Rheumatoid arthritis

Rheumatoid Arthritis
Dr. DOHA RASHEEDY ALY
Assistant Professor
Department of Geriatric and Gerontology
Ain Shams University
10/26/2017 Doha Rasheedy

• Rheumatoid arthritis is the most commonly
diagnosed systemic inflammatory arthritis with a
lifetime prevalence of up to 1-2 % worldwide.
• Peak age of onset between 30 and 50 years. with
increasing prevalence with age.
• Risk factors:
– family history of the disease
– female sex 3:1, although the sex differential is less
prominent in older patients
– Hormonal
• early menarche and very irregular menstrual periods
increase risk.
• Parity, breast feeding decrease the risk
• Use of oral contraceptive pills or vitamin E does not
affect RA risk

The etiology of RA is unknown and
may be multifactorial.
• Genetic susceptibility:
– human leukocyte antigen-DR4 and -DRB1
• environmental triggers:
– Smoking
– infections (Mycoplasma organisms, Epstein-Barr virus (EBV), and rubella virus,
Porphyromonas gingivalis, present in the mouths of people with periodontal disease
stimulate the production of ACPA.
– trauma
• Hormonal factors:
– More common in females
– its amelioration during pregnancy, its recurrence in the early postpartum
period,
– reduced incidence in women using oral contraceptives (coflicting data)
• Immunologic factors
– activated T helper 1 (Th1) CD4 cells
– autoantibodies

Pathogenesis:
1. An external trigger (eg, cigarette smoking, infection, or trauma) in genetically
susceptible individuals activates T helper 1 (Th1) CD4 cells, Which play a
pivotal role in the initiation of RA, and the key player in this respect is
assumed to be the T helper 1 (Th1) CD4 cells.
2. Th1 cells produce IL-2 and interferon [IFN] gamma.)
3. These cells may subsequently activate macrophages and other cell
populations, including synovial fibroblasts.
4. Macrophages and synovial fibroblasts are the main producers of TNF-a and
IL-1,6,8.
5. B cells are important in the pathologic process and may serve as antigen-
presenting cells. B cells also produce numerous autoantibodies (eg, RF and
ACPA) and secrete cytokines.
6. autoimmune reaction, leading to synovial hypertrophy and chronic joint
inflammation along with the potential for extra-articular manifestations.
7. The hyperactive and hyperplastic synovial membrane is ultimately
transformed into pannus tissue and invades various tissues, including
cartilage ,bone, tendons, ligaments, and blood vessels. Although the articular
structures are the primary sites involved by RA, other tissues are also
affected.

• Infiltration of the synovial membrane with
– Lymphocytes
– Plasma cells
– Dendritic cells
– Macrophages.
• CD4+ T lymphocytes, including Th1 cells and Th17
cells play a central role by interacting with other cells
in the synovium.
• Lymphoid follicles form within the synovial membrane in
which T cell–B cell interactions, lead B cells to produce
cytokines and autoantibodies, including RF and ACPA.
• Synovial macrophages - activated by immune complexes
produce proinflammatory cytokines, including TNF, IL-1,
IL-6 and IL-15.

• Proinflammatory cytokines act on synovial
fibroblasts, to promote swelling of the synovial
membrane and damage to soft tissues and
cartilage.
• Activation of osteoclasts and chondrocytes drives
destruction of bone and cartilage
• The RA joint is hypoxic and this promotes new blood
vessel formation (neoangiogenesis).
• The inflammatory granulation tissue (pannus) formed
by the above sequence of events spreads over and
under the articular cartilage, which is progressively
eroded and destroyed.
• Later, fibrous or bony ankylosis may occur.
• Muscles adjacent to inflamed joints atrophy and may
be infiltrated with lymphocytes

CLINICAL PRESENTATIONS

Onset
1. In most patients, RA has an insidious onset.
2. 25% subacute onset
3. A small percentage (approximately 10%) of patients with
this disease have an abrupt onset with the acute
development of synovitis and extra-articular
manifestations
• It may begin with systemic features (eg, fever,
malaise, arthralgias, and weakness) before the
appearance of overt joint inflammation and swelling.
• Polyarticular>> oligoarticular>> monoarticular
• Palindromic rheumatism (episodic, self-limited
attacks of polyarthritis) may evolve into RA.
• Rarely, extraarticular features of RA (eg, scleritis) may
present before the joint problems occur.

