This document discusses rheumatoid arthritis (RA), an autoimmune disorder where the immune system attacks the synovial membrane of joints. It describes the etiology and pathogenesis of RA, including the role of cytokines like IL-1 and TNF-α in causing inflammation and joint damage. Symptoms of RA include stiffness, swelling and pain in small joints of hands and feet typically in a symmetrical pattern. Long-term RA can lead to joint deformities and loss of function. The document also covers diagnostic criteria, epidemiology, microscopic findings, and treatment of RA.
Rheumatology Sheet from Rheumatology Department, Faculty of Medicine, Zagazig University, Egypt.
Disclaimer : not my slide. Just uploading for my personal use..
Dr. Swamy Venuturupalli talks about Rheumatoid Arthritis, Early Diagnosis and Treatment at the James R. Klinenberg symposium on Rheumatic diseases in Pasadena, CA.
Dermatomyositis is a rare inflammatory myopathy with characteristic skin manifestations and muscular weakness.
Polymyositis is a similar disease without skin lesions.
Amyopathic dermatomyositis: typical cutaneous manifestation of DM without clinical and/or laboratory findings of muscle involvement for at least 6 months after the onset of skin rash.
A Power Point Presentation on the Disease Rheumatoid Arthritis covering everything from explanation and history to causes, effects, treatments, diagnosis, and prognosis.
Rheumatology Sheet from Rheumatology Department, Faculty of Medicine, Zagazig University, Egypt.
Disclaimer : not my slide. Just uploading for my personal use..
Dr. Swamy Venuturupalli talks about Rheumatoid Arthritis, Early Diagnosis and Treatment at the James R. Klinenberg symposium on Rheumatic diseases in Pasadena, CA.
Dermatomyositis is a rare inflammatory myopathy with characteristic skin manifestations and muscular weakness.
Polymyositis is a similar disease without skin lesions.
Amyopathic dermatomyositis: typical cutaneous manifestation of DM without clinical and/or laboratory findings of muscle involvement for at least 6 months after the onset of skin rash.
A Power Point Presentation on the Disease Rheumatoid Arthritis covering everything from explanation and history to causes, effects, treatments, diagnosis, and prognosis.
TREATMENT OF RHEUMATOID ARTHRITIS BY DR BASHIR AHMED DAR ASSOCIATE PROFESSOR ...Prof Dr Bashir Ahmed Dar
Dr Bashir ahmed dar associate professor medicine chinkipora sopore kashmir presently working in medical college malaysia describes rheumatoid arthritis which is a autoimmune disorder in which Immune system identifies the synovial membrane as "foreign" and begins attacking it.
Localization of brainstem lesion by Prof Dr Bashir Ahmed Dar Sopore KashmirProf Dr Bashir Ahmed Dar
Localizing neurological lesions in the brainstem can be very precise, it relies on a clear understanding on the functions of brainstem .Brainstem lesions usually produce cranial nerve palsy one one side and hemiplegia or hemiparesis on other side
RHEUMATOID ARTHRITIS BY DR BASHIR AHMED DAR ASSOCIATE PROFESSOR MEDICINE SOPO...Prof Dr Bashir Ahmed Dar
Dr Bashir ahmed dar associate professor medicine chinkipora sopore kashmir presently working in medical college malaysia describes rheumatoid arthritis which is a autoimmune disorder in which Immune system identifies the synovial membrane as "foreign" and begins attacking it.
Shock results from the failure of the cardiovascular system to provide sufficient blood circulation.
To maintain circulatory homeostasis the following mechanisms must be present –
1. a functioning of heart to circulate blood .
A sufficient amount of blood volume .
The capability of the vascular system , accommodating blood flow to the capillaries and returning to the right side of the heart.
aetiology of inflammation; types of inflammation; how inflammation occur; cells involve in inflammation; role of wbc in inflammation; outcome of inflammation; how inflammation associated with immunity, clotting system, complementary system kinin system, how inflammation is associated with oral cavity; disease associated with inflammatory system
INTRODUCTION
HISTORY
CAUSES OF INFLAMMATION
CLASSIFICATION
ACUTE INFLAMMATION
CHEMICAL MEDIATORS OF INFLAMMATION
OUTCOMES OF ACUTE INFLAMMATION
CHRONIC INFLAMMATION
INFLAMMATORY DISEASES
REFERENCES
The main aim of this slide presentation is to localize abnormal neurological findings to their main site of origin within the nervous system. After reading the presentation the doctor should be able to localise neurological disorders to their main site of origin.if you fail to identify the clinical signs correctly, then you will be unable to identify where the problem is.Read my slide presentation on localization of brainstem lesion which i will upload very soon
Taking the patient's history is traditionally the first step in virtually every clinical encounter. A thorough neurologic history allows the clinician to define the patient's problem and, along with the result of physical examination, assists in formulating an etiologic and/or pathologic diagnosis
Taking the patient's history is traditionally the first step in virtually every clinical encounter. A thorough neurologic history allows the clinician to define the patient's problem and, along with the result of physical examination, assists in formulating an etiologic and/or pathologic diagnosis
Doctors need to be aware of a rare, hard to diagnose condition called Porphyria. To reach an accurate diagnosis of Porphyria a crystal clear understanding is needed
Doctors need to be aware of a rare, hard to diagnose condition called Porphyria. To reach an accurate diagnosis of Porphyria a crystal clear understanding is needed
Thalassemia (British English: thalassaemia), also called Mediterranean anemia, is a form of inherited autosomal recessive blood disorder characterized by abnormal formation of hemoglobin
Facial nerve disorders can be caused by infection, injury or other conditions.Facial nerve disorders can cause weakness on one or both sides of the face. Those affected may experience loss of facial expression and also difficulties with eating, drinking and clarity of speech. Closing of the eye and blinking can also become difficult.
