Rheumatoid
ArthritisMuhammad HussainGoran Muhammad
Huzaifa Hamid
INTRODUCTION EPIDEMOLOGY ETIOLOGY PATHOGENESIS RISK FACTORS DISTINCTIVE CLINICAL FEATURES COMPLICATIONS INVESTIGATIONS TREATMENT Non –Pharmacological pharmacological• PREVENTION CONCLUSION
CONTENTS
Rheumatoid arthritis (RA) is an autoimmune disease that causes
chronic inflammation of the joints & can also cause inflammation of the tissue around the joints, as well as in
other organs in the body.
An autoimmune disease is a disease where the immune
system attacks healthy parts of the body.
As it can affect multiple other organs of the body, RA is referred to as a systemic illness and is sometimes called rheumatoid disease.
Introduction
Diagram showing the affected organ
Comparison of normal joint and
affected joint
A joint (the place where two bones meet) is surrounded by a capsule
that protects and supports & it is lined with a type of tissue called Synovium, which produces synovial fluid that lubricates and nourishes joint tissues
It becomes inflamed, causing warmth, redness, swelling, and pain & unable to move freely
As the disease progresses, the inflamed synovium invades and damages the cartilage and bone of the joint. Surrounding muscles, ligaments, and tendons become weakened
This process eventually leads to deformity and destruction of the joints
RA also can cause more generalized bone loss that may lead to osteoporosis (fragile bones that are prone to fracture)
RA Contd…
The incidence of RA is in the region of 3 cases per 10,000
population per annum. Onset is uncommon under the age of 15 and from then on the incidence rises with age until the age of 80.
Some Native American groups have higher prevalence rates (5–6%) and people from the Carribean region have lower prevalence rates.
First-degree relatives prevalence rate is 2–3% and disease genetic concordance in monozygotic twins is approximately 15–20%.
Epidemiology
The cause of RA is unknown. It is assumed that a genetically
susceptible host is exposed to an unknown antigen & this interaction gives rise to a persistent immunological response
The activation of immune response is triggered by the following factors.
They are:- GENETIC FACTORS:-RA is documented by presence of
immune cell reactivity and production of antibodies to endogenous elements such as immunoglobulins,collagen,andcellular components
Etiology
PRESENCE OF HLA (human lymphocyte antigen):-The most
definite genetic association with RA is with HLA alleles.The HLA-DR4 allele is associated with development & severity of RA.
Risk of an individual with HLA-DR4 to develop the disease is between 2 & 6. In American Whites,60-70% of RA patients are positive for HLA-DR4.
Frequency of this allele among Dutch patients is greater than 90%.
Contd…
There is a 30% concordance in monozygotic twins compared to
5% in fraternal twins and first degree relatives.
First degree relatives of patients develop RA at 4-6 times the rate of standard population rate.
INFECTIOUS FACTORS:- Presence of Epstein-Barr virus as antigen. Of patients with RA ,80% have a circulating antibody directed against antigens specific for this virus.
Parvovirus particularly B19 & also Mycobacteria(as it expresses HSP,heat sensitive protein)have been linked to RA.
Contd…
ENDOCRINOLOGIC FACTORS:-. disease may improve
during pregnancy and flare after pregnancy. Breastfeeding may also aggravate the disease
Contraceptive use reduces the risk of developing RA. This suggests possible deficiencies or changes in certain hormones, may promote the development of RA
ENVIRONMENTAL FACTORS:-Changes in barometric pressures are associated with acute worsening of RA. Besides climate,diet,trauma are also known to influence RA.
Contd…
RA is characterised by the infilteration of various
inflammatory cells into the joint The synovial membrane becomes highly vascularised &
synovial fibroblasts proliferate & inflammatory cells release numerous CYTOKINES & GROWTH FACTORS into the joint
These agents cause synovial cells to release proteolytic enzymes &Proliferating inflammatory tissue (PANNUS-tissue serving as origin of joint erosions) subsequently leads to the destruction of intra articular & peri articular structures leading to the joint deformities and dysfunction
Pathogenesis
Gender Age Family history Smoking Overweight HLA gene
Risk factors
Tender, warm, swollen joints Symmetrical pattern of affected joints Joint inflammation often affecting the wrist and finger joints
closest to the hand Joint inflammation sometimes affecting other joints, including
the neck, shoulders, elbows, hips, knees, ankles, and feet Fatigue, occasional fevers, a general sense of not feeling well Pain and stiffness lasting for more than 30 minutes in the
morning or after a long rest Variability of symptoms among people with the disease
Distinctive clinical features of RA
Symmetrical pattern of affected joints
Since RA is a systemic disease, its inflammation can affect
organs and areas of the body other than the joints like eyes,skin,lungs,heart & blood vessels
Examples of other areas that may be affected include:- SJOGREN’S SYNDROME:-inflammation of the glands of the
eyes and mouth and causes dryness of these areas PLEURITIS causes chest pain with deep breathing or coughing Tissue inflammation surrounding the heart, PERICARDITIS
Complications
Rheumatoid disease can reduce the number of red blood cells
ANEMIA and white blood cells. Decreased white cells can be associated with an enlarged spleen
i.e FELTY'S SYNDROME and can increase the risk of infections.
RHEUMATOID NODULES can occur around the elbows and fingers where there is frequent pressure.
VASCULITIS rare and serious complication is blood-vessel inflammation which can impair blood supply to tissues and lead to tissue death. This is most often initially visible as tiny black areas around the nail beds or as leg ulcers.
EROSIVE CHANGES GIVE RISE TO JOINT INSTABILITY
&SUBLUXATION.CHARACTERISTIC DEFORMITIES INCLUDE ULNAR
DEVIATION,SWAN NECK,BOUTONNIERE SYNDROME.
