synovitis
• Joints
• Tendon sheaths
• Bursae
• Nodules
• Vasculitis

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Signs and Symptoms

• Joint inflammation
• Tender, warm swollen joints
• Symmetrical pattern
• Pain and stiffness
• Symptoms in other parts of the body
• Nodules
• Anemia
• Fatigue, occasional fever, malaise

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• JOINT INVOLVEMENT ON PRESENTATION OF RA
• Polyarticular 75 Monoarticular
  25
• Small joints Knee
  50
• of hands and feet 60
• Large joints 30 Shoulder
  
• 
  Wrist
• Large and Hip
  50
• Small joints 10 Ankle
  
• 
  Elbow

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• Articular features seen in the Rheumatoid Hand
• WRIST PIPs
• Synovitis Synovitis
• Prominent ulnar styloid Fixed flexion or
  extension
• Subluxation and collapse of deformities
• carpus (Swan neck or boutonniere
• Radial deviation deformity)
• MCPs THUMBS
• Synovitis Synovitis
• Ulnar deviation Z deformity
• Subluxation

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Joint Destruction
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Extra-articular manifestations

• General
• fever, lymphadenopathy, weight loss, fatigue
• Dermatologic
• palmar erythema, nodules, vasculitis
• Ocular
• episcleritis/scleritis, scleromalacia perforans,
  choroid and retinal nodules

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Extra-articular manifestations

• Cardiac
• pericarditis, myocarditis, coronary vasculitis,
  nodules on valves
• Neuromuscular
• entrapment neuropathy, peripheral neuropathy,
  mononeuritis multiplex
• Hematologic
• Feltys syndrome, large granular lymphocyte
  syndrome, lymphomas

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Extra-articular manifestations

• Pulmonary
• pleuritis, nodules, interstitial lung disease,
  bronchiolitis obliterans, arteritis, effusions
• Others
• Sjogrens syndrome, amyloidosis

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Investigations

• Hematology CBC , ESR
• Biochemistry LFT , Renal profile
• Serology RF , Anti-CCP
• Radiography Joints , Spines ,Chest

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Treatment Goals

• Relieve pain
• Reduce inflammation
• Prevent/slow joint damage
• Improve functioning and quality of life

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Treatment Approaches

• Lifestyle modifications
• Rest
• Physical and occupational therapy
• Medications
• Surgery

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Rationale for the Early Treatment of
R.A. Erosions develop early in the disease
course Destruction is irreversible Disease
activity is strongly associated with joint
destruction later in the disease course Early
treatment can slow down radiographic
progress Disease activity must be suppressed
maximally in its early stages to prevent
destruction and preserve function
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Drug Treatments

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Disease-modifying antirheumatic drugs (DMARDs)
• Biologic response modifiers
• Corticosteroids

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Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

• COX-2 Inhibitors
• Celecoxib
• Rofecoxib

• Traditional NSAIDs
• Aspirin
• Ibuprofen
• Ketoprofen
• Naproxen

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Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

• To relieve pain and inflammation
• Use in combination with a DMARD
• Gastrointestinal side effects

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Disease-Modifying Antirheumatic Drugs (DMARDs)

• Hydroxychloroquine

• Sulfasalazine
• Methotrexate
• Leflunomide
• Gold
• Azathioprine

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Disease-Modifying Antirheumatic Drugs (DMARDs)

• Control symptoms
• No immediate analgesic effects
• Can delay progression of the disease
  (prevent/slow joint and cartilage damage and
  destruction)
• Effects generally not seen until a few weeks to
  months

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DMARDs

• hydroxychloroquine
• mild non-erosive disease
• combinations
• 200 mg bid
• eye exams

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DMARDs

• Sulfasalazine
• 1 gm bid - tid
• CBC, LFTs
• onset 1 - 2 months
• Methotrexate
• most commonly used drug
• fast acting (4-6 weeks)
• po, SQ - weekly
• CBC, LFTs

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DMARDs

• IM Gold
• slow onset (3-6 months)
• weekly then monthly injections
• CBC, UA before each injection
• Oral Gold
• less effective
• slow acting (4-6 months)
• daily
• CBC, UA

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Biologic Response Modifiers

• Etanercept
• Infliximab
• Anakinra

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Biologic Response Modifiers

• Etanercept and infliximab target tumor necrosis
  factor alpha (TNF-?)
• Anakinra targets interleukin-1 receptor

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OSTEOARTHRITIS
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• MULTIFACTORAL ETIOLOGY OF OA
• ? Joint instability
• ? Age
• ? Hormonal factors
• ? Trauma
• ? Altered biochemistry
• ? Inflammation
• ? Genetic predisposition
• ? ? Others

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• SYMPTOMS AND SIGNS OF OA
• Pain worse on use of joint
• Stiffness mild after immobility
• Loss of movement
• Pain on movement/restricted range
• Tenderness (articular or periarticular)
• Bony swelling
• Soft tissue swelling
• Joint crepitus

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• RADIOLOGICAL FEATURES OF OA
• Narrowing of joint space
• Osteophytosis
• Altered bone contour
• Bone sclerosis and cysts
• Periarticular calcification
• Soft-tissue swelling

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MANAGEMENT OF OSTEOARTHTITIS

• Confirm diagnosis
• Initial Therapy
• Pysiotherapy
• Wt loss
• Local therapy
• Paracetamol

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MANAGEMENT OF OSTEOARTHTITIScont

• Second-line approach
• NSAIDS
• Intra-articular therapy
  steroids,hyalurinate
• Opioids
• ?glucosamines
• Arthroscopy
• Surgery

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