Facial nerve disorders can be caused by infection, injury or other conditions.Facial nerve disorders can cause weakness on one or both sides of the face. Those affected may experience loss of facial expression and also difficulties with eating, drinking and clarity of speech. Closing of the eye and blinking can also become difficult
OBESITY AND WEIGHT LOSS SURGERY, HOW MUCH BENEFICIAL AND SAFE?BY DR MANZOOR A...Prof Dr Bashir Ahmed Dar
Obesity is recognized as a global health crisis. Weight loss surgery offers a treatment that can reduce weight, induce remission of obesity-related diseases, and improve the quality of life. This review summarizes recent evidence related to the safety, efficacy, and metabolic outcomes of weight loss surgery for morbid obesity. The article also highlights various issues when lifestyle modifications and weight loss medications have failed to provide significant weight loss in the majority of obese people.
Research article on anti aging tool by Prof Dr Bashir Ahmed Dar Sopore KashmirProf Dr Bashir Ahmed Dar
A research article HbA1c:A Biomarker of Anti Aging By Prof Dr Bashir Ahmed Dar Chinki Pora Sopore Kashmir
Glycosylated hemoglobin (HbA1c) is a marker of evaluation of long-term glycemic control in diabetic patients that predict risks for the development and progression of diabetic complications. The aim of this study is to evaluate the significance of Glycosylated hemoglobin (HbA1c) in relation to aging
Systemic lupus erythematosus (SLE) is an autoimmune disease and as we know immune
system is vast and complex and presents an enormous challenge to scientists working in this field as well as presents a challenge to anyone seeking to explain where pathogenesis research stands at the end of 2011
A research article Fountain of Youth by Prof Dr Bashir Ahmed Dar Sopore KashmirProf Dr Bashir Ahmed Dar
Calorie restriction (CR) is as close to a real fountain of youth as any known technique is. Caloric restriction known to extend the human lifespan by up to five years has quietly become accepted among leading researchers. Even scientists who are cautious about anti-aging hype say it works
HYPERTHYROIDISM PART-2 BY DR BASHIR ASSOCIATE PROFESSOR MEDICINE SOPORE KASHMIRProf Dr Bashir Ahmed Dar
Read hyperthyroidism part-1 and part-2 for better understanding of the subject.Consulted many books and available litrature on the subject
brought their points together to produce precise simple easy to understand slide presentation.Thankful to all these masters.If you need a copy to download just message me on the email drbashir123@gmail.com.Your comments on the site is highly appreciable and welcome, gives me some feedback to improve my work in future
HYPERTHYROIDISM PART-1 BY DR BASHIR ASSOCIATE PROFESSOR MEDICINE SOPORE KASHMIRProf Dr Bashir Ahmed Dar
This slide presentation on hyperthyroidism is divided into two parts.Part-1 deals with causes of hyperthyroidism.I have tried to explain and give clear understanding about the causes of hyperthyroidism which to my knowledge is made very simple and easily understandable.
Part-2 deals with signs symptoms and treatment.Treatment part has been explained in detail.I hope you will enjoy reading it.
ANTI THYROID DRUGS BY DR BASHIR ASSOCIATE PROFESSOR MEDICINE SOPORE KASHMIRProf Dr Bashir Ahmed Dar
The thyroid gland is the biggest gland in the neck. It is situated in the anterior part of the neck below the skin and muscle layers. The thyroid gland takes the shape of a butterfly with the two wings being represented by the left and right thyroid lobes which wrap around the trachea. The sole function of the thyroid is to make thyroid hormone. This hormone has an effect on nearly all tissues of the body where it increases cellular activity. The function of the thyroid, therefore, is to regulate the body's metabolism
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
7. RHEUMATOID ARTHRITIS Rheumatoid arthritis isautoimmune disorder in which Immune system identifies the synovial membrane as "foreign" and begins attacking it. Synovial membrane shown in picture
8. RHEUMATOID ARTHRITIS With long-term or intensive exposure to the antigen, normal antibodies become auto-antibodies that target self-antigens in the synovial membrane.
9. RHEUMATOID ARTHRITIS Once the antigen or immune complex reaches the synovial membrane .The antigen presenting cell deals with it.
10. RHEUMATOID ARTHRITIS First, the APC usually a macrophage in synovium engulfs the antigen. Enzymes (peroxides) inside the APC break down the antigen into smaller particles.
11. RHEUMATOID ARTHRITIS The processed antigens are transported to the surface of the APC, where it binds with MHC (major histocompatibility complex).
12. RHEUMATOID ARTHRITIS This complex ie (part of a foreign substance and MHC) is now presented to T-cells (CD4 cells ie T-helper cell ) or CD8 (cytotoxic T cells) which the T-cell receptor (TCR) recognizes and binds to.
19. Effects of IL-1 On exposure to IL-1, synoviocytes proliferate and produce following factors Interleukin-6 (IL-6) Prostaglandin's (e.g. , PGE2) , and platelet-activating factor, which are involved in the pain mechanism. Matrix Metalloproteases(e.g. stromelysin) that cause activation of collagenase, an enzyme required for cartilage breakdown.
