Rheumatoid arthritis is an autoimmune disease where the body's immune system attacks the joints, causing chronic inflammation. It most commonly affects the small joints in hands and feet, though any joint can be involved. Symptoms include swollen, painful, and stiff joints. While medications can help manage symptoms and slow disease progression, there is no cure. Treatment involves medications like NSAIDs, DMARDs such as methotrexate, biologics that target TNF, steroids, and lifestyle changes including exercise and diet. The goal of treatment is to reduce inflammation and prevent further joint damage.

1. Rheumatoid Arthritis
Dr. Hitesh Patel
M.D.,FIPM

2. What Is Rheumatoid Arthritis?
 Rheumatoid arthritis (RA) is an
autoimmune disease where
the body attacks itself, causing
chronic joint inflammation.

3. • Unlike the wear-and-tear damage
of OA, RA affects the lining of
joints, synovial membrane that
protects and lubricates joints
becomes inflamed, causing pain
and swelling that can eventually
result in cartilage and bone
erosion.
• The tendons and ligaments that
hold the joint together weaken and
stretch.
• Joint deformity

4.  While it primarily affects joints, it can also cause
inflammation of organs as the disease progresses.
Can affects any joint, most common involved joints are the
small joints in hands and feet.
 There is no definitive cure for rheumatoid arthritis, but
medications can slow the progression of the disease and
ease the symptoms.

5. Who is at Risk for RA?
 Women > men
 Ages - at any ,most
common 30 – 60 yrs
 Genetic component.
 Cigarette smoking
 Infections
 Occupational exposure to
certain dusts such as silica,
wood, or asbestos

6. Symptoms of RA?
 Hallmark symptoms of swollen, painful, and stiff joints and
muscles.
 The muscle and joint stiffness is usually worst in the
morning or after extended periods of inactivity.
 Patients may also experience symptoms such as fatigue, low-
grade fever, lack of energy, and loss of appetite.

7.  Hands are almost always
affected. However, RA can
affect any joint in the body,
including wrist, elbows, MCP,
PIP, knee, feet, hip.
 In most cases joints are
affected symmetrically,

8. Remission, Relapse, and Flares
 When a person with rheumatoid arthritis has symptoms
including joint inflammation and pain, this is called a flare,
may last from weeks to months.
 This can alternate with periods of remission, when
symptoms are minimal to nonexistent. Periods of remission
can last weeks, months, or even years.
 After a period of remission, if the symptoms return this is
called a relapse
 It is common for RA patients to have periods of flares,
remissions, and relapses, and the course of the illness varies
with each patient.

9. RA and Inflammation of Organs
 RA is a systemic disease, can
affect the entire body
 Eyes and mouth:
inflammation of the glands,
causes dryness & a condition
called Sjögren's syndrome, can
also lead to inflammation of
the white part of the eye
(scleritis).
 Lungs: inflammation of the lung lining (pleuritis) or
the lungs, can cause shortness of breath and chest
pain.

10. RA and Inflammation of Organs
 Heart: Pericarditis, can cause chest
pain, pts are also at greater risk for
CVD.
 Spleen: inflammation of the spleen
Felty's syndrome) can cause a
decrease in WBC, which raises the
risk of infections.

11. RA and Inflammation of Organs
 Skin: firm lumps under the skin
(rheumatoid nodules), typically
located around affected joints,
often on pressure points such as
elbows, fingers, and knuckles
 Blood vessels: inflammation of
the blood vessels (vasculitis) can
limit blood supply to
surrounding tissues,
causing tissue death (necrosis).

12. How Is RA Diagnosed?

13. Education and Counseling
Biofeedback and cognitive behavioral therapy
Reduce pain and disability and improve self-esteem.

14. Rest
Fatigue is a common symptom of rheumatoid arthritis.
Inflamed joints should be rested, but physical fitness
should be maintained as much as possible.

15. Exercise
 Pain and stiffness  become inactive.
 Inactivity can lead to a loss of joint motion, contractions,
and a loss of muscle strength.
 Weakness, in turn, decreases joint stability and further
increases fatigue.

16. Exercises
 Preserve and restore joint motion,
 Increase strength (isometric, isotonic, and isokinetic
exercises)
 exercises to increase endurance (walking, swimming, and
cycling)

17. Physical and Occupational
therapy
 Physical and occupational therapy can relieve pain, reduce
inflammation, and help preserve joint structure and
function.

