Rheumatoid arthritis 

Rheumatoid arthritis is an autoimmune condition characterized by chronic inflammation, granulosa tissue formation, and joint destruction.

Rheumatoid arthritis is the most common persistent inflammatory arthritis.

The earliest change is swelling and congestion of the synovial membrane.

MALE: FEMALE RATIO= 1:3.

Up to 50% of genetic susceptibility is due to genes in the HLA region(particularly HLA-DR4).

TNF(Tumor Necrosis Factor) plays a central role in triggering local inflammation and regulating cytokines responsible for the systemic effect of rheumatoid arthritis.

Hypertrophy of the synovial membrane occurs, and inflammatory granulation tissue spreads over and under the articular cartilage, causing progressive cartilage destruction.

CLINICAL FEATURES 

INVOLVEMENT OF JOINTS

-Most common joints

 SMALL JOINTS

1) Metacarpophalangeal joints

2) Proximal interphalangeal joints

3)The most common presentation is with gradual onset of symmetrical arthralgia (joint pain) and synovitis of the small joints of hands, feet, and wrists.

4) Large joint involvement may also occur.

5)Sometimes RA has a very acute onset, with florid morning stiffness, polyarthritis, and pitting edema. This occurs mostly in old age.

6) Some patients may present with proximal muscle stiffness and mimicking polymyalgia rheumatica(inflammatory disease).

7) Swan neck deformity.

8) Buttonhole deformity

9) Ulnar deviation.

10) Cock-up toe deformity.

11) Popliteal cysts( bakers cysts).

12) Occasionally, the onset is palindromic, with relapsing and remitting episodes pain, stiffness, and swelling that lasts only for a few hours or days.

NON ARTICULAR FEATURES :

1) Blood- Anemia, WBC count increased

2) Cardio - Pericarditis, Endocarditis

3) Vascular - Involvement of small arteries

4) Skin- Ulcerative lesions

5) Rheumatoid nodules

AETIOLOGY OF RHEUMATOID ARTHRITIS:

Mainly 2 types of factors involved:

1) Immunological factors 

• They involve HUMAN LEUKOCYTE ANTIGEN ( HLA-DRB1)
• Chromosome 6 gets affected by the gene.

2) Menopause, oral contraceptive pills, pregnancy.

CRITERIA FOR DIAGNOSIS OF RHEUMATOID ARTHRITIS:

CRITERIA                                                         SCORE

JOINTS AFFECTED                                                  

1 LARGE JOINT                                                                    0

2-10 LARGE JOINTS                                                            1

1-3 SMALL JOINTS                                                              2

4-10 SMALL JOINTS                                                            5

SEROLOGY

NEGATIVE  RHEUMATOID FACTOR                                 0

LOW POSITIVE R.F. or ACPA                                               2

HIGH POSITIVE R.F. or ACPA                                              3

ACPA= anti-citrullinated Peptide Antibody.

DURATION OF SYMPTOMS:

<6 weeks                                                                                  0

> 6 weeks                                                                                 1

ACUTE PHASE REACTANTS:

Normal CRP & ESR                                                                 0

Abnormal CRP & ESR                                                             1

CRP= C-Reactive Protein

ESR= Erythrocyte Sedimentation Rate

PATIENT WITH A SCORE GREATER THAN OR EQUALS TO 6 ARE CONSIDERED TO HAVE DEFINITE RHEUMATOID ARTHRITIS.

Examination reveals typical symmetrical swelling of the metacarpophalangeal and proximal interphalangeal joints.

The joints are tender on pressure when actively inflamed and have stress pain on passive movements.

INVESTIGATIONS:

• The diagnosis is based on clinical criteria.
• ESR & CRP are usually elevated.
• ACPA is positive in ~70% cases and is highly specific for rheumatoid arthritis.
• Serological test (RF is positive in ~70% of cases)
• Ultrasound and MRI examinations mainly used to detect synovitis. Patients who are suspected of having atlantoaxial disease should have MRI.
• X-Ray(Deformities, bone density is decreased in the case of rheumatoid arthritis).
• Synovial fluid analysis (Color- yellow/green; Cloudy, Less viscous).

MANAGEMENT:

Disease-Modifying Anti-rheumatic Drugs (DMARDs)

• Regular monitoring of DMARDs therapy is essential because of the risk of the liver & hematological toxicity.
• Methotrexate  
• Sulfasalazine 
• Hydroxychloroquine
• D- Penicillamine

BIOLOGICAL THERAPIES:

• Well tolerated
• Expensive
• Increases risk of serious infections due to suppression of immune response.

Anti TNF therapy: 

•  These are first line biological drugs to rheumatoid arthritis.
• Most are prescribed with methotrexate.
• Infliximab, etanercept, adalimumab.
• The main adverse effects are serious infections and reactivation of latent T.B.
• It increases risk of some malignancies , but may reduce the risk of vascular disease in R.A patients.

 Rituximab- suppresses immune system 

• Mostly used in patients with rheumatoid arthritis who fails to respond to TNF blockade.
• Anti CD 20 receptor antibody that depletes B lymphocytes.

Abatacept- T- cell activation inhibitor

Tocilizumab- also known as atlizumab

• Anti-IL-6
• immunosuppressive

Prednisolone- Steroid medication

• used to treat inflammation and autoimmune disorders.

Corticosteroids- Glucocorticoids

• Rapid and dramatic anti-inflammatory actions.

LOCAL INJECTIONS:

• Intra-articular injections of long-acting corticosteroids.
• Triamcinolone can be useful adjunctive therapy for controlling synovitis affecting one or a few joints.
• Symptoms relief typically lasts for 2-8 weeks.
• Peri articular steroid injections can be used to provide rapid, effective pain relief for conditions such as bursitis, tenosynovitis & lateral epicondylitis.
• The steroid is sometimes combined with local anesthetics to provide more rapid analgesia.

SURGERY:

• Synovectomy
• Osteotomy
• Arthrodesis
• Arthroplasties.

PHYSIOTHERAPY:

• Static splints
• Correction of deformities
• Prevention of deformities.

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