NB
• In the elderly with abrupt onset of
polyarthritis, remitting seronegative
symmetric synovitis with pitting edema
(RS3PE), paraneoplastic syndromes, and drug-
induced lupus should be considered

• pain and stiffness in multiple joints.
• Morning stiffness lasting more than one hour
suggests an inflammatory etiology.
• Boggy swelling due to synovitis may be visible or
subtle synovial thickening may be palpable on
joint examination.
• more indolent arthralgias before the onset of
clinically apparent joint swelling.
• Systemic symptoms of fatigue, weight loss, and
low-grade fever may occur with active disease.

Articular manifestations
• The small joints of the hands and feet are affected in a relatively
symmetric distribution.
• In decreasing frequency, the metacarpophalangeal (MCP), wrist, proximal
interphalangeal (PIP), knee, metatarsophalangeal (MTP), shoulder, ankle,
cervical spine, hip, and elbow joints are most commonly affected.
• RA may involve the temporomandibular, cricoarytenoid and
sternoclavicular joints.
• Affected joints show inflammation with swelling, tenderness, warmth,
and decreased range of motion (ROM)
• Non affected joints:
– DIP, first carpometacarpal, thoracolumbar, sacroiliac joints
• Active synovitis is characterized by warmth, swelling, pain, and palpable
effusions. Synovial proliferation is appreciated on physical examination
by the presence of soft or rubbery tissue around the joint margins
• Chronic joint destruction with significant degree of cartilage loss produces
crepitus on palpation

Hands
1. Atrophy of the interosseous muscles of the hands is
a typical early finding.
2. Joint and tendon destruction may lead to
deformities such as
– swan-neck (hyperextension at PIP, flexion at DIP),
– boutonniere (flexion at PIP, hyperextension of DIP)
– Z-shaped thumb (hyperextension of first interphalangeal
joint with palmar subluxation of first MCP)
3. Flexor tenosynovitis of the fingers is common lead
to nodule formation with subsequent catching
“Triggering” or tendon rupture.

Boggy swelling in proximal interphalangeal and metacarpophalangeal
joints (more prominent on patient’s right hand) in a patient with new-
onset rheumatoid arthritis. Note that with joint swelling, the skin
creases over the proximal interphalangeal joints become less apparent.

• Subluxation in the
metacarpophalangeal joints, with
ulnar deviation, in a patient with
rheumatoid arthritis of the hands10/26/2017 Doha Rasheedy

Swan-neck deformity:
hyperextension at the PIP joint with
flexion of the DIP joint
• Boutonniere deformity:
nonreducible flexion at the PIP joint
along with hyperextension of the
distal interphalangeal (DIP) joint of
the finger.

The wrists
• Radio- ulnar subluxation and subluxation of
carpal bones with radial deviation.
• Synovitis at the wrist can lead to median
nerve entrapment, resulting in carpal tunnel
syndrome (CTS) or, more rarely, ulnar nerve
entrapment, resulting in Guyon’s canal
syndrome.

Elbow
• Elbow involvement is evident by fullness at
the radial-humeral joint with the tendency of
patients to maintain the joint in flexion.
• Over time, this can lead to flexion
contractures.
• inflammation can lead to compressive
neuropathy of the ulnar nerve with
paresthesias and weakness in the ulnar
distribution.

shoulder
• Involvement of the shoulder usually manifests as loss
of range of motion, with decreased abduction and
limited rotation.
• Effusions are difficult to appreciate, because the
shoulder joint lies underneath the rotator cuff.
• Pain in the shoulder can lead to limited range of
motion, and adhesive capsulitis, or frozen shoulder, can
develop rapidly
• Patients with shoulder involvement may have findings
of subacromial-subdeltoid bursitis, glenohumeral
synovitis, and tenosynovitis of long head of biceps
similar to that in PMR. However, a predominant
intra-articular involvement favors RA compared to
predominant periarticular involvement seen in PMR

Cervical spine
• Mainly affects C1-C2
• Can cause serious neurologic consequences.
• Patients who are to undergo intubation or procedures
that may involve manipulation of the neck should
undergo careful evaluation of the cervical spine.
• early cervical spine disease consist primarily of neck
stiffness that is perceived throughout the entire arc of
motion.
• Neck pain on motion and occipital headache are
common manifestations of cervical spine involvement.
• RA involvement of the thoracic and the lumbar spine is
rare.

foot and ankle
• Affected joints include the MTP, talonavicular,
and ankle joints.
• MTP joints can develop cocking-up
deformities with subluxation of the MTP fat
pads, causing pain with ambulation.
• Inflammation of the talonavicular joint and
ankle joints results in eversion of the foot and
can cause nerve entrapment, resulting in
paresthesias of the sole.

