Dr Jean Lee
Video Duration: 7 minutes
Rheumatoid arthritis is a chronic, seropositive, inflammatory, autoimmune form of arthritis.
As with other autoimmune conditions, it is more common in women (four times in this case).
Approximately 10,000 new RA cases diagnosed annually.
Again, similar to other autoimmune diseases, the exact pathology remains unknown. Most likely it is a combination of genetic predisposition, environmental stimuli, foetal factors, hormonal environment.
Rheumatoid arthritis is commonly associated with other autoimmune conditions such as type one DM. It has also been suggested that there is a link between the presence of HLA DR4 and severe disease.
There is now an emphasis on diagnosis and initiating treatment as early as possible in RA. ? starting treatment within the first 12 weeks of symptoms can alter the course of the disease?
Bilateral and symmetrical arthritic joints (must be synovial). this can occur anywhere, but there is a high incidence of it occurring in the joints of the hands and feet.
Morning stiffness lasting over an hour in duration.
progressive disability/activity limitation due to deformity.
Venous: FBC (increased CPR and ESR), Anti-cyclic citrullinated peptide (anti-CCP) antibodies, rheumatoid factor. Note that approximately 1/3 of people suffering from RA are seronegative for Rheumatoid factor, so a negative result does not necessarily exclude a diagnosis of rheumatoid arthritis.
Recommended that all patients have and X-ray of their hands and feet as well as a chest x-ray prior to starting therapy.
Early referral to a rheumatologist is essential. However, GP should prescribe NSAID's and possibly neuropathic pain killers such as amitriptyline to reduce level of pain.
RA patients should be reffered to the likes of podiatrists, physiotherapists and occupational therapists.
Rheumatologists may prescribe the likes of corticosteroids, DMARD's (disease modifying anti rheumatic drugs) or biologics. The prescription of these will vary from patient to patient depending on severity of disease, ADR's, what has been previously tried etc.
Currently popular are methotrexate and sulfasalazine due to being less toxic than some other options.
Patients are commonly initiated on multi-drug therapy.
Biologicals are second line where patients may be resistant to the likes of methotrexate. These are cytokine modulating therapies.
Patients should have a yearly review.
Orthopaedic surgeons may be involved to improve joint mobility in patients who are on maximum therapy but are still in a significant amount of pain.
Chronic, inflammatory autoimmune disease, causing a symmetrical polyarthritis
Global prevalence ~ 0.5-1%
Peak prevalence at 30-50 years
Increased prevalence in pre-menopausal women than men (3:1), but post-menopause, male:female prevalence ~1:1
Inflammatory infiltration of the synovial lining of joints leads to synovitis and eventually pannus formation. This causes destruction of the articular cartilage and subchondral bone.
Gradual onset of symptoms.
For RA to be diagnosed, symptoms must be present for at least 6 weeks.
Early morning joint stiffness, lasting > 1 hour.
Symmetrical distribution of affected joints.
Tender swelling of hand joints, especially MCP, PIP and Wrist (but DIPJ is spared)
Other joints that can be affected include wrist, elbow, knee, ankle, MTP.
More general symptoms include:
Neurological findings include:
Pulmonary findings include:
Vasculitic features include:
Cardiovascular features include:
Acute Phase Reactants (CRP, ESR)
Auto-antibodies (Rheumatoid Factor, Anti-CCP)
Ultrasound scan (to detect synovitis)
Annual X-ray of affected joints
Joint aspirate for synovial fluid analysis
Early recognition and rapid referral to a rheumatologist
DMARDs, e.g. Methotrexate, Sulphasalazine
Biological agents, e.g. Infliximab (Anti-TNF-alpha monoclonal antibody)
Optimize cardiovascular risk factors