This document summarizes the various systemic manifestations of rheumatoid arthritis. It discusses how rheumatoid nodules can form on areas of friction and rheumatoid vasculitis can cause skin ulceration and necrosis. It also outlines potential involvement of major organ systems like the eyes, heart, lungs, blood, muscles and bones. Key diagnostic tests like rheumatoid factor, anti-CCP antibodies and radiography are mentioned. Common disease-modifying drugs for treatment as well as general measures and surgery are briefly covered.

1. Andrea R S

3.  CUTANEOUS ANDVASCULAR
 Rheumatoid nodules-
 Occur usually in seropositive patients at sites
of frictions like extensor surface of forearm,
sacrum, achiles tendon and toes.

5.  Rheumatoid vasculitis
 Vary from benign nailfold infarcts to
widespread cutaneous ulceration and skin
necrosis

6.  Ocular involvement

7.  Cardiac and pulmonary
 Granulomatous lesions can cause heart block,
cardiomyopathy, coronary artery occulusion.
 Serositis is commonly assymptomatic but
may present as pleurisy or breathlessness.
 Pulmonary fibrosis can cause dyspnea

8.  Neurological involvement
 Rheumatoid arthritis tends to spare CNS but
vasculitis can cause peripheral neuropathy
 Peripheral entrapment neuropathy
 Cervical cord compression

9.  Hematological
 Anemia,thrombocytopenia
 Musculoskeletal
 Muscle wasting,osteoporosis,bursitis
 Amyloidosis-presents as nephrotic syndrome

11.  BLOODTESTS AND RADIOGRAPHY
BLOOD RADIOGRAPHY
Rheumatoid factor PLAIN X-RAY
ACPA USG
ESR and CRP MRI

12.  RHEUMATOID FACTOR
 Not specific for RA as its found in 5% of
healthy people
 Can be of prognostic value as people with
high titres tend to have more severe and
progressive disease with non articular
manifestation

13.  ACPA-Anti citrullinated peptide antibodies
 As better specificity than RF
 Presence of ACPA is most common in persons
with aggressive disease with tendency to
develop bone erosions
 Useful to confirm the diagnosis

14.  RADIOGRAPHY
 Plain x-ray of hands,wrist and feet
 Ultrasound and MRI-not routinely done
 Main value is in patients with symptom
suggestive of inflammatory arthritis

15.  DAS28
 Count number of tender joints
 Count number of swollen joints
 Measure ESR
 Ask patient to rate global activities of arthritis
during the past week from 0(no symptom) to
100(very severe)
 Enter data into an online calculator or work
out using formula

16.  To establish diagnosis-
 Clinical criteria
 ESR and CRP
 Rheumatoid factor and ACPA
 USG and MRI
 To monitor disease activity and drug efficacy
 Pain
 Early morning stiffness
 Joint tenderness
 Joint swelling
 DAS28
 USG
 ESR and CRP

17.  To monitor disease damage
 X-ray and functional assesment
 To monitor drug safety
 Urinanalysis
 Complete blood count
 Liver function test
 Urea, creatinine

18.  MEDICAL
 Disease modifying anti rheumatoid
drugs(DMARD’s)
 Corticosteroids
 Biological therapies
 NSAID’s
 SURGICAL
 GENERAL MEASURES

19. Drug Mechanism Dose Side effects Monitoring
requirement
Monitoring
frequency
Methotrexate Inhibits DNA
synthesis
and cell
division
5-25mg/wk GI upset,
stomatitis,
rash,
alopecia,hep
atotoxicity,
acute
pneumonitis
Complete
blood
count,LFT
Initially monthly
then every 3
months
Sulfasalazine unknown 2-4mg/day Nausea, GI
upset,hepati
tis,rash
CBC,LFT Monthly for
3mnths and then
3-monthly
Hydroxychlor
oquine
unknown 200-
400mg/day
Rash,nausea
,diarrhoea,c
orneal
deposits,reti
nopathy
Visual
acuity,fundo
scopy
12 monthly

20. Leflunomide Blocks
Tcell
division
10-
20mg/day
Nausea,GI
upset,rash,he
petitis
CBC,LFT 2-4 weekly
D-penicillamine unknown 250-
750mg/day
Rash,
stomatis,meta
llic
taste,thrombo
cytopenia,prot
einuria
CBC,urine Initial 1-2/wk
then 4-6/wk for
maintenance
Gold unknown 50mg/mnth
IM injection
Rash,stomatiti
s,proteinuria
CBC,urine Each injection
Cyclosporine BlocksTcell
activation
150-
300mg/day
Nausea,renal
impairement,
hypertension
CBC,urine
,BP,LFT
2-4times a week

21.  Corticosteroids
 Primary role-is in the induction of remission
in patients with early RA who are starting
synthetic DMARD treatment
 High dose oral prednisolone(60mg/day)
initially to reduce and stop this gradually over
3 months as DMARD’s start to take effect
 Low dose prednisolone every 6-8 weeks
 Side effect-osteoporosis

22.  Biological therapy
 Although well tolerated they increase the risk
of serious infection due to suppression of
immune system. Better than DMARD’s but
cost is high

23. Agent dose Side effect
AntiTNF-α
Etanercept
Infliximab
Adalimumab
50mg every week SC
3mg/kg every 8wks IV
40mg every 2 wks SC
Infusion reaction,
increased risk of infection,
reactivation ofTB
Anti B cell therapy
Rituximab
1000mg IV repeat after
2wks
Infections ,infusion
reaction

24. T-cell activation inhibitor
Abatacept
125 mg SC once a wk infection
Anti –IL6
Toclizumab
8mg/kg every 4 wks IV Infection, infusion reaction
Anti-IL1
Anakinra
100mg daily SC Infection,infusion reaction

25.  Surgery-synovectomy of wrist or finger
tendon sheath
 Later stage when joint damage has occurred
arthroplasty is done
 General measures-physical
rest,analgesics,NSAID’s,passive exercise

27. THANKYOU