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.
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
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
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)