RHEUMATOID ARTHRITIS (RA)
Gergely Péter dr
Definition: Chronic destructive of joint inflammation
with pain and swelling,mainly characterized by
inflammation of the lining( synovium) of the joints .In a
considerable proportion of patients, the arthritis is
progressive, resulting in joint destruction and
ultimately incapacitation and increased mortality.
prevalence: 0.3-1.5 %
, the male:female ratio cca. 1:3.
Typical case: woman aged 30-40 years with
polyarthritis and early joint deformities.
History of Rheumatoid Arthritis
1858 – Dr Alfred Baring Garrod, named the condition Rheumatoid
1895 – X-Ray was discovered.
1912 – Dr. Frank Billings introduced the concept of focal infection.
In the 1920’s, physicians suspected the cause of RA was bacterial
infection, they used gold and malaria drugs.
RA in European Art
Dutch Priest 1631
Renoit in 1911
w/ classic RA in his
1-gentic factor : may be involved because it is usually
associated with HLA-DR4
In white people and DR1 in indo-pak.
2-autoimmunity: RA is considered to be an
autoimmune disease for the following reasons:
*autoantibodies are present .
*immune comlex are common in synovial
There is defect in cell mediated immunity .
3-female gender: is a risk factor and this susceptibility
is increased post-partum and by breast feeding
4-cigarette smoking : is also a risk factor
Is a disease of the synovium.
*inflammation :the synovium shows signs of chronic
inflammation .there swilling and congestion of synovial
membrane , and the underlying connective tissue which
becomes infilterated with lymphocyte,plasma cells and
*proliferation : the synovial membrane then proliferates and
grows out over the surface of the cartilage, which causes
erosion and destruction of the cartilage .
Symptoms of Rheumatoid Arthritis:
• Symptoms first begin in the small joints of the fingers, wrists and
feet, with warm, swollen
and tender joints that are painful and difficult to move.
• Joints of both sides of the body (symmetrical) are typically
• People with RA often experience fatigue, loss of appetite and
• There is often stiffness in the morning that lasts for several hours
• Nodules may form under the skin, often over the bony areas
exposed to pressure (such
as the elbows).
• Over time, damage to the cartilage and bone of the joints may
lead to joint deformities.
Classification criteria of RA (ARA, 1987)
1. Morning stiffness – for at least 1 hr and present for at
least 6 weeks
2. Swelling of 3 or more joints for at least 6 weeks
3. Swelling of wrist, metacarpophalangeal (MCP) or
proximal interphalangeal (PIP) joints for at least 6
4. Symmetric joint swelling
5. Typical radiologic changes in hands (erosions or
unequivocal bony decalcification)
6. Rheumatoid nodules
7. Serum rheumatoid factor (RF) positivity
Diagnosis is made by the presence of 4 or more criteria
Differential diagnosis of polyarthritis
RA should be differentiated from:
- Other autoimmune diseases (SLE, primary Sjögren’s syndrome,
MCTD, PM/DM, PSS, PAN, gian cell vasculitis, polymyalgia rheumatica,
adult onset Still’s disease)
- Viral diseases (parvovirus B19 infection, rubella, hepatitis B & C
- Bacterial infections (tbc, rheumatic fever, Jaccoud’s arthritis, septic
endocarditis, mycoplasma arthritis)
- Seronegative spondylarthritides (erosive psoriatic arthitis, reactive
arthritis, enteropathic arthritis)
- Paraneoplastic arthritis
- Other diseases (e.g. hyperthrophic osteoarthropathy, erythema
nodosum, agammaglobulinemia, acromegaly, diabetes mellitus)
- Other rheumatic diseases (chronic gout, inflamed erosive
Signs of early RA
In the early stage (within the first 3-6 months) (ARA)
classification criteria cannot be used.
The patient should be referred to a rheumatologist, if
the patient has 3 or more swollen joints
the metacarpophalangeal (MCP) and/or
metatarsophalangeal (MTP) joints are
involved; the squeeze test is positive
morning stiffness is 30 min or more.
How to diagnose a case of
Slow development of sign & symptoms
Most common: PIP & MCP of hands
Morning stiffness > 1hr
Fatigue, malaise, depression
Joint involvement in RA
The most specific sign of RA is arthritis.
It is progressive and deforming in the
majority (2/3) of cases (= erosive
RA early stage
Early assymmetric RA
PIP joint involvement in RA
RA: swan neck deformity
RA: ulnar deviation
Ulnar deviation in RA with severe atrophy of interosseal
1-Early: no sig changes
-Juxta-articular osteoporosis w/ decr bone density
*Uniform jt narrowing.
*Marginal cortical erosions
*Juxtaarticular osteoporosis of lesser mets
Ill-defined ersosion of posteroanterior aspect of calcaneus
Resiters, PA, AS, hyperparathyroidism
Periarticular osteoporosis (decalcification)
Erosions and sclerosis (in late stage)
Erosion in RA
Early erosions (MRI)
Extraarticular manifestations of RA
• rheumatoid nodules
- in internal organs (lung,
Interstitial pneumonitis in RA
Rheumatoid nodules in the lungs
Episcleritis in RA
Scleritis in RA
Vasculitis in RA
Vasculitis in RA
Leg ulcers in Felty’s
Large granular lymphocytes in Felty’s syndrome
What is “Quality of Life”?
• Ability to
– Be a parent
– Socialize with others
– Exercise and be mobile
Management of Rheumatoid Arthritis:
• The goals of treatment of RA are to reduce joint pain and
swelling, relieve stiffness and
prevent joint damage.
• Evaluation by a rheumatologist for the development and
monitoring of a treatment plan is
required in most people with RA.
• Treatment plans often include a combination of rest, physical
activity, joint protection, use
of heat or cold to reduce pain, and physical or occupational
• Maintain a healthy body weight and maintain a physical activity
plan (i.e. Arthritis
• Drugs play a very important role in the treatment of RA.
• Many people with RA take nonsteroidal anti-inflammatory drugs
(NSAIDs) to help reduce
joint pain, stiffness and swelling.
• Low doses of corticosteroids such as prednisone may also be
used to relieve joint pain,
stiffness and swelling and to reduce the risk of joint swelling.
• People with RA are often treated with disease-modifying antirheumatic drugs
(DMARDs), such as methotrexate or leflunomide
Disease modifying antirheumatic drugs (DMARD):
25-50 mg /2-4
less frequently used, brecause of lower
chloroquine (hydroxy- retinopathia, pigment250 mg/day
Regular ophthalmology check is required
Owing to low tolerability it is not used any more
hepatitis, bone marrow depression 50-150
Scarcely given in RA
hepatotoxicity, pulmonary fibrosis, 7,5-25
bone marrow depression
most frequently used therapy
diarrhea, bone marrow depression
creatinine and blood pressure should be
local reaction, autoimmune disease (SLE, SM)
etanercept: 25 mg 2x weekly s.c.
infliximab: 3 mg/kg every 8 week i.v.
anakinra (IL-1 blocker)
rituximab (anti-CD20 antibody)
abatacept (T cell activation blocker antibody)