Are made after a full medical and family history and physical
and diagnostic testing are evaluated by a qualified health care professional.
Medical testing may include a wide variety of tests like:- ESR (Erythrocyte Sedimentation Rate CRP (C – Reactive prot ) INFLAMMATORY RF (Rheumatoid factor)blood tests MARKERS ANA (Anti nuclear antibodies) JOINT X-RAYS MRI (Magnetic resonance imaging) & US (ultra sound)
Investigations
ESR…It is a test that measures how fast red blood cells
(erythrocytes) drop to the bottom of a collection tube.
CRP…C-reactive protein, another common test for inflammation is useful both in making a diagnosis and monitoring disease activity and response to anti-inflammatory therapy.
RA FACTOR… is an autoantibody that is present in the blood of most people with RA & directed against host immunoglobulin & present in 75-80% in patients with RA.
• ANA ….These are investigated to rule out possibility of other
connective tissue disorders like SLE. ANA’s are raised in 80% of patients with SLE & 20% of patients with RA.
• X-RAYS….Erosions can be seen at the joint margins & loss of joint space due to erosion of cartilage & bone may be identified.
• MRI & US SCAN…used to detect inflammatory activity. so these are increasingly used to detect early changes in RA patients.
Laboratory tests include an • elevated alkaline phosphatase, elevated platelet count, decreased serum albumin level
Anti-CCP antibodies: This blood test detects antibodies to cyclic citrullinated peptide (anti-CCP). This test is positive in most people with RA
and can even be positive years before rheumatoid arthritis symptoms develop.
Goals of Treatment Relieve pain Reduce inflammation Slow down or stop joint damage Improve a person's sense of well-being and ability to
function. Current Treatment Approaches Lifestyle Medications Surgery Routine monitoring and ongoing care.
Treatment
Physiotherapy is a vital part of treating RA Heat,cold and electrotherapy helps to reduce pain and swelling program of exercise strengthens joints & minimize deformity
and increase the range of movement and functions Natural treatments include using massage with herbs,magneto
therapy etc Occupational therapy educates patients to protect joints with the
use of appliances and splints. Surgical techniques can be effective in relieving pain and
restoring function.
Non-Pharmacological
• ANALGESICS –used only for pain relief
Eg:-Paracetamol-325 to 650mg every 4-6hrs or 1gm 3-4 times/day
Topical Analgesic(Capsaicin)-apply 3-4 times/day• NSAID’s-used as an adjunct along with DMARD’s to reduce
the inflammation
Eg:-Ibuprofen-1.2-3.2 gms/day in 4 divided doses TID
Aspirin-325-650mg for every 4hrs for pain
3,600mg for inflammation 4 times daily
NSAID’S mainly act by inhibiting COX -1 &2 enzymes blocking COX enzyme site & thus reduces inflamation
Pharmacological
CORTICOSTEROIDS-used because of their anti inflammatory &
immunosuppressive property
Eg:-Prednisone & methyl prednisolone given orally or IV,IM-7.5mg daily as single dose/infusion
-Act by suppressing the cytokines
• DMARD,s(disease modifying anti-rheumatic drugs)-used to slow down the progression of disease
• These include METHOTREXATE-5 to 25 mg once weekly;Oral or IM• SULFASALAZINE-initially 500mg OD,increasing in weekly steps 0f
500mg to 1gm BD
The primary purpose is to reduce pain, improve the affected
joint’s function, and improve the patient’s ability to perform daily activities
Joint replacement:involves removing all or part of a damaged joint and replacing it with synthetic components.
Most commonly replaced joints are the hips and knees.
Current Surgery Approaches
Arthrodesis (fusion): is a surgical procedure that involves
removing the joint and fusing the bones into one immobile unit, often using bonegrafts from the person’s own pelvis
useful for increasing stability and relieving pain in affected joints
Tendon reconstruction: RA can damage and even rupture tendons, the tissues that attach muscle to bone
reconstructs the damaged tendon by attaching an intact tendon to it
Routine monitoring and ongoing care: Regular medical care is
important to monitor the course of the disease, determine the effectiveness and any negative effects of medications, and change therapies as needed
Healthful diet:- overall nutritious diet with enough—but not an excess of—calories, protein, and calcium is important
Those taking methotrexate need to avoid alcohol as most serious long-term side effects is liver damage
General Approaches
Stress reduction:- Stress also may affect the amount of pain a
person feels Regular rest periods can help, as can relaxation, distraction, or
visualization exercises Joint care:- using a splint for a short time around a painful joint
reduces pain and swelling by supporting the joint and letting it rest
Rest and exercise:- good balance between rest and exercise is required
They reduce active joint inflammation and pain and to fight fatigue,maintaining healthy and strong muscles, preserving joint mobility, and maintaining flexibility
There is no known way to prevent RA because the exact cause of the
disease is not known
Preventive measures can be taken only after diagnosis of the disease.
But making some modifications in :-
Diet(consume nutritious food )
Relaxed Life style
Avoiding smoking & alcohol consumption
Maintaining ideal body weight
Exercises like swimming,cycling ,yoga can prevent the increased risk of RA.
Prevention
RA is the most common inflammatory disease affecting 1% of
population & can affect virtually every area of a person’s life from work life to family life
One study showed that more than a quarter of women stopped working within 4 years after being diagnosed with rheumatoid arthritis &also interferes with the joys and responsibilities of family life
Fortunately, current treatment strategies, including pain-relieving drugs and medications that slow joint damage, a balance between rest and exercise, and patient education and support programs, allow most people with the disease to lead active and productive lives
Conclusion
Thank You