PERM STATE

MEDICAL
UNIVERSITY
TOPIC – RHEUMATOID ARTHRITIS
By-HAPPY MALIK
 RHEUMATOID ARTHRITIS
• Rheumatoid arthritis (RA) is a chronic systemic inflammatory disorder
that may affect many tissues and organs-skin, blood vessels, heart,
lungs and muscles. But principally attacks the joints, producing a non-
suppurative proliferative and inflammatory synovitis that often
progresses to destruction of the articular cartilage and ankylosis of
the joints.
• Simply an autoimmune disorder, rheumatoid
arthritis that occurs when your immune system
mistakenly attacks your own body's tissues.
 ANAMNESIS OF RA (HISTORY)
• Anflammation in rheumatoid arthritis develops slowly over a period of weeks to months with the
classic initial appearance of joint stiffness, pain and swelling. This condition can be intermittent
and is called palindromic rheumatism, which is swelling of one or two joints that can last several
days to weeks and then disappears and returns to the same joint in a pattern that increases over
time.
• The clinical marker of rheumatoid arthritis is symmetric polyarthritis involving the proximal
interphalangeal (PIP) joint, the metacarpophalangeal joint (MCP), wrist, elbow, shoulder, hip,
knee, heel, and the metatarsophalangeal joint (MTP). Early in the disease, rheumatoid arthritis
involves only one or a few joints which progressively increase over time. It generally begins at the
hand and wrist joints in 90% of patients.
• Over time, synovitis that initially causes joint swelling and pain turns proliferative and destructive.
[6,15] In general, patients experience an explosive polyarticular onset within 24 to 48 hours and
persistent joint stiffness for up to several hours, which is characteristic of rheumatoid arthritis. .
Similar stiffness can also occur in a state of inactivity or prolonged sitting (gel phenomenon).
• There are also systemic symptoms such as malaise, fatigue, fever, weight loss,
and weakness as well as extra-articular manifestations with the mnemonic
FACEBOOKS, namely:
• Felty's syndrome
• Atlanto-axial subluxation
• Caplans syndrome and pulmonary nodules
• Effusions (pleural exudates)
• Blood - normochromic normocytic anemia
• Olecranon bursitis
• Oral dryness (sicca syndrome)
• Kidneys (amyloid, gold and penicilliame)
• Sensory neuropathy and scleromalacia
 EPIDEMIOLOGY
• RA affects approximately 0.5–1% of the adult population worldwide.
• The overall incidence of RA has been decreasing in recent decades,
whereas the prevalence has remained the same because individuals
with RA are living longer.
• Occurs more commonly in females, with a 2–3:1 ratio.
o various theories have been proposed to explain the possible role of estrogen in disease
pathogenesis.
o Experimental studies have shown that estrogen can stimulate production of tumor necrosis
factor a (TNF-α)
STAGES OF RHEUMATOID ARTHRITIS
 TYPES OF RA
Seropositive
• Rheumatoid arthritis patients who are classified as seropositive have the presence of anti-cyclic citrullinated peptides
(anti-CCPs) in their blood test results. These are also referred to as anti-citrullinated protein antibodies (ACPAs). These
are the antibodies that attack the body and produce the symptoms of rheumatoid arthritis.

Seronegative
• It’s still possible for patients to develop rheumatoid arthritis without the presence of antibodies in their blood. This is
referred to as seronegative type rheumatoid arthritis. Seronegative patients are those who do not test positive for the
anti-CCPs or another antibody called rheumatoid factor.
• Though seronegative patients lack the antibodies that help doctors diagnose the condition, they can still be diagnosed
with rheumatoid arthritis in a number of ways. These include the demonstration of clinical rheumatoid arthritis
symptoms, as well as X-ray results indicating patterns of cartilage and bone deterioration.
• Though it’s possible for seronegative patients to have milder rheumatoid arthritis symptoms than seropositive patients,
this isn’t always the case. It can still depend on a number of factors, including genetics and other underlying conditions
as well.
• Unfortunately, many seronegative patients may not respond to typical rheumatoid arthritis treatments. This provides
further motivation for researchers to identify rheumatoid arthritis sub-types in order to provide treatment for those who
don’t have any long-term solutions as of now.
 Rheumatoid Factor
• Whether or not a rheumatoid arthritis patient possesses the rheumatoid factor is another type or classification of
the disease. Rheumatoid factor is another antibody that is used to determine the presence of the autoimmune
disorder that causes rheumatoid arthritis. This is in addition to testing positive for anti-CCPs.
• However, rheumatoid factor can also appear in patients who have other conditions. Even infections. This is why the
presence of rheumatoid factor isn’t always a firm confirmation of whether or not a patient will develop rheumatoid
arthritis.
• Most patients who test positive for anti-CCPs, also test positive for rheumatoid factor.