20. Effects of IL-1 IL-1 also activates endothelial cells and induce stimulation of adhesion molecule expression on endothelial cells. Enhances activity of NK cells and leads to Pyrogen (cause fever).
21. Effects of IL-1 IL-1 also causes increased production of inducible nitric oxide synthase and consequently high levels of nitric oxide kill chondrocytes, the cells responsible for cartilage remodeling. Induce osteoblast apoptosis and thereby prevent new bone formation Prevent formation of the cartilage matrix by inhibition of proteoglycan synthesis.
22. Effects of IL-1 The end result of these of IL-1 and TNF-a include activation and migration of leukocytes and lymphocytes from the blood into inflammatory tissues as well as formation of pannus and damage to cartilage and surrounding normal cells.
24. MICROSCOPY- RA Micro: dense perivascular inflammatory infiltrate of T lymphocytes, plasma cells (often with eosinophilic cytoplasmic inclusions called Russell bodies) inflammation extends to subchondral bone (relatively specific for rheumatoid arthritis); proliferative synovitis with synovial cell hyperplasia and hypertrophy, necrobiotic nodules and fibrosis; increased vascularity with hemosidrin deposition; organizing fibrin floating in joint space as rice bodies; neutrophils present on synovial surface;
25. MICROSCOPY- RA Neutrophils, lymphocytes, plasma cells, macrophages, and fibroblasts are responsible for increased cellularity. Superficial areas of necrosis are present and masses of inflammatory cells can be seen free above the synovial surface.
30. MICROSCOPY- RA The inflammation can spread to soft tissues as shown in fig and destroy these structure causing laxity and deformity of joint. Muscles /tendons /ligaments
35. Mast Cells Mast cells are implicated in the pathology of autoimmune disorders like rheumatoid arthritis. Mast cells are basophils that have "homed in" on tissues characteristically surrounding blood vessels and contains many granules rich in histamine and heparin.
36. Mast Cells Mast cells has a receptor for the Fc region of IgE. As a result, mast cells are coated with IgE. Mast cells usually remain inactive until an allergen binds to IgE already in association with the cell. It appears that binding of two or more IgE molecules is required to activate the mast cell.
38. Mast Cells The molecules thus released by mast cell into the extracellular environment include: Cytokines Histamine/Serotonin/Heparin Eosinophil chemotactic factor Prostaglandin D2 leukotrienes C4 Platelet-activating factor TNFa
39. Mast Cells Histamine and serotonin dilates capillaries activates the endothelium, and increases blood vessel permeability. This leads to local edema (swelling), warmth, redness, and the attraction of other inflammatory cells to the site of release.
40. RHEUMATOID ARTHRITIS Increase in the permeability of blood vessels in the synovial membranes. This attracts several types of leukocytes and lymphocytes to the synovial membrane out of the circulation. Synovial inflammation (synovitis)
41. RHEUMATOID ARTHRITIS The phagocytes of inflammation (neutrophils and macrophages) ingest the immune complexes which releases powerful enzymes that degrade synovial tissue and articular cartilage.
42. RHEUMATOID ARTHRITIS Inflammation causes hemorrhage, coagulation, and fibrin deposits on the synovial membrane, in the intracellular matrix, and in the synovial fluid.
43. RHEUMATOID ARTHRITIS On the denuded areas of the synovial membrane, fibrin gets deposited and develops into granulation tissue called pannus, which is the earliest tissue produced in the healing process.
44. RHEUMATOID ARTHRITIS The pannus is a sheet of inflammatory granulation tissue that spreads from the synovial membrane and invades the joint in rheumatoid arthritis ultimately leading to fibrous ankylosis.
45. RHEUMATOID ARTHRITIS The synovial membrane undergoes hyperplasic thickening as its cells abnormally proliferate and enlarge. These vascular derangements decrease blood flow to the synovial tissue and compromised circulation. This, coupled with increased metabolic needs due to hypertrophy and hyperplasia, causes hypoxia (oxygen depletion) and metabolic acidosis.
46. RHEUMATOID ARTHRITIS Acidosis stimulates the release of hydrolytic enzymes from synovial cells into the surrounding tissue, initiating erosion of the articular cartilage and inflammation spreads into the supporting ligaments and tendons.
47. RHEUMATOID ARTHRITIS The synovitis or inflammation, results in the warmth, redness, swelling, and pain that are typical symptoms of RA.
48. RHEUMATOID ARTHRITIS In this disease process, an interaction between antibodies and antigens occurs, and causes alterations in the composition of the synovial fluid. Infiltration of cells in it etc.
49. RHEUMATOID ARTHRITIS Once the composition of this fluid is altered, it is less able to perform the normal functions and results in soft tissue destruction that eventually leads to laxity in tendons and ligaments.
50. RHEUMATOID ARTHRITIS Stage One: Congestion and edema of the synovial membrane and joint capsule. Stage Two: Formation of pannus occurs, covering the cartilage and eventually destroying the joint capsule and bone.
51. RHEUMATOID ARTHRITIS Stage Three: Fibrous ankylosis, which is a fibrous invasion of pannus and scar tissue that fills the joint space. Mal-alignment cause visible deformities and disrupt the articulation of opposing bones. This, in turn, causes muscle atrophy and imbalance that may also include partial dislocations (subluxation).
52. RHEUMATOID ARTHRITIS Stage Four: Fibrous tissue begins to calcify, resulting in bony ankylosis (total immobility).
53. Epidemiology RA affects 0.5-1.0% of population in USA Females > males 3:1 but people of any age can be affected Peak age 45-65 but onset early from age 20-45 yrs Smoking risk factor Genetic 70% of patients with RA express HLA-DR4 twins indicate a concordance of about 15%–20%
54. Epidemiology It occurs worldwide, affecting more than 6.5 million people in the U.S. alone. About 75% of these are women. The disease strikes women three times more often than men.