18.  Heat or cold
 Ultrasound may reduce inflammation of the sheaths
surrounding tendons (tenosynovitis).
 Passive and active exercises can improve and maintain
range of motion of the joints.
 Rest and rest splinting can reduce joint pain and improve
joint function.
 Finger splinting and other assistive devices can prevent
deformities and improve hand function.

19. Diet
 Eat an adequate amount of calories and nutrients.
 However, weight loss may be recommended for
overweight and obese people to reduce stress on inflamed
joints.

20. Cholesterol
 People with rheumatoid arthritis have a higher risk of
developing CAD.
 High blood cholesterol is one risk factor for coronary
disease that can respond to changes in diet

21. Smoking and Alcohol
 Quit completely.
 Moderate alcohol consumption is not harmful to
rheumatoid arthritis, although it may increase the risk of
liver damage from some drugs such as Methotrexate.

22. Measures to reduce bone loss
 Bone loss, which can lead to osteoporosis  inactive pts.
 The use of glucocorticoids, such as Prednisone, further
increases the risk of bone loss, especially in
postmenopausal women.
 Use the lowest possible dose of glucocorticoids 
minimize bone loss.
 Consume  calcium and vitamin D.

23. NSAIDS
 Relieve pain and reduce minor inflammation.
 NSAIDs do not reduce the long-term damaging effects of
rheumatoid arthritis on the joints.
 NSAIDs must be taken continuously and at a specific dose
to have an antiinflammatory effect.

24. DMARDs
 Reduce the inflammation of rheumatoid arthritis.
 Prevent joint damage.
 Preserve joint structure and function.
 Enable a person to continue his or her daily activities.

25. Conventional DMARDs
Drugs in this class include
 Methotrexate
 Hydroxychloroquine
 Sulfasalazine
 Leflunomide

26. Biologic DMARDs
 Sometimes termed targeted biologic agents, which are
manufactured using molecular biology (recombinant
DNA) techniques.
 Biologics are often reserved for people who have not
completely responded to conventional DMARDs and for
those who cannot tolerate DMARDs in doses large enough
to control inflammation.

27. Conventional Vs Biologics
 Unlike DMARDs, which can take a month or more to
begin working, biologics tend to work rapidly, within two
weeks for some medications and within four to six weeks
for others.
 Biologics may be used alone or in combination with other
 All biologic agents must be injected.
 Testing for tuberculosis (TB) is necessary before starting
anti-TNF therapy.
 interfere with the immune system's ability to fight
infection so may aggravates Lymphoma.

28. Anti-TNF agents or TNF
inhibitors.
 Etanercept
 Adalimumab
 Infliximab
 certolizumab pegol
 golimumab

29. Steroids
 Strong antiinflammatory effects.
 Drugs in this class include prednisone and
prednisolone.
 Routes - mouth, intravenous, or injected directly
into a joint.

30. Pain Relievers
 Pain relievers relieve pain, but they have no effect
on inflammation.
 Drugs in this class include Acetaminophen,
Tramadol, and capsaicin cream or ointment.
 Use of narcotics like codeine, oxycodone, and
hydrocodone is generally discouraged because
they also have no effect on inflammation.

31. Flares
 In people who are already taking methotrexate or
oral steroids, flares can often be controlled by
increasing the doses of these drugs.
 Alternatively, flares can be controlled by steroids
that are given by injection.

32. Surgery
 Replacement
 Surgical fusion may be recommended to limit
movements that cause pain.

33. JAK inhibitors
 A new subcategory of DMARDs known as “JAK
inhibitors” block the Janus kinase, or JAK,
pathways, which are involved in the body’s
immune response.
 Tofacitinib belongs to this class.
 Unlike biologics, it can be taken by mouth.

34. Dose of NSAIDS
 If the initial dose of NSAIDs does not improve
symptoms, a clinician may recommend increasing the
dose gradually or switching to another NSAID.
 You should not take two NSAIDs at the same time.
 Dose of a medication is increased until inflammation
is suppressed or until drug side effects become
unacceptable.
 If side effects occur, they can often be minimized or
eliminated by reducing the dose or by switching to a
different drug.

35. THANK YOU