Juvenile Rheumatoid Arthritis

• Juvenile rheumatoid arthritis is another type that affects patients under the age of 17 years old. It is also known as
juvenile idiopathic arthritis. It is the most common type of arthritis for this age group and symptoms can be
persistent. Swelling, stiffness, and joint pain can last months for those suffering from juvenile rheumatoid arthritis.
Some patients may experience rheumatoid arthritis symptoms for the rest of their lives.
• The effects of juvenile rheumatoid arthritis differ from those seen in adult patients because children and youth can
experience growth issues as a result of the disease. Eye and lymph node inflammation are also a concern.
• Like adult patients, juvenile rheumatoid arthritis is diagnosed from a series of different blood tests including testing
for rheumatoid factor and the presence of anti-CCPs. In some cases, doctors may not be able to detect abnormalities
in the blood tests of children and youth who have clinical symptoms.
• X –rays and scans are also performed in order to assess any other health threats like bone fractures, infections or
tumors.
CLASSIFICATION CRITERIA FOR RA
 SIGNS AND SYMPTOMS
• Signs and symptoms of rheumatoid arthritis may include:
• Tender, warm, swollen joints
• Joint stiffness that is usually worse in the mornings and after inactivity
• Fatigue, fever and loss of appetite
• Early rheumatoid arthritis tends to affect your smaller joints first —
particularly the joints that attach your fingers to your hands and your toes
to your feet.
• As the disease progresses, symptoms often spread to the wrists, knees,
ankles, elbows, hips and shoulders. In most cases, symptoms occur in the
same joints on both sides of your body.
 • About 40 percent of the people who have rheumatoid arthritis also experience signs
and symptoms that don't involve the joints. Rheumatoid arthritis can affect many
nonjoint structures, including:
• Skin
• Eyes
• Lungs
• Heart
• Kidneys
• Salivary glands
• Nerve tissue
• Bone marrow
• Blood vessels
❖ Rheumatoid arthritis signs and symptoms may vary in severity and may even come
and go. Periods of increased disease activity, called flares, alternate with periods of
relative remission — when the swelling and pain fade or disappear. Over time,
rheumatoid arthritis can cause joints to deform and shift out of place.
 COMPLICATIONS
• Rheumatoid arthritis increases your risk of developing:
• Osteoporosis
• Rheumatoid nodules. These firm bumps of tissue most commonly form around pressure points, such as the elbows. However, these
nodules can form anywhere in the body, including the lungs.
• Dry eyes and mouth. People with RA can also experience Sjogren's syndrome, a disorder that decreases the amount of moisture in
your eyes and mouth.
• Infections. RA and medications to treat it , can impair the immune system, leading to increased infections.
• Abnormal body composition. The proportion of fat to lean mass is often higher in people who have RA , even in people who have a
normal body mass index (BMI).
• Carpal tunnel syndrome. If RA affects your wrists, the inflammation can compress the nerve that serves most of your hand and
fingers.
• Heart problems. RA can increase your risk of hardened and blocked arteries, as well as inflammation of the sac that encloses your
heart.
• Lung disease. People with RA have an increased risk of inflammation and scarring of the lung tissues, which can lead to progressive
shortness of breath.
• Lymphoma. Rheumatoid arthritis increases the risk of lymphoma, a group of blood cancers that develop in the lymph system.
RHEUMATOID NODULES
 CAUSES
• Rheumatoid arthritis occurs when your immune system attacks the
synovium — the lining of the membranes that surround your joints.
• The resulting inflammation thickens the synovium, which can
eventually destroy the cartilage and bone within the joint.
• The tendons and ligaments that hold the joint together weaken and
stretch. Gradually, the joint loses its shape and alignment.
• Doctors don't know what starts this process, although a genetic
component appears likely. While your genes don't actually cause
rheumatoid arthritis, they can make you more susceptible to
environmental factors — such as infection with certain viruses and
bacteria — that may trigger the disease.
 RISK FACTORS
• Factors that may increase your risk of rheumatoid arthritis include:
• Your sex. Women are more likely than men to develop rheumatoid arthritis.
• Age. Rheumatoid arthritis can occur at any age, but it most commonly begins in
middle age.
• Family history. If a member of your family has rheumatoid arthritis, you may have
an increased risk of the disease.
• Smoking. Cigarette smoking increases your risk of developing rheumatoid arthritis,
particularly if you have a genetic predisposition for developing the disease.
Smoking also appears to be associated with greater disease severity.
• Environmental exposures. Although poorly understood, some exposures such as
asbestos or silica may increase the risk of developing rheumatoid arthritis.
• Obesity. People — especially women age 55 and younger — who are overweight
or obese appear to be at a somewhat higher risk of developing rheumatoid
arthritis.
 DIAGNOSIS
Rheumatoid arthritis can be difficult to diagnose in its early stages because the early signs and
symptoms mimic those of many other diseases. There is no one blood test or physical finding
to confirm the diagnosis.
During the physical exam, your doctor will check your joints for swelling, redness and warmth.
He or she may also check your reflexes and muscle strength.