55. Epidemiology Although it can occur at any age, the peak onset period is between the ages of 35 and 50. The disease may come on slowly or may appear suddenly.
56. Diagnostic Criteria for RA ≥ 4 criteria present > 6 wks Morning stiffness > 1 hour Arthritis of ≥ 3 joints areas (PIP, MCP, wrist, elbow, knee, ankle, and MTP) Arthritis of hand joints (wrist, MCP, PIP) Symmetric arthritis Rheumatoid nodules RF+ Radiographic changes erosions Unequivocal Periarticular osteopenia
57. ETIOLOGY OF RA The cause of rheumatoid arthritis is unknown. Even though infectious agents such as viruses, bacteria, and fungi have long been suspected as well as smoking, but none has been proven as the cause. It is believed that the tendency to develop rheumatoid arthritis may be genetically inherited.
58. ETIOLOGY OF RA For example, the genetic marker HLA-DR4 has been identified in as many as 66% of patients with disease. This marker, which is present in white blood cells, plays a role in helping the immune system to distinguish between foreign cells (e.g., germs) and the body's own cells.
59. ETIOLOGY OF RA Because RA often is affected by pregnancy—symptoms improve before the infant is born and then worsen after delivery—it may be that hormones in the body influence disease development and progression.
60. ETIOLOGY OF RA Stress — Patients often report episodes of stress or trauma preceding the onset of their rheumatoid arthritis. Stressful "life events" (divorce, accidents, grief, etc) are more common in people with RA in the six months before their diagnosis compared to the general population.
61. ETIOLOGY OF RA All this might trigger the activation of the immune system in susceptible individuals. This misdirected immune system then attacks the body's own tissues. This leads to inflammation in the joints and sometimes in various organs of the body, such as the lungs or eyes.
62. SYMPTOMS AND SIGNS OF RHEUMATOID ARTHRITIS The joints of the hands are often the very first joints affected by rheumatoid arthritis. These joints are tender when squeezed, and the hand's grip strength is often reduced. Rheumatoid arthritis may lead to visible redness and swelling and pain of joints or entire the entire hand.
63. SYMPTOMS AND SIGNS OF RHEUMATOID ARTHRITIS The joints of the hands are often the very first joints affected by rheumatoid arthritis. These joints are swollen red and tender when squeezed. Swelling due to synovitis
66. SYMPTOMS AND SIGNS OF RHEUMATOID ARTHRITIS Metacarpophalangeal and proximal inter phalangeal are involved. The joint stiffness is most bothersome in the morning and after sitting still for a period of time. The stiffness can persist for more than one hour.
67. SYMPTOMS AND SIGNS OF RHEUMATOID ARTHRITIS The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation. When body tissues are inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in remission).
68. SYMPTOMS AND SIGNS OF RHEUMATOID ARTHRITIS Remissions can occur spontaneously or with treatment and can last weeks, months, or years. During remissions, symptoms of the disease disappear, and people generally feel well. When the disease becomes active again (relapse), symptoms return.
69. SYMPTOMS AND SIGNS OF RHEUMATOID ARTHRITIS The return of disease activity and symptoms is called a flare. The course of rheumatoid arthritis varies among affected individuals, and periods of flares and remissions are typical.
71. SYMPTOMS AND SIGNS OF RHEUMATOID ARTHRITIS Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity. Arthritis is common during disease flares. Also during flares, joints frequently become red, swollen, painful, and tender.
72. SYMPTOMS AND SIGNS OF RHEUMATOID ARTHRITIS This occurs because the lining tissue of the joint (synovium) becomes inflamed (synovitis) , resulting in the production of excessive joint fluid (synovial fluid).
73. SYMPTOMS AND SIGNS OF RHEUMATOID ARTHRITIS In rheumatoid arthritis, multiple joints are usually inflamed in a symmetrical pattern (both sides of the body affected). The small joints of both the hands and wrists are often involved.
74. SYMPTOMS AND SIGNS OF RHEUMATOID ARTHRITIS Simple tasks of daily living, such as turning door knobs and opening jars, can become difficult during flares. The small joints of the feet are also commonly involved.
75. SYMPTOMS AND SIGNS OF RHEUMATOID ARTHRITIS Chronic inflammation can cause damage to body tissues, including cartilage, tendons, ligaments and bone.
76. SYMPTOMS AND SIGNS OF RHEUMATOID ARTHRITIS This leads to a loss of cartilage and erosion and weakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function which often leads to difficulty performing every day tasks (e.g., buttoning a shirt, opening a jar).
77. SYMPTOMS AND SIGNS OF RHEUMATOID ARTHRITIS Occasionally, only one joint is inflamed. When only one joint is involved, the arthritis can mimic the joint inflammation caused by other forms of arthritis, such as gout or joint infection.
78. SYMPTOMS AND SIGNS OF RHEUMATOID ARTHRITIS Certain characteristic hand deformities can occur with long-standing rheumatoid arthritis like Swan neck deformities Boutonniere deformities Z deformity of thumb Bow string sign The tendons on the back of the hand may become very prominent and tight, called the bow string sign.
79. Swan neck deformity The deformity arises from hyperextension of the proximal interphalangeal joint, while the distal interphalangeal joint is flexed.