Hip:
• decreased range of motion and pain radiating
to the groin, thigh, buttock, low back, or knee
• Protrusio acetabuli: often progressive Flexion
deformity

knee
• Involvement of the knee includes detectable
effusions and synovial thickening.
• Prolonged inflammation can lead to significant
instability.
• Posterior herniation of the synovial capsule can result
in a popliteal (Baker’s) cyst, and rupture can mimic
thrombophlebitis.
• In the knee joint, symmetric joint space narrowing
occurs in RA compared to asymmetric involvement in
OA.
• Concomitant OA features such as marginal
osteophytes and subchondral sclerosis with
subchondral cysts may also be seen in elderly RA

Extra-Articular Manifestations of RA
Cardiac Accelerated atherosclerosis
Pericarditis
Eye Episcleritis/scleritis
Keratoconjunctivitis sicca
Peripheral ulcerative keratitis
Hematologic Amyloidosis
Felty syndrome
Nervous system Cervical myelopathy(Caused by C1-C2 subluxation)
Neuropathy (Carpal tunnel, mononeuritis multiplex )
Pulmonary Caplan syndrome
Interstitial lung disease
Pleural effusion
Skin Rheumatoid nodules
Vasculitis10/26/2017 Doha Rasheedy

Skin
• Rheumatoid nodules typically form during active
inflammation over pressure points in bursae and tendon
sheaths. Common sites include the olecranon bursa, the
extensor surface of the forearm, the Achilles tendon, and
the tendons of the fingers.
• Rheumatoid nodules are strongly associated with
rheumatoid factor
• carry a worse prognosis, with a higher propensity toward
erosive and destructive rheumatoid disease.
• Subcutaneous rheumatoid nodules may resolve with
effective therapy of the associated articular disease. A
subset of rheumatoid patients, however, experience
paradoxical accelerated nodulosis with methotrexate
therapy
• vasculitic skin ulcerations

Ocular involvement
• Ocular manifestations occur in 25% of patients
with RA
– sicca symptoms of dry eyes (and dry mouth in
Sjögren’s syndrome)
– episcleritis : may be self-limited but is often
treated with topical corticosteroid drops
– scleritis
– scleromalacia perforans.
– Keratitis: mainly Peripheral ulcerative keratitis

• Treatment of secondary Sjögren syndrome is
symptomatic.
• Artificial tears or cyclosporine 0.05% emulsion
drops twice daily can ease ocular symptoms.
Pilocarpine hydrochloride 5 mg orally three to
four times daily increased salivary production
• cevimeline 30 mg three times daily may be
effective in promoting increased salivary
production but can cause hyperhidrosis

SCLEROMALACIA PERFORANS ANTERIOR SCLERITIS

Pulmonary involvement
1. Interstitial fibrosis generally involves the lower lung fields
and is often not clinically symptomatic, but it may be
severely debilitating in some cases. Patients with
preexisting interstitial lung disease may be at increased risk
for methotrexate-induced pneumonitis
2. Pulmonary nodules: Caplan syndrome usually an
asymptomatic finding in seropositive RA. Radiographically
they are coin-shaped lesions that can be difficult to
distinguish from malignancy. In patients in whom
malignancy is clinically suspected, further imaging or tissue
biopsy may be required.
3. Pleurisy or pleural effusion or both can be the initial
manifestation of RA preceding the onset of articular
disease (an extremely low level of pleural-fluid glucose,
with the result frequently approaching zero)
4. bronchiolitis obliterans organizing pneumonia poorly
respond to therapy.10/26/2017 Doha Rasheedy

Neurologic manifestations
1. nerve entrapment (carpal tunnel)
2. cervical spine instability (myelopathy)
3. Vasculitis of vasa vasorum can lead to
symptoms of mononeuritis multiplex.

