Rheumatoid arthritis (RA) is an autoimmune disease that causeschronic inflammation of the joints & can also causeinflammation of the tissue around the joints, as well as inother organs in the body.An autoimmune disease is a disease where the immunesystem attacks healthy parts of the body.As it can affect multiple other organs of the body, RA is referred toas a systemic illness and is sometimes called rheumatoiddisease.Introduction
A joint (the place where two bones meet) is surrounded by a capsulethat protects and supports & it is lined with a type of tissue calledSynovium, which produces synovial fluid that lubricates and nourishesjoint tissuesIt becomes inflamed, causing warmth, redness, swelling, andpain & unable to move freelyAs the disease progresses, the inflamed synoviuminvades and damages the cartilage and bone of the joint. Surroundingmuscles, ligaments, and tendons become weakenedThis process eventually leads to deformity and destruction of the jointsRA also can cause more generalized bone loss that may lead toosteoporosis (fragile bones that are prone to fracture)RA Contd…
The incidence of RA is in the region of 3 cases per 10,000population per annum. Onset is uncommon under the age of 15and from then on the incidence rises with age until the age of80.Some Native American groups have higher prevalence rates (5–6%) and people from the Carribean region have lowerprevalence rates.First-degree relatives prevalence rate is 2–3% and diseasegenetic concordance in monozygotic twins is approximately15–20%.Epidemiology
The cause of RA is unknown. It is assumed that a geneticallysusceptible host is exposed to an unknown antigen & thisinteraction gives rise to a persistent immunological response The activation of immune response is triggered by the followingfactors.They are:- GENETIC FACTORS:-RA is documented by presence ofimmune cell reactivity and production of antibodies toendogenous elements such asimmunoglobulins,collagen,andcellular componentsEtiology
PRESENCE OF HLA (human lymphocyte antigen):-The mostdefinite genetic association with RA is with HLA alleles.TheHLA-DR4 allele is associated with development & severity ofRA. Risk of an individual with HLA-DR4 to develop the disease isbetween 2 & 6. In American Whites,60-70% of RA patients arepositive for HLA-DR4. Frequency of this allele among Dutch patients is greater than90%.Contd…
There is a 30% concordance in monozygotic twins compared to5% in fraternal twins and first degree relatives.First degree relatives of patients develop RA at 4-6 times therate of standard population rate. INFECTIOUS FACTORS:- Presence of Epstein-Barr virus asantigen. Of patients with RA ,80% have a circulating antibodydirected against antigens specific for this virus. Parvovirus particularly B19 & also Mycobacteria(as itexpresses HSP,heat sensitive protein)have been linked to RA.Contd…
ENDOCRINOLOGIC FACTORS:-. disease may improveduring pregnancy and flare after pregnancy. Breastfeeding mayalso aggravate the disease Contraceptive use reduces the risk of developing RA. Thissuggests possible deficiencies or changes in certain hormones,may promote the development of RA ENVIRONMENTAL FACTORS:-Changes in barometricpressures are associated with acute worsening of RA. Besidesclimate,diet,trauma are also known to influence RA.Contd…
RA is characterised by the infilteration of various inflammatorycells into the joint The synovial membrane becomes highly vascularised &synovial fibroblasts proliferate & inflammatory cells releasenumerous CYTOKINES & GROWTH FACTORS into thejoint These agents cause synovial cells to release proteolytic enzymes&Proliferating inflammatory tissue (PANNUS-tissue serving asorigin of joint erosions) subsequently leads to the destruction ofintra articular & peri articular structures leading to the jointdeformities and dysfunctionPathogenesis
Tender, warm, swollen joints Symmetrical pattern of affected joints Joint inflammation often affecting the wrist and finger jointsclosest to the hand Joint inflammation sometimes affecting other joints, includingthe neck, shoulders, elbows, hips, knees, ankles, and feet Fatigue, occasional fevers, a general sense of not feeling well Pain and stiffness lasting for more than 30 minutes in themorning or after a long rest Variability of symptoms among people with the diseaseDistinctive clinicalfeatures of RA
Since RA is a systemic disease, its inflammation can affectorgans and areas of the body other than the joints likeeyes,skin,lungs,heart & blood vessels Examples of other areas that may be affected include:- SJOGREN’S SYNDROME:-inflammation of the glands of theeyes and mouth and causes dryness of these areas PLEURITIS causes chest pain with deep breathing or coughing Tissue inflammation surrounding the heart, PERICARDITISComplications
Rheumatoid disease can reduce the number of red blood cellsANEMIA and white blood cells. Decreased white cells can be associated with an enlarged spleeni.e FELTYS SYNDROME and can increase the risk ofinfections. RHEUMATOID NODULES can occur around the elbows andfingers where there is frequent pressure. VASCULITIS rare and serious complication is blood-vesselinflammation which can impair blood supply to tissues andlead to tissue death. This is most often initially visible as tinyblack areas around the nail beds or as leg ulcers.
EROSIVE CHANGES GIVE RISE TO JOINTINSTABILITY&SUBLUXATION.CHARACTERISTICDEFORMITIES INCLUDE ULNARDEVIATION,SWAN NECK,BOUTONNIERESYNDROME.