81. Swan neck deformity In the PIP joint the strongest ligament is the volar plate. This ligament connects the proximal phalanx to the middle phalanx on the palm side of the joint. The ligament tightens as the joint is straightened and keeps the PIP joint from bending back too far (hyperextending). Swan neck deformity
85. Swan neck deformity Although characteristic in RA, swan-neck deformity has several causes, including untreated mallet finger, laxity of the ligaments of the volar aspect of the PIP joint in old age or a normal variant. True swan-neck deformity does not affect the thumb, which has only one interphalangeal joint.
86. Mallet Finger Mallet finger is a simple flexion deformity of the distal interphalangeal joint preventing extension. This deformity results from an extensor tendon rupture.
87. Z- deformity of Thumb Severe hyperextension of the interphalangeal joint of the thumb with flexion of the metacarpophalangeal (MCP) joint can occur; this is called a duck bill, Z (zigzag) type, or 90°-angle deformity. With simultaneous thumb instability, pinch is greatly impaired.
88. Buttonhole Deformity Flexion of the PIP joint accompanied by hyperextension of the DIP joint . This deformity can result from tendon laceration, dislocation, fracture, osteoarthritis, or RA.
89. Buttonhole Deformity The tendons which straighten finger joints are like strings running from the sides and the back of the finger to a sheet on the top of the finger.
90. Buttonhole Deformity When the finger is hit or bent forcefully in just the wrong way, the sheet on the top of the finger (the central slip of tendon) tears away from its attachment to the top of the middle finger bone.
91. Buttonhole Deformity The tear in the tendon sheet looks like a buttonhole ("boutonniere" in French), and the end of the finger bone actually begins to stick through the hole. As a result, the tendons can't straighten the middle joint (which stays bent) and all of the force of the tendons bypasses the middle joint and goes to the end joint (which flips backward).
99. Rheumatoid nodules Painless firm lumps that appear beneath the skin, often single or multiple, and range in size from millimeters to centimeters in diameter occur on the underside of the forearm and on the elbow.
100. Rheumatoid nodules But they can also occur on other pressure points, including the back of the head, the base of the spine, the Achilles tendon, and the tendons of the hand
102. Rheumatoid nodules These nodules may move easily when touched or they may be fixed to deeper tissues and cause pressure on surrounding nerves or can rupture, causing pain and discomfort in surrounding tissue.
103. Rheumatoid nodules Although nodules are mostly benign, complications such as infection, ulceration, and gangrene can occur following breakdown of skin overlying the nodules.
104. Rheumatoid nodules Usually no treatment is necessary unless nodules become debilitating, ulcerated, or infected. Surgical removal may be performed.
109. Skin complications of RA A rare, serious complication, usually with long-standing rheumatoid disease, is blood vessel inflammation (Vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue death (necrosis). This is most often initially visible as tiny black areas around the nail beds or as leg ulcers. Atrophic skin
110. Skin complications of RA Dark purplish areas on the skin (purpura) are caused by bleeding into the skin from blood vessels damaged by rheumatoid arthritis.
111. Skin complications of RA Rheumatoid Vasculitis can cause many internal symptoms, , hepatomegaly (enlarged liver), splenomegaly (enlarged spleen), bowel ulcers, and haematuria (blood in urine).
112. Skin complications of RA Skin ulcers (usually leg ulcers) may be extensive and painful Petechiae (purplish spots) or purpura Nail fold or edge breakdown Gangrene
114. Skin complications of RA Neutrophilic dermatoses Neutrophils are a type of white blood cell (leucocyte). They are present in bacterial infections. They are the prominent cell seen on skin biopsy of some uncommon inflammatory skin diseases known as neutrophilic dermatoses.
115. Skin complications of RA Sweet disease and pyoderma gangrenosum are other neutrophilic disorders sometimes seen in association with rheumatoid arthritis. Pyoderma gangrenosum
116. Skin complications of RA Interstitial granulomatous dermatitis. also known as ‘rheumatoid papules’, interstitial granulomatous dermatitis presents as skin coloured or red papules often on the trunk. It is rare.
117. Skin complications of RA RA can affect the glands located near the eyes and mouth, resulting in a condition called secondary Sjogren's syndrome Decreased tear and saliva production can cause dry mouth, and dry eyes. Sjogren's syndrome
118. GASTRO-INTESTINAL COMPLICATIONS Dry mouth, related to Sjogren syndrome, is the most common symptom of gastrointestinal involvement. Gastritis (stomach inflammation) or stomach ulcer caused by NSAID therapy.
119. Urinary complications of RA The kidneys are not usually affected directly by rheumatoid arthritis. Kidney problems in rheumatoid arthritis are much more likely to be caused by medications used to treat the condition.
120. Hematological complications of RA Anemia Low white blood cell count (leukopenia) can occur from Felty's syndrome, a complication of rheumatoid arthritis that is also characterized by enlargement of the spleen.
121. Hematological complications of RA Immune thrombocytopenic purpura caused by an autoimmune reaction against platelets. drug induced neutropenia; thrombocytopenia, particularly autoimmune and drug induced thrombocytopenia; and hematological malignancy.
122. Nervous complications of RA Entrapment of nerves. Carpal tunnel syndrome or ulnar nerve neuropathy including sensory or motor neuropathy (loss of sensation)
123.
124. Nervous complications of RA Formation of a Baker's cyst (a cyst filled with joint fluid and located in the hollow space at the back of the knee). Its herniation of posterior capsule
125. RESPIRATORY COMPLICATIONS OF RA CAPLANS SYNDROME The combination of RA and exposure to coal dust produces the condition. It develops especially in miners working in anthracite coal-mines and in persons exposed to silica and asbestos.