Hematologic effects
• Anemia of chronic disease is seen in most patients with RA, and the
degree of anemia is proportional to the activity of the disease.
• Thrombocytosis is common when RA is active, with platelet counts
returning to normal as the inflammation is controlled.
• Non-Hodgkin lymphoma occurs 2–3 times more frequently in
patients with RA than in the general population. Development of B-
cell lymphomas, particularly those linked to Epstein-Barr virus, is a
rare complication of methotrexate therapy for RA. The use of anti-
TNF agents is associated with slightly increased risk of lymphoma,
but a cause and effect relationship has not been established.
• Felty’s syndrome (the triad of leukopenia, lymphadenopathy, and
splenomegaly)
• Cryoglobulinemia
• Amyloidosis

Cardiac involvement
• may include:
– Accelerated Atherosclerosis
– pericardial effusions
– pericarditis,
– valvular lesions
– conduction defects
– cardiomyopathy

Kidney
• In general, the kidney is spared in RA, and
renal impairment in RA patients is most often
due to drug toxicity (especially NSAIDs) or to
comorbidities such as hypertension or
diabetes mellitus.
• Renal amyloidosis is a rare complication of
long-standing RA.

Course
• the common course of RA, is waxing and
waning pattern of synovitis coupled with
progressive structural damage, leading to
significant deformities and disabilities with
advanced disease

DIAGNOSTIC CRITERIA
• In more recent criteria effort to diagnose RA
earlier in patients who may not meet the 1987
American College of Rheumatology classification
criteria.
• The 2010 criteria do not include presence of
rheumatoid nodules or radiographic erosive
changes, both of which are less likely in early RA.
Symmetric arthritis is also not required in the
2010 criteria, allowing for early asymmetric
presentation

The American Rheumatism Association 1987
4 out of 7
1,2,3,4 criteria should last for ≥ 6 weeks
1. morning stiffness in and around joints lasting at least 1 hour before maximal improvement
2. soft tissue swelling (arthritis) of 3 or more joint areas observed by a physician;
3. swelling (arthritis) of the proximal interphalangeal, metacarpophalangeal, or wrist joints;
4. symmetric swelling (arthritis)
5. rheumatoid nodules
6. the presence of rheumatoid factor;
7. radiographic erosions and/or periarticular osteopenia in hand and/or wrist joints

2010 criteria
Joint involvement
One large joint 0
Two to 10 large joints 1
One to three small joints (with or without involvement of large joints) 2
Four to 10 small joints (with or without involvement of large joints) 3
> 10 joints (at least one small joint)** 5
Serology (at least one test result is needed for classification)
Negative RF and negative ACPA 0
Low positive RF or low positive ACPA 2
High positive RF or high positive ACPA 3
Acute phase reactants (at least one test result is needed for classification)
Normal CRP and normal ESR 0
Abnormal CRP or abnormal ESR 1
Duration of symptoms
< six weeks 0
≥ six weeks 110/26/2017 Doha Rasheedy

• patients with a score of less than 6 out of 10
are not classifiable as having RA, their status
can be reassessed, and the criteria might be
fulfilled cumulatively over time.
• Large joints” refers to shoulders, elbows, hips,
knees, and ankles.
• Small joints” refers to the
metacarpophalangeal joints, proximal
interphalangeal joints, second to fifth
metatarsophalangeal joints, thumb
interphalangeal joints, and wrists.

Elderly onset rheumatoid arthritis
– RA in elderly can either be elderly onset (EORA defined
as onset ≥60 years) or young onset (YORA) that persists
into older age
– EORA has a lower female predominance (1.5–2:1 vs. 4–
4.5:1) compared to YORA.
– The onset is more acute in nature with more
constitutional symptoms and disabling early morning
stiffness.
– The involvement of large joints, especially shoulder
joints is a prominent feature
– Rheumatoid nodules are less common

• Three patterns of disease onset are identified In
EORA:
– The most common pattern seen in 70% of cases is
similar to classical RA, with RF positivity and erosive
joint disease.
– The next pattern, seen in 25% of patients, is that of
proximal joint involvement that needs to be
differentiated from PMR. Simultaneous involvement
of small joints of hand and presence of
anti-citrullinated peptide antigen (ACPA) helps to
differentiate these patients from PMR.
– A third type with pitting edema of dorsum of hands
and feet, acute onset symmetrical synovitis, and
negative RF, mimicking remitting seronegative
symmetrical synovitis (RS3PE) may also be seen in
around 10% patients.

