Rheumatoid Arthritis

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Clinical Description

Chronic systemic inflammatory disease characterized by a symmetrical, deforming, peripheral polyarthritis.

Clinical Features

SIGNS AND SYMPTOMS 

  • Arthritis: Symmetrical, polyarthritis of MCPs, PIPs of hands and feet → pain, swelling, deformity, Swan neck, Boutonniere, Z-thumb, Ulnar deviation of the fingers, Dorsal subluxation of ulnar styloid
  • Morning stiffness >1 hour
    • Improves with exercise
    • Larger joints may become involved
  • Nodules
    • Commonly elbows also fingers, feet, heal
    • Firm, non-tender, mobile or fixed

Diagnosed when any 4 out of the following findings are present

  • Morning stiffness >1h (lasting >6wks), Arthritis ≥3 joints, Arthritis of hand joints, Symmetrical, Rheumatoid nodules, +ve RF, Radiographic changes

INVESTIGATIONS

  • Anti-CCP: 98% specific (Ag derived from collagen)
  • Rheumatoid Factor +ve in 70% 
  • ANA: +ve in 30%
  • FBC (anaemia, ↓PMN, ↑platelet),
  • ↑ESR
  • ↑CRP
  • Radiography

Treatment

Treatment objectives

  • Relief symptoms
  • Modulate immunity with DMARDs as soon as possible

NON-PHARMACOLOGICAL 

  • Regular exercise
  • Physiotherapy
  • Occupational therapy: aids, splints
  • Surgical: ulna stylectomy, joint prosthesis

PHARMACOLOGICAL

Principles:

  • Disease Modifying Anti-Rheumatoid Drugs (DMARDs): use early
  • Steroids: IM, PO or intra-articular for exacerbations
    • Prednisolone 0.5-1 mg/kg body weight 24hourly
    • Take corticosteroids with food and Omeprazole 20mg 12hourly to prevent gastric ulcers
  • NSAIDs: good for symptom relief
    • Diclofenac 50 mg 8 hourly PO or 100 mg 12 hourly as required
    • Ibuprofen 400mg 12 hourly
    • Add Omeprazole 20mg 12hourly to the steroids to prevent gastric ulcers

Consider addition of Paracetamol 1g 6 hourly or Tramadol 50 to 100 mg 12 hourly to help relieve acute pain 

  • Prevent osteoporosis and gastric ulcers

DMARDs

  • 1st line for treating RA
  • Early DMARD use associated with better long-term outcome
  • All DMARDs can → myelosuppression → pancytopenia

Main agents (discuss with a specialist before initiating these drugs)

  • Methotrexate 7.5 to 25 mg PO weekly : It is generally continued indefinitely
  • (SE: hepatotoxic, pulmonary fibrosis, anaemia and leucopenia)
  • Give it together with Folic acid 5 to 15mg daily
  • Sulfasalazine 500 mg daily, increased by 500 mg every week to 2-3 grams daily in divided doses
    • (SE: hepatotoxic, SJS, ↓ sperm count)  
    • Preferred agent in pregnancy
  • Hydroxychloroquine 200 – 400 mg daily. Maximum dose of 6.5 mg/kg per day
    • (SE: retinopathy, seizures)
    • Regular eye checkup needed

Combination triple therapy (methotrexate plus sulfasalazine plus hydroxychloroquine).

Other Agents (discuss with a specialist before initiating these drugs)

  • Leflunomide (SE: ↑ risk of infection and malignancy)
  • Gold (Gold sodium thiomalate 10mg/ml )(SE: nephrotic syndrome)
  • Penicillamine (SE: drug-induced lupus, taste change)
  • Biologicals
  • Anti-TNF (SE: ↑ infection (sepsis, TB), ↑ AI disease, ↑ Ca)
  • Severe RA not responding to DMARDs
  • Screen and treat for TB first

 Complications

  • De Quervain’s Tenosynovitis
  • Atlanto-axial subluxation
  • Immune
  • AIHA
  • Vasculitis
  • Amyloid
  • Lymphadenopathy
  • Cardiac: pericarditis and pericardial effusion
  • Carpal Tunnel Syndrome
  • Pulmonary
    • Fibrosing alveolitis (lower zones)
    • Pleural effusions (exudates)
  • Ophthalmic
    • Epi-/scleritis
  • Raynaud’s
  • Felty’s Syndrome (RA + splenomegaly + neutropenia)

When to refer a rheumatoid arthritis patient

  • Presence or suspicion of complications listed above
  • No response to DMARDs
  • Suspicion of life-threatening drug side effects