Rheumatoid ArthritisValencia Bailey

Aetiology

• Genetic- HLA DR4, HLA DR1 and IL2RA/CD25, VTCN1 genes

• Infectious- Mycoplasma, EBV, Rubella, others

• Hormones- F>M, in pregnancy and breastfeeding

• Immunological factors- B and T lymphocytes, antigen-presenting cells, cytokines

• Cigarette smoking

Pathophysiology

• Infiltration of the synovial membrane with lymphocytes, plasma cells and macrophages

• CD4+ cells- interacts with other cells in synovium

• Activated T cells- stimulate B cells to produce antibodies including RF

Pathophysiology

• Macrophages- produce pro-inflammatory cytokines

• These act on endothelium, synovial fibroblasts, bone cells and chondrocytes to promote swelling and congestion of the synovial membrane and destruction of bone, cartilage and soft tissues.

• TNF-α- regulates production of other cytokines

Pathophysiology

• B cells- produce Ig which can form immune complexes in the joint and extra-articular tissues, leading to vasculitis

• Inflammatory granulation tissue (pannus) spreads over and under the articular cartilage, which is progressively destroyed

• Fibrous or bony alkylosis and atrophy of adjacent muscles with lymphocytic infiltration

Clinical Criteria for Diagnosis (old)Duration ≥ 6 wks4 of 7 are needed for diagnosis:• Morning stiffness > 1hr• Arthritis of ≥ 3 joint areas• Arthritis of hand joint• Symmetrical arthritis• Rheumatoid nodules• Serum rheumatoid factor (RF) +ve• Radiological changes

American Rheumatism Association 1988 revision

The ACR and EULAR Revised Criteria

Joint involvement consists of swelling or tenderness upon examination. The presence of synovitis may be confirmed on imaging studies. • 1 large joint (ie, shoulders, elbows, hips, knees, ankles) = 0

points• 2-10 large joints = 1 point• 1-3 small joints (ie, MCP, PIP, second-fifth MTP, thumb IP, and

wrist joints ) = 2 points• 4-10 small joints = 3 points• More than 10 joints (at least 1 small joint, plus any

combination of large and additional small joints or joints such as temporomandibular, acromioclavicular, sternoclavicular, etc) = 5 points

The ACR and EULAR Revised Criteria

At least 1 serology test result is needed for classification. • Negative RF and negative ACPA = 0 points• Low-positive RF or low-positive ACPA = 2

points• High-positive RF or high-positive ACPA = 3

points

The ACR and EULAR Revised Criteria

At least 1 test acute-phase reactant test result is needed for classification. • Normal CRP and normal ESR = 0 points• Abnormal CRP or abnormal ESR = 1 point

The ACR and EULAR Revised Criteria

Patient-reported duration of synovitis signs/symptoms of joints clinically involved at the time the patient is assessed, with or without treatment. • Shorter than 6 weeks = 0 points• 6 weeks or longer = 1 point

A score of 6 of 10 is needed for diagnosis

Management

• Physical rest, anti-inflammatory agents, passive exercises, rehabilitation

• Periodic assessment of disease progression and disability

Drugs

• Disease-modifying antirheumatic drugs • methotrexate, sulfasalazine, leflunomide,

hydroxychoroquine, azothioprine, cyclosporin, auranofin, minocycline, penicillamine, IM gold

• Biologicals• rituximab, etanercept, infliximab, and

adalimumab

Drugs

• NSAIDS• ibuprofen, ketoprofen, naproxen, diclofenac,

celecoxib

• Analgesics• acetaminophen, tramadol, codeine, opiates

• Corticosteroids• prednisone, methylprednisolone

Surgery

• Myofascial techniques• Excisions• Reconstructions• Joint fusions• Joint replacements

Features of a Rheumatoid Hand

• Symmetrical swelling of the MCP and proximal IP joints

• Swan neck deformity• Boutonnière or button hole deformity• Z deformity of thumb• Dorsal subluxation of the ulna at the distal

radio-ulnar joint• Triggering of fingers (stenosing tenosinovitis)

References

• Davidson’s Principles and Practice of Medicine• www.emedicine.com• www.cks.nhs.uk• www.herbalgranny.com