Rheumatoid Arthritis. Nicole Klett,, M.D.

Rheumatoid Arthritis Nicole Klett,, M.D.

Rheumatoid Arthritis Systemic Chronic Inflammatory Primarily targets the synovium of diarthrodial joints Etiology likely combination genetic and environmental

Diarthrodial Joint

Rheumatoid Arthritis Female: male 3:1 4 th -6 th decades of life Symmetric polyarthritis Extra-articular articular manifestations Subcutaneous nodules/lung nodules Scleritis Vasculitis Felty s syndrome

Stages of RA Pathogenesis Stage 1. Antigen Presentation to T Cells 2. T and B Cell Proliferation, Angiogenesis in Synovium Symptoms None Malaise, Mild, Joint Stiffness Swelling Findings None Normal X-rayX Swelling or Pain of Small Joints Wrists, Knees Normal, X-rayX ACR

Stages of RA Pathogenesis (Continued) Stage Symptoms Findings 3. SFPMN Accumulation Synovial Cell Proliferation Joint Pain, Swelling AM Stiffness, Malaise, Weakness Warm, Swollen Joints, Inc SF Soft Tissue Proliferation, Limited ROM, Nodules, Soft Tissue Swelling on X-rayX ACR

ACR Stages of RA Pathogenesis (continued) Stage Symptoms Findings 4. Pannus Invasion, Stage 3 Chondrocyte Activation, Enzyme Activation Same as Same as Stage 3 Stage 3 Periarticular Osteopenia, Proliferative Pannus on MRI

Stages of RA Pathogenesis (continued) Stage Symptoms Findings 5. Subchondral Same as Same as stage 3 Bone Erosion, Stage 3 Plus Instability Pannus Plus Loss Flexion Invasion of of Function Contractures, Cartilage Deformity Extra-Articular Stretched Disease, Early Ligaments Erosions and Joint Space Narrowing on X-RayX ACR

Synovium in RA

ACR Criteria Morning Stiffness 1 hour Soft tissue swelling of 3 joints observed by physician Swelling of proximal interphalangeal (PIP), metacarpophalangeal (MCP), or wrist joints These signs and symptoms must be present 6 weeks

ACR Criteria Continued Symmetric Arthritis present for 6 weeks Subcutaneous nodules Positive Rheumatoid Factor Radiographic Erosions or periarticular osteopenia in hand or wrist joints Must have 4 criteria to meet diagnosis of RA

PIP Swelling

Ulnar Deviation, MCP Swelling, Left Wrist Swelling

Joints involved in RA

Joints involved in RA Don t forget the cervical spine!! Instability there can lead to impingement of the spinal cord Thoracolumbar, sacroiliac, and distal interphalangeal joints of the hand are not involved

Radiographic Features Peri-articular articular osteoporosis Uniform joint space narrowing Marginal erosions Soft tissue swelling Subluxations Symmetric Cysts

Synovial Fluid Inflammatory WBCs 5000-50,000 50,000 50% neutrophils No crystals Negative Cultures

Noninflammatory on left Inflammatory on right

Rheumatoid Factor Antibodies that recognize Fc portion of IgG Can be IgM, IgG, IgA, IgE 85% of patients with RA over the first 2 years become RF+

Labs Can also see nonspecific abnormalities High sedimentation rate Anemia Hypergammaglobulinemia Thrombocytosis

Extra-articular articular Symptoms Patients that are more likely to get are: RF+ HLA DR4+ Male

Corneal Melt

Nodules

Pulmonary Nodules

ACR Felty s Syndrome Seropositive Rheumatoid Arthritis Splenomegaly Granulocytopenia

Large Granular Lymphocytes

Criteria for Progression of RA Stage I Early No Destructive Changes Osteoporosis on X-RayX Stage II Moderate Osteoporosis and Slight Subchondral Bone or Cartilage Destruction No Joint Deformaties,, Mobility May be Limited Adjacent Muscle Atrophy Nodules or Tenosynovitis May be Present ACR

Criteria for Progression of RA Stage III Severe (continued) Osteoporosis and Erosions Deformity Without Ankylosis Extensive Muscle Atrophy Nodules and Tenosynovitis Stage IV Terminal Fibrous or Bony Ankylosis Features of Stage III ACR

Management Focused on relieving pain and preventing damage/disability Patient education about the disease is key Physical Therapy for stretching and range of motion exercises Occupational Therapy for splints and adaptive devices Surgery

Rheumatoid Arthritis: Classification of Function Class I: No Limitations Class II: Adequate for Normal Activities Despite Joint Discomfort of Limitation of Movement Class III: Inadequate for Most Self-Care and Occupational Activities Class IV: Largely or Wholly Unable to Manage Self- Care; Restricted to Bed or Chair ACR

Medicines Non-Steroidal Steroidal anti-inflammatories inflammatories (NSAIDS) for symptom control Prednisone for quick control of joint inflammation but cannot use long term due to side effects Osteoporosis, cataracts, weight gain, insulin resistance, dyslipidemias

Disease Modifying Anti- rheumatic Agents Drugs that actually control the disease and not just treat symptoms Should be used early on in patients Erosions can develop in the joints of patients within the first two years of disease

Disease Modifying Anti- rheumatic Agents Hydroxychloroquine-for mild disease, takes a long time to reach steady state, very benign in side effect profile Sulfasalazine-for for mild disease, toxicities include GI upset Azathioprine-for moderate disease, not as modifying as other drugs, cytopenias

Disease Modifying Anti- rheumatic Agents Methotrexate-moderate to severe disease, very successful in preventing erosions, liver toxicities Anti-TNF TNFα agents-used for mod-severe disease, but moving up as first line drug, TB reactivation a concern

Prognosis RA can shorten the life span 3-183 years Most die from cardiovascular disease, infection or lymphoproliferative disorders Overall RA patients are much better off than at any other time in history due to ongoing research and new meds!!