126. RESPIRATORY COMPLICATIONS OF RA CXR shows multiple, round, well defined nodules, usually 0.5 - 2.0 cm in diameter, which may cavitate and resemble tuberculosis. CT scanning gives a better picture of cavitation.
127. RESPIRATORY COMPLICATIONS OF RA well defined nodules, usually 0.5 - 2.0 cm in diameter, which may cavitate and resemble tuberculosis.
128. RESPIRATORY COMPLICATIONS OF RA The syndrome is named after Dr. Anthony Caplan, a physician on the Cardiff Pneumoconiosis Panel.
130. OCULAR COMPLICATIONS OF RA RA can also cause inflammation of the sclera (white part of the eye), which may make the sclera appear red or bluish in color.
146. Bow string sign The tendons on the back of the hand may become very prominent and tight, called the bow string sign. Ulnar deviation The direction of prominent tendons is like bow string
147. Rheumatoid Arthritis Differential Diagnosis Pyogenic arthritis: usually monoarticular, fever and chills, abnormal joint fluid Chronic Lyme disease: commonly monoarticular and associated with positive titers Human Parvovirus infection: arthralgia more common than arthritis, rash may be present, serologic evidence of parvovirus B19 infection Polymyalgia rheumatica is associated with proximal muscle weakness and stiffness
148. Rheumatoid Arthritis Differential Diagnosis several cancers produce paraneoplastic syndromes including polyarthritis; e.g., hypertrophic pulmonary osteoarthropathy produced by lung and gastrointestinal cancers. Diffuse swelling of the palmar fascia has been associated with several cancers including ovarian cancer.
150. Laboratory – RF Rheumatoid Factor Antibody igM against the Fc fragment of IgG Not sensitive 80% of RA patients RF+ patients more likely to have More severe disease Extraarticular manifestations
152. TREATMENT OF RHEUMATOID ARTHRITIS Nonsteroidal anti inflammatory drugs (NSAIDs) are a class of drugs that reduce inflammation, pain, fever, and swelling and are commonly prescribed for the inflammation of the joints (arthritis) and other tissues, such as in tendinitis and bursitis.
153. Nonsteroidal anti inflammatory drugs Examples of NSAIDs include: Aspirin Indomethacin Ibuprofen Naproxen Piroxicam Nabumetone Diclofenac All NSAIDs should be taken with meals to prevent stomach upset.
154. Nonsteroidal anti inflammatory drugs NSAIDs work by blocking the production of prostaglandins, chemical messengers that often are responsible for the pain and swelling of inflammatory conditions.
155. Nonsteroidal anti inflammatory drugs Prostaglandins are made by two different enzymes, cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2). The prostaglandins made by the two different enzymes have slightly different effects on the body.
156. Nonsteroidal anti inflammatory drugs COX-2 inhibitors are NSAIDs that selectively block the COX-2 enzyme and not the COX-1 enzyme. Blocking this enzyme impedes the production of prostaglandins.
157. Nonsteroidal anti inflammatory drugs Some of the prostaglandins made by COX-1 protect the inner lining of the stomach. Common NSAIDs such as aspirin block both COX-1 and COX-2 .
158. Nonsteroidal anti inflammatory drugs When the COX-1 enzyme is blocked, inflammation is reduced, but the protection of the lining of the stomach also is lost. This can cause stomach upset as well as ulceration and bleeding from the stomach and even the intestines.
159. Nonsteroidal anti inflammatory drugs COX-2 enzyme is located specifically in areas of the body that commonly are involved in inflammation but not in the stomach.
160. Nonsteroidal anti inflammatory drugs When the COX-2 enzyme is blocked, inflammation is reduced; however, since the COX-2 enzyme does not play a role in protecting the stomach or intestine, therefore do not injure the stomach or intestines as compared to COX-1 inhibitors.
161. Nonsteroidal anti inflammatory drugs Older NSAIDs (for example, ibuprofen, naproxen, etc.) all act by blocking the action of both the COX-1 and COX-2 enzymes.
162. Nonsteroidal anti inflammatory drugs NSAIDs, including COX-2 inhibitors, may increase the risk of heart attacks, stroke, and related conditions. This risk may increase in patients with risk factors for heart disease and related conditions.
163. Nonsteroidal anti inflammatory drugs Aspirin Indomethacin 500-1000 mg every 6 hours or BD. Heart attacks are prevented with 50/75 or 325 mg daily. 50-200 mg per day split into 2-3 doses
164. Nonsteroidal anti inflammatory drugs Ibuprofen 200 or 400 mg every 6 hours. Individuals should not use ibuprofen for more than 10 days for the treatment of pain or more than 3 days for the treatment of a fever unless directed by a physician.
165. Nonsteroidal anti inflammatory drugs Naproxen Piroxicam Nabumetone Diclofenac 250-500 mg twice daily 20 mg once daily or 10 mg twice daily 1000 mg daily as a single dose. Some patients may respond better to 1500 or 2000 mg daily. The lowest effective dose should be used 50-100 mg /day
167. COX-2 inhibitors Celecoxib . 100 or 200 mg twice daily. The lowest effective dose should be used for each patient.
168. Disease-Modifying Antirheumatic Drugs or DMARDs While "first-line" medications (NSAIDs and corticosteroids) can relieve joint inflammation and pain, they do not necessarily prevent joint destruction or deformity.