COMPLICATIONS
• Increased risk of infections
• at increased risk for lymphoproliferative disorders,
particularly lymphomas.
• Rheumatoid vasculitis
• Cervical instability at the atlantoaxial articulation
• cardiovascular disease.
• Monoarticular fl are — A single joint worsening should
always be viewed with suspicion in RA, and septic
arthritis needs to be looked for. It is prudent to initiate
treatment for possible septic arthritis until the results
of the joint aspirate rule it out.10/26/2017 Doha Rasheedy

Diagnostic Testing
• Serologic markers for RA, including RF and anti-CCP
antibodies, should be tested. Anti-CCP antibodies have
been found in the serum of affected patient’s years before
the onset of clinically apparent disease, and are more
specific for RA than RF.
• The diagnosis of EORA is complicated by the fact that titers
of IgM RF rise with age
• RF should be drawn at baseline and repeated 6 to 12
months later if initially negative, as approximately 50% of
RA patients are positive in the first 6 months of illness and
85% become positive over the first 2 years.
• Anti-citrullinated protein antibody is more specific for RA
and may play a role in disease pathogenesis.
• A small number of RA patients (10%–15%) will remain
seronegative (RF and CCP antibody negative) throughout
the course of the disease.10/26/2017 Doha Rasheedy

• 20% to 30% of RA patients have a positive
antinuclear antibody (ANA), but this is at a low
titer.
• Antineutrophil cytoplasmic antibodies (ANCA),
particularly of the perinuclear type (∼30% of
patients)
• Erythrocyte sedimentation rate (ESR) and C-
reactive protein (CRP) are markers of inflammation
and may be useful to monitor disease activity,
although they are not specific for RA.
• (CBC), electrolyte panel, creatinine, hepatic
function panel, urinalysis and stool occult blood to
assess general organ function and comorbidities
before initiating medications.

Arthrocentesis
• The synovial fluid in RA patients is
inflammatory. Arthrocentesis is useful to rule
out infectious and crystalline arthritis, if these
are suspected, particularly if one joint is
inflamed out of proportion to the others.

Imaging
• plain radiographs of feet are more likely to show erosions
with early RA than hands.
• radiographic features of RA(The mnemonic ABCDE’S)
– A—Alignment, abnormal; no ankylosis
– B—Bones—periarticular (juxta-articular) osteoporosis; no
periostitis or osteophytes
– C—Cartilage—uniform (symmetric) joint-space loss in weight-
bearing joints; no cartilage or soft tissue calcification
– D—Deformities (swan neck, ulnar deviation, boutonnière) with
symmetrical distribution
– E—Erosions, marginal
– S—Soft-tissue swelling; nodules without calcification

A: Symmetric loss of cartilage space that is typical of inflammatory arthritis such as rheumatoid
arthritis. Note that both the medial and lateral compartments are severely narrowed. Despite
this severe narrowing, there is very little in the way of subchondral sclerosis or osteophyte
formation since these repair mechanisms are generally shut off in active rheumatoid arthritis.
B: Complete loss of the cartilage in the medial joint compartment with significant subchondral
sclerosis and osteophyte formation. The lateral compartment in this patient is not involved.
These features are typical of osteoarthritis.

Progressive destruction of a metacarpophalangeal joint by rheumatoid arthritis. Shown are
sequential radiographs of the same second metacarpophalangeal joint.
A: The joint is normal 1 year prior to the development of rheumatoid arthritis.
B: Six months following the onset of rheumatoid arthritis, there is a bony erosion adjacent to
the joint and joint-space narrowing.
C: After 3 years of disease, diffuse loss of articular cartilage has led to marked joint-space
narrowing.