Are made after a full medical and family history and physicaland diagnostic testing are evaluated by a qualified health careprofessional. Medical testing may include a wide variety of tests like:- ESR (Erythrocyte Sedimentation Rate CRP (C – Reactive prot ) INFLAMMATORY RF (Rheumatoid factor)blood tests MARKERS ANA (Anti nuclear antibodies) JOINT X-RAYS MRI (Magnetic resonance imaging) & US (ultra sound)Investigations
ESR…It is a test that measures how fast red blood cells(erythrocytes) drop to the bottom of a collection tube. CRP…C-reactive protein, another common test forinflammation is useful both in making a diagnosis andmonitoring disease activity and response to anti-inflammatorytherapy. RA FACTOR… is an autoantibody that is present in the bloodof most people with RA & directed against hostimmunoglobulin & present in 75-80% in patients with RA.
• ANA ….These are investigated to rule out possibility of otherconnective tissue disorders like SLE. ANA’s are raised in 80%of patients with SLE & 20% of patients with RA.• X-RAYS….Erosions can be seen at the joint margins & loss ofjoint space due to erosion of cartilage & bone may be identified.• MRI & US SCAN…used to detect inflammatory activity. sothese are increasingly used to detect early changes in RApatients.
Laboratory tests include an• elevated alkaline phosphatase, elevated platelet count, decreased serum albumin level Anti-CCP antibodies: This blood test detects antibodies tocyclic citrullinated peptide (anti-CCP). This test is positive inmost people with RAand can even be positive years before rheumatoid arthritissymptoms develop.
Goals of Treatment Relieve pain Reduce inflammation Slow down or stop joint damage Improve a persons sense of well-being and ability tofunction. Current Treatment Approaches Lifestyle Medications Surgery Routine monitoring and ongoing care.Treatment
Physiotherapy is a vital part of treating RA Heat,cold and electrotherapy helps to reduce pain and swelling program of exercise strengthens joints & minimize deformityand increase the range of movement and functions Natural treatments include using massage with herbs,magnetotherapy etc Occupational therapy educates patients to protect joints with theuse of appliances and splints. Surgical techniques can be effective in relieving pain andrestoring function.Non-Pharmacological
• ANALGESICS –used only for pain reliefEg:-Paracetamol-325 to 650mg every 4-6hrs or 1gm 3-4times/dayTopical Analgesic(Capsaicin)-apply 3-4 times/day• NSAID’s-used as an adjunct along with DMARD’s to reducethe inflammationEg:-Ibuprofen-1.2-3.2 gms/day in 4 divided doses TIDAspirin-325-650mg for every 4hrs for pain3,600mg for inflammation 4 times dailyNSAID’S mainly act by inhibiting COX -1 &2 enzymes blockingCOX enzyme site & thus reduces inflamationPharmacological
CORTICOSTEROIDS-used because of their anti inflammatory& immunosuppressive propertyEg:-Prednisone & methyl prednisolone given orally or IV,IM-7.5mg daily as single dose/infusion-Act by suppressing the cytokines• DMARD,s(disease modifying anti-rheumatic drugs)-used toslow down the progression of disease• These include METHOTREXATE-5 to 25 mg onceweekly;Oral or IM• SULFASALAZINE-initially 500mg OD,increasing in weeklysteps 0f 500mg to 1gm BD
The primary purpose is to reduce pain, improve the affectedjoint’s function, and improve the patient’s ability to performdaily activities Joint replacement:involves removing all or part of a damagedjoint and replacing it with synthetic components. Most commonly replaced joints are the hips and knees.Current Surgery Approaches
Arthrodesis (fusion): is a surgical procedure that involvesremoving the joint and fusing the bones into one immobile unit,often using bonegrafts from the person’s own pelvis useful for increasing stability and relieving pain in affectedjoints Tendon reconstruction: RA can damage and even rupturetendons, the tissues that attach muscle to bone reconstructs the damaged tendon by attaching an intact tendonto it
Routine monitoring and ongoing care: Regular medical care isimportant to monitor the course of the disease, determine theeffectiveness and any negative effects of medications, andchange therapies as needed Healthful diet:- overall nutritious diet with enough—but not anexcess of—calories, protein, and calcium is important Those taking methotrexate need to avoid alcohol as mostserious long-term side effects is liver damageGeneral Approaches
Stress reduction:- Stress also may affect the amount of pain aperson feels Regular rest periods can help, as can relaxation, distraction, orvisualization exercises Joint care:- using a splint for a short time around a painful jointreduces pain and swelling by supporting the joint and letting itrest Rest and exercise:- good balance between rest and exercise isrequiredThey reduce active joint inflammation and pain and to fightfatigue,maintaining healthy and strong muscles, preserving jointmobility, and maintaining flexibility
There is no known way to prevent RA because the exact cause ofthe disease is not knownPreventive measures can be taken only after diagnosis ofthe disease.But making some modifications in :-Diet(consume nutritious food )Relaxed Life styleAvoiding smoking & alcohol consumptionMaintaining ideal body weightExercises like swimming,cycling ,yoga can prevent the increasedrisk of RA.Prevention
RA is the most common inflammatory disease affecting 1% ofpopulation & can affect virtually every area of a person’s lifefrom work life to family lifeOne study showed that more than a quarter of womenstopped working within 4 years after being diagnosed withrheumatoid arthritis &also interferes with the joys andresponsibilities of family lifeFortunately, current treatment strategies, including pain-relieving drugs and medications that slow joint damage, abalance between rest and exercise, and patient education andsupport programs, allow most people with the disease to leadactive and productive livesConclusion