169. Disease-Modifying Antirheumatic Drugs or DMARDs For patients with an aggressively destructive form of rheumatoid arthritis, medications other than NSAIDs and corticosteroids are needed. These "second-line" or "slow-acting" medicines may take weeks to months to become effective.
170. Disease-Modifying Antirheumatic Drugs or DMARDs They are used for long periods of time, even years, at varying doses. If effective, they can promote remission, thereby retarding the progression of joint destruction and deformity. Sometimes a number of second-line medications are used together as combination therapy.
171. Disease-Modifying Antirheumatic Drugs or DMARDs Hydroxychloroquine is related to quinine, and is used in the treatment of malaria. It is used over long periods for the treatment of rheumatoid arthritis. Side effects include upset stomach, skin rashes, muscle weakness, and vision changes.
172. Disease-Modifying Antirheumatic Drugs or DMARDs The usual adult dose for treating malaria is 800 mg initially, followed by 400 mg 6 hours later then 400 mg on days 2 and 3. The dose for malaria prevention is 400 mg every week starting 1 or 2 weeks before exposure and for 4 weeks after leaving the high risk area.
173. Disease-Modifying Antirheumatic Drugs or DMARDs The recommended adult dose for rheumatoid arthritis is 400-600 mg daily for 4-12 weeks followed by 200-400 mg daily. Systemic lupus erythematosus is treated with 400 mg once or twice daily for several weeks then 200-400 mg daily. Hydroxychloroquine should be taken with food or milk in order to reduce stomach upset.
174. Disease-Modifying Antirheumatic Drugs or DMARDs Sulfasalazine is an oral medication traditionally used in the treatment of mild to moderately severe inflammatory bowel diseases, such as ulcerative colitis and Crohn's colitis.
175. Disease-Modifying Antirheumatic Drugs or DMARDs Sulfasalazine is used to treat rheumatoid arthritis in combination with anti- inflammatory medications. Sulfasalazine is generally well tolerated. Common side effects include rash and upset stomach. Because sulfasalazine is made up of sulfa and salicylate compounds, it should be avoided by patients with known sulfa allergies.
176. Disease-Modifying Antirheumatic Drugs or DMARDs Gold salts have been used to treat rheumatoid arthritis throughout most of this century. Gold thioglucose (SOLGANAL) and gold thiomalate (MYOCHRYSINE) are given by injection, initially on a weekly basis for months to years. Oral gold, auranofin (RIDAURA) was introduced in the 1980's.
177. Disease-Modifying Antirheumatic Drugs or DMARDs Side effects of gold (oral and injectable) include skin rash, mouth sores, kidney damage with leakage of protein in the urine, and bone marrow damage with anemia and low white cell count. Patients receiving gold treatment are regularly monitored with blood and urine tests. Oral gold can cause diarrhea.
178. Immunosuppressive Medicines Are powerful medications that suppress the body's immune system. A number of immunosuppressive drugs are used to treat rheumatoid arthritis. They include Methotrexate Azathioprine Cyclophosphamide Chlorambucil and Cyclosporine
179. Immunosuppressive Medicines Because of potentially serious side effects, immunosuppressive medicines (other than methotrexate) are generally reserved for those who have very aggressive disease or those with serious complications of rheumatoid inflammation, such as blood vessel inflammation (vasculitis).
180. Immunosuppressive Medicines The exception is methotrexate, which is not frequently associated with serious side effects and can be carefully monitored with blood testing. Methotrexate has become a preferred second-line medication as a result.
181. Immunosuppressive Medicines Methotrexate may be taken with or without food.7.5 mg dose weekly. Thinning of the bones due to osteoporosis may be prevented by calcium and vitamin D supplements.
183. Newer "second- line“ drugs or "biologic" medications Each of these medications can increase the risk for infections, and the development of any infections should be reported to the health-care professional when taking these newer second-line drugs.
184. Newer "second- line“ drugs or "biologic" medications Most of biologic medications intercept a messenger protein in the joints (tumor necrosis factor or TNF) that promotes inflammation of the joints in rheumatoid arthritis. This effectively blocks the recruiting the cells of inflammation.
185. Newer "second- line“ drugs or "biologic" medications Etanercept must be injected subcutaneously once or twice a week Infliximab is given by infusion directly into a vein (intravenously) Adalimumab is injected subcutaneously once or twice a week Golimumab is injected subcutaneously on a monthly basis. Certolizumab is injected subcutaneously once or twice a week
186. Newer "second- line“ drugs or "biologic" medications They are currently recommended for use after other second-line medications have not been effective. Are expensive , frequently used in combination with methotrexate and other DMARDs.
187. Newer "second- line“ drugs or "biologic" medications These medications should be avoided by persons with significant congestive heart failure or demyelinating diseases (such as multiple sclerosis) because they can worsen these conditions.
188. Newer "second- line“ drugs or "biologic" medications Rituximab Depletes B-cells, which are important cells of inflammation and in the production of abnormal antibodies.
189. Newer "second- line“ drugs or "biologic" medications Abatacept Prevents the activation of the T-lymphocytes and blocks both the production of new T-lymphocytes and the production of the chemicals that destroy tissue and cause the symptoms and signs of arthritis.
190. Newer "second- line“ drugs or "biologic" medications DOSING: Abatacept is infused over 30 minutes. The initial dose of abatacept is followed by additional doses two and four weeks after the first infusion with further doses every 4 weeks thereafter. Patients weighing < 60 kg should receive a 500 mg dose, weighing 60-100 kg a 750 mg dose and weighing >100 kg a 1000 mg dose.