• Radiographs of the cervical spine in flexion and
extension can demonstrate C1–C2 subluxation; MRI
is the preferred imaging technique to evaluate
possible impingement on the spinal cord.
The expected distance between anterior arch of C1 and the dens in the fully flexed position
should be <3 mm in an adult10/26/2017 Doha Rasheedy

Disease activity assessment
• the routine use of a validated measure of
disease activity, which allows the clinician to
compare disease activity between visits and
assess response to therapy objectively.
• The Clinical Disease Activity Index
• The Patient Activity Scale
• The Disease Activity Score

DIFFERENTIAL DIAGNOSIS
• The other common causes of symmetric inflammatory polyarthritis are
– SLE
– psoriatic arthritis
– Viral (parvovirus B19 and hepatitis B and C associated) arthritis.
• Other causes of inflammatory arthritis that are less symmetric and
typically oligo- or monoarticular include:
– gout,
– pseudogout,
– septic arthritis,
– HLA-B27 associated spondyloarthropathies,
– and adult-onset Still’s disease.
• Conditions with noninflammatory polyarthralgias should not be confused
with RA, such as
– Fibromyalgia
– osteoarthritis
– malignancy,
– hypo- or hyperthyroidism, or hyperparathyroidism.

• Acute viral syndromes, especially acute hepatitis
B, erythrovirus (parvovirus B19), rubella
(infection or vaccination), and Epstein- Barr virus
can produce a polyarthritis that mimics early RA
but is self-limited, usually resolving over 2–4
weeks.
• Chronic infection with hepatitis C commonly
causes polyarthralgias (less often, polyarthritis)
in a joint distribution similar to that of RA as well
as serum rheumatoid factor (but not anti-CCP
antibodies or radiographic erosions)

DIFFERENTIAL DIAGNOSIS
• Palindromic rheumatism is a condition similar to RA in which
patients develop recurrent onset of acute, self-limited arthritis.
• Attacks usually last hours to a few days and may involve any set of
joints.
• Laboratory tests are nonspecific, and synovial fluid analysis reveals
an inflammatory reaction.
• Joint damage and systemic manifestations are rare.
• Diagnosis is based on the presence of a relapsing and remitting
course of arthritis.
• Many patients with palindromic rheumatism later progress to
develop RA.
• Treatment is similar to that for RA. Nonsteroidal anti-inflammatory
drugs (NSAIDs) may provide pain relief. Corticosteroids and some
disease modifying anti-rheumatic drugs (DMARDs) may also be
beneficial

Relapsing seronegative symmetrical synovitis with pitting
edema (RS3PE)
• is a condition usually characterized by the sudden onset of
polyarthritis associated with pitting edema of the hands
and/or feet.
• Laboratory markers of inflammation are variable, and RF is
absent.
• Synovitis is commonly present but rarely leads to joint
destruction.
• Treatment involves the use of low-dose corticosteroids
(prednisone, 5– 10 mg), typically with dramatic
improvement of symptoms. NSAIDs and hydroxychloroquine
may also provide symptomatic relief and may be useful as
steroid-sparing agents.
• RS3PE may be related to polymyalgia rheumatica and
sometimes occur in association with malignancies.

Poor prognostic criteria
1. The prognosis of RA is generally much worse among
patients with positive RF
2. radiologic evidence of bony injury,
3. persistent anemia of chronic disease
4. elevated levels of the C1q component of complement,
5. the presence of ACPA (the presence of ACPA and
antikeratin antibodies (AKA) in sera has been linked
with severe erosive disease)
6. RA that remains persistently active for longer than 1
year
Needs aggressive disease modifying treatment

Management
• Management guidelines of RA need to be modified in the elderly
considering comorbidities and associated polypharmacy,
alterations in pharmacokinetics, and cognitive impairment in the
elderly that may all predispose to increased risk of adverse events.
• Medical treatment includes the use of NSAIDs, DMARDs, and
corticosteroids.
• Early recognition and diagnosis is absolutely essential, with the
immediate initiation of treatment at time of diagnosis, with
DMARDs, which have been shown to reduce irreversible injury.
• the target is to achieve remission or low disease activity
• non-pharmacologic treatment, including patient education,
physical therapy, occupational therapy, orthotics, and surgery.
• Prior to starting DMARD therapy, patients should receive
vaccinations, live attenuated vaccines are contraindicated once
individuals have started biologic DMARDs

Nonsteroidal Anti-inflammatory Drugs
• help alleviate symptoms from pain and
inflammation in most patients with RA
• Some patients may benefit from selective
cyclooxygenase (COX)-2 inhibitors
• NSAIDs do not prevent progression of bone and
cartilage damage; therefore, current treatment
strategies recommend NSAID use in combination
with DMARDs for initial therapy