191. Newer "second- line“ drugs or "biologic" medications Tocilizumab Blocks interleukin-6 (IL-6), Tocilizumab (Actemra) is an intravenous infusion given monthly.
192. Newer "second- line“ drugs or "biologic" medications Anakinra Is a synthetic (man-made), injectable, interleukin-1 receptor antagonist that blocks the effects of human interleukin-1.
193. Newer "second- line“ drugs or "biologic" medications The IL-1 attaches to receptors on the tissues within and surrounding the joints as well as on the cells that are responsible for inflammation, for example, white blood cells. The attachment of IL-1 activates the cells to promote inflammation and release enzymes. The enzymes destroy the cartilage and bone and contribute to pain and swelling of the joints.
194. Newer "second- line“ drugs or "biologic" medications Anakinra attaches to the IL-1 receptor and prevents IL-1 from attaching to the receptor. Thus, the inflammatory and enzyme-releasing effects of IL-1 are prevented and pain and swelling of the joints are reduced. Anakinra was approved by the Food and Drug Administration in November, 2001
195. Newer "second- line“ drugs or "biologic" medications DOSING: The daily dose of anakinra in rheumatoid arthritis is one subcutaneous injection of 100 mg daily. The dose should be administered at approximately the same time every day.
196. Newer "second- line“ drugs or "biologic" medications Infliximab is an antibody that blocks the effects of tumor necrosis factor alpha (TNF alpha). Infliximab is administered by intravenous infusion. There are two other injectable drugs that block TNF alpha--adalimumab(Humira) and etanercept (Enbrel).
197. Newer "second- line“ drugs or "biologic" medications Adalimumab DOSING: Adalimumab is injected under the skin. The recommended dose for adults is 40 mg every other week, but some patients may need weekly administration.
198. Newer "second- line“ drugs or "biologic" medications DOSING: Infliximab is administered intravenously. For moderate to severe Crohn's disease the dose is 5 mg/kg administered as a single dose. For fistulizing Crohn's disease, the dose is 5 mg/kg followed by additional doses of 5 mg/kg two and six week after the first dose.
199. Newer "second- line“ drugs or "biologic" medications The recommended dose for the treatment of rheumatoid arthritis is 3 mg/kg as a single dose. The initial dose should be followed by additional 3 mg/kg doses two and six weeks after the first dose. Thereafter, the maintenance dose is 3 mg/kg every eight weeks.
200. Newer "second- line“ drugs or "biologic" medications Etanercept Is an injectable drug that blocks tumor necrosis factor alpha (TNF alpha) and is used for treating rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis.
201. Newer "second- line“ drugs or "biologic" medications Etanercept is a synthetic (man-made) protein that binds to TNF alpha. It thereby acts like a sponge to remove most of the TNF alpha molecules from the joints and blood.
202. Newer "second- line“ drugs or "biologic" medications DOSING: Etanercept is injected under the skin. Adults usually inject 25mg twice weekly. Children 4 to 17 years old should receive 0.4mg/kg (maximum 25mg) twice weekly.
203. Newer "second- line“ drugs or "biologic" medications While biologic medications are often combined with traditional DMARDs in the treatment of rheumatoid arthritis. Biologic medications are generally not used with other biologic medications because of the unacceptable risk for serious infections.
204. Corticosteroid Therapy Medications can be given orally or injected directly into tissues and joints. They are more potent than NSAIDs in reducing inflammation and in restoring joint mobility and function.
205. Corticosteroid Therapy Corticosteroids are useful for short periods during severe flares of disease activity or when the disease is not responding to NSAIDs. However, corticosteroids can have serious side effects, especially when given in high doses for long periods of time . Safe dose like Prenisolone is 5-10 mg daily.
206. Corticosteroid Therapy These side effects include weight gain, facial puffiness, thinning of the skin and bone, easy bruising, cataracts, risk of infection, muscle wasting, and destruction of large joints, such as the hips.
207. Prosorba column Therapy The Prosorba column therapy involves pumping blood drawn from a vein in the arm into an apheresis machine, or cell separator. This machine separates the liquid part of the blood (the plasma) from the blood cells.
208. Prosorba column Therapy The Prosorba column is a plastic cylinder about the size of a coffee mug that contains a sand-like substance coated with a special material called Protein A. Protein A is unique in that it binds unwanted antibodies from the blood that promote the arthritis.
209. Prosorba column Therapy The exact role of this treatment is being evaluated by doctors, and it is not commonly used currently.
212. ODB Indications for Biologic Drugs RA: Failure of DMARD therapy Failure or Intolerance to MTX 20mg/week sc or po x 3 months Arava 20 mg po x 3 months Any combination DMARD
213. Drugs & Pregnancy NSAIDS: safe until week 34 (patent ductus) OH-chloroquine: safe, ?cleft palate Sulfasalzine: continue if on it; safe Imuran: continue if on it; safe Methotexate: teratogen ??? ok in small doses; stop 3 months before conception Arava: teratogenmay be present for 2 yrs Cyclophosphamide:? teratogen ? Safe > 2nd trimester Biologic agents: unknown; stop 3 months before conception Steroids: non-fluorinated do NOT cross placenta
214. THANK YOU SO MUCH Trust the physician and the teacher, and drink his remedy in silence and tranquility. For his hand though heavy and hard is guided by tender hand of unseen. And the cup he brings, though it burn your lips has been fashioned of the clay which the potter have moistened with his tears and sacred feelings.