Glucocorticoids
• Corticosteroids in low doses (e.g., prednisone, 5–10
mg) are extremely effective for promptly reducing the
symptoms of RA and are useful in helping patients
recover their previous functional status.
• Corticosteroids are appropriate in patients with
significant limitations in their activities of daily living,
particularly early in the course of disease while
awaiting the efficacy of slow-acting DMARDs.
• taper to the lowest possible dose and to eliminate
steroid therapy when feasible.
• should be slowly tapered over several months to avoid
adrenal insufficiency.

Disease-Modifying Anti-Rheumatic Drugs
• can slow or arrest the progression of RA.
• DMARDs should be instituted early (within the first few
weeks to 3 months of diagnosis).
• These medications take 2–6 months to reach maximal effect.
Therefore, other measures, such as low-dose glucocorticoid
therapy, may be needed to control the disease while these
medications are starting to work
• initiation of therapy with NSAIDs and DMARDs
simultaneously is recommended. For severe disease flares,
the use of oral corticosteroids may also be necessary while
waiting for optimal benefit from DMARDs.
• Oral methotrexate is considered to be the DMARD of choice
for most patients, and is imperative in patients with rapid
disease progression or functional limitations.

Oral methotrexate better Subcutaneous
• From a starting dose of 7.5 to 10 mg once a week, the dose
may be increased to 20 mg weekly rapidly.
• Common side effects include stomatitis, nausea, diarrhea,
and hair loss, Supplementation with folic acid, 1 to 2 mg
daily, can reduce such side effects without significantly
reducing efficacy.
• Bone marrow suppression is uncommon, but it may occur
at low doses in elderly patients.
• liver toxicity may occur
• Liver function tests and blood counts are checked every
month until the dose is stable and every 2 to 3 months
thereafter
• but it is important to monitor renal function. Because
methotrexate is renally excreted, it can accumulate in the
setting of progressive renal impairment, leading to
myelotoxicity10/26/2017 Doha Rasheedy

Contraindications to methotrexate include:
1. preexisting liver disease
2. infection with hepatitis B or C
3. ongoing alcohol use
4. renal impairment (creatinine clearance <30 mL/minute).
Toxicity:
• Oral ulcers, nausea, hepatotoxicity, bone marrow suppression,
and pneumonitis are the most commonly encountered toxicities.
With the exception of pneumonitis (which is a hypersensitivity
reaction), these toxicities respond to dose adjustments and are
reduced by the concomitant use of folic acid.
• Renal function is critical for clearance of methotrexate and its
active metabolites; previously stable patients may experience
severe toxicities when renal function deteriorates.
• Pneumonitis, while rare, is unpredictable and may be fatal,
particularly if the methotrexate is not stopped or is restarted.

Hydroxychloroquine
• effective in mild to moderate, nonerosive RA
• doses of 200 to 400 mg/day,
• not to be used in patients with moderate to
severe renal or hepatic insufficiency.
• Macular toxicity, an ophthalmologist should
perform a baseline examination and monitor the
patient every 6 to 12 months.
• Nausea and skin discoloration occur occasionally

Sulfasalazine
• started at 500 mg twice daily and gradually
increased to 2 to 3 g daily in divided doses.
• Monitoring for neutropenia and hepatotoxicity
should be performed every 1 to 3 months.
• Sulfasalazine should be avoided in patients with
sulfa allergies or glucose- 6-phosphate
dehydrogenase deficiency

Leflunomide
• The effective starting dose is 20 mg/day which
can be reduced to 10 mg/day if the medication is
not tolerated or if transaminase levels become
elevated
• The most common toxicity is diarrhea, which may
respond to dose reduction.
• nausea, and hair loss are common side effects.
• Liver functions need to be monitored every 1 to 3
months.

Cyclosporine
• is an inhibitor of T-cell activation with known
clinical efficacy in treatment of RA.
• limited its use to the treatment of severe,
refractory RA
• severe renal toxicity
• Blood pressure and renal function should be
monitored closely.

Minocycline
• 100 mg twice daily, is an effective treatment for
RA, particularly when used in early seropositive
disease.
• Long-term therapy (more than 2 years) may lead
to cutaneous hyperpigmentation.

• Other DMARDs less commonly used to treat
RA include gold salts, azathioprine,
penicillamine, and cyclophosphamide (for
rheumatoid vasculitis).

Biologic therapy
• Biologic therapy should be initiated when
adequate disease control is not achieved with the
oral DMARDs. using methotrexate with a bDMARD,
often results in superior outcomes and protects
against immunogenicity and the development of
neutralizing antibodies
• The onset of action of biologic DMARDs is rapid:
days to weeks.
• These include TNF-αantagonists and other non–
TNF-αmediated biologic agents.
• TNF-αantagonists are the initial biologic therapies
used in RA patients who fail oral DMARDs.10/26/2017 Doha Rasheedy

• TNF-α antagonists are contraindicated in patients with indolent
chronic infections such as osteomyelitis or tuberculosis (TB), and
in anyone with an active infection.
• Screening for latent TB should be performed with a tuberculin
skin test before beginning therapy with a TNF antagonist and
then yearly
• Treatment with TNF-α antagonist should be temporarily
suspended in patients undergoing surgery.
• Biological drugs predispose to infection, herpes zoster,
mycobacteria, and other atypical infections, such as
encapsulated organisms
• Biologic DMARDs should not be administered to patients with
untreated hepatitis B infection.
• Progressive multifocal leukoencephalopathy is an exceedingly
rare but devastating infection associated with
immunosuppression.
• Another rare but important side effect to consider is
demyelinating disorders, which have been associated with TNF
inhibitors10/26/2017 Doha Rasheedy

• The five currently available TNF-α antagonists are
etanercept, infliximab, adalimumab, golimumab, and
certolizumab.
• Non–TNF antagonizing biologics include anakinra,
rituximab, abatacept, and tocilizumab
– Anakinra is an IL-1 receptor antagonist.
– Rituximab is a monoclonal antibody directed against the CD20
antigen on B lymphocytes.
– Abatacept is a selective costimulation modulator which inhibits
Tlymphocyte activation by blocking the interaction between
antigen-presenting cells and T cells.
– Tocilizumab is an antagonist of IL-6.
• Combination regimens of multiple DMARDs or DMARDs
plus biologic agents are increasingly popular treatment
regimens. If tolerated, methotrexate should be part of every
combination.10/26/2017 Doha Rasheedy

• There is a paucity of data regarding the use of
biologic DMARDs in patients with a history of
malignancy. Currently, biologic agents (except
rituximab) are not recommended for patients
with a solid malignancy or nonmelanoma skin
cancer treated within 5 years, a history of
treated skin melanoma, or a history of treated
lymphoproliferative malignancy.
• Anti-TNF agents should not be administered to
patients with New York Heart Association class
III or IV congestive heart failure or with ejection
fractions less than 50%.

Non-pharmacologic Therapies
• Occupational therapy usually focuses on the hand
and wrist and can help patients with splinting,
work simplification, activities of daily living, and
assistive devices.
• Physical therapy:
1. assists in stretching and strengthening exercises for
large joints such as the shoulder and knee,
2. gait evaluation, and
3. fitting with crutches and canes.
4. Moderate exercise is appropriate for all patients and
can help reduce stiffness and maintain joint range of
motion. In general, an exercise program should not
produce pain for >2 hours after its completion

• Orthopedic surgery:
– to correct hand deformities and replace large joints
such as the hip, knee, and shoulder may benefit
patients with advanced disease.
– The primary indication for reconstructive hand
surgery is refractory functional impairment limiting
activities of daily living.
– Total joint arthroplasty to replace the knee or hip
should also be considered when pain cannot be
controlled adequately with medications or when
joint instability causes significant fall risk.

Geriatrics considerations
• Health promotion: Influenza and pneumococcus are
recommended, as is hepatitis B for those at high risk; live
vaccines are generally not considered safe.
• Psychosocial interventions are important in the
management of RA. Depression is often underrecognized
and undertreated in the older adult population and is not
an uncommon comorbidity in RA.
• Cardiovascular disease risk reduction is important as it is an
important cause of death in those with RA, particularly in
older adults with multiple additional risks.
• Osteoporosis is also associated with RA and should be
considered and appropriately addressed.

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