Blood tests
People with rheumatoid arthritis often have an elevated erythrocyte sedimentation rate (ESR, or
sed rate) or C-reactive protein (CRP), which may indicate the presence of an inflammatory
process in the body. Other common blood tests look for rheumatoid factor and anti-cyclic
citrullinated peptide (anti-CCP) antibodies.
Imaging tests
Your doctor may recommend X-rays to help track the progression of rheumatoid arthritis in your
joints over time. MRI and ultrasound tests can help your doctor judge the severity of the
disease in your body.
Appearance of synovial fluid Close up of bone erosions in RA X-ray from a of the hand in
RA
joint with inflammatory arthritis (RA).
 TREATMENT
There is no cure for rheumatoid arthritis. But clinical studies indicate that remission of symptoms is more likely when
treatment begins early with medications known as disease-modifying antirheumatic drugs (DMARDs).

Medications
The types of medications recommended by your doctor will depend on the severity of your symptoms and how long
you've had rheumatoid arthritis.
• NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-
counter NSAIDs include ibuprofen (Advil, Motrin IB) and naproxen sodium (Aleve). Stronger NSAIDs are available by
prescription. Side effects may include stomach irritation, heart problems and kidney damage.

• Steroids. Corticosteroid medications, such as prednisone, reduce inflammation and pain and slow joint damage.
Side effects may include thinning of bones, weight gain and diabetes.

• Disease-modifying antirheumatic drugs (DMARDs). These drugs can slow the progression of

rheumatoid arthritis and save the joints and other tissues from permanent damage. Side effects vary but may include
liver damage, bone marrow suppression and severe lung infections.

• Biologic agents. Also known as biologic response modifiers, this newer class of DMARDs includes abatacept
(Orencia), adalimumab (Humira), anakinra (Kineret), baricitinib (Olumiant), certolizumab (Cimzia), etanercept (Enbrel),
golimumab (Simponi), infliximab (Remicade), rituximab (Rituxan), sarilumab (Kevzara), tocilizumab (Actemra) and
tofacitinib (Xeljanz).
These drugs can target parts of the immune system that trigger inflammation that causes joint and tissue damage.
 PHYSIOTHERAPY
Your doctor may send you to a physical or occupational therapist
who can teach you exercises to help keep your joints flexible. The
therapist may also suggest new ways to do daily tasks, which will be
easier on your joints. For example, you may want to pick up an object
using your forearms.
Assistive devices can make it easier to avoid stressing your painful
joints. For instance, a kitchen knife equipped with a hand grip helps
protect your finger and wrist joints. Certain tools, such as
buttonhooks, can make it easier to get dressed.
Catalogs and medical supply stores are good places to look for ideas.
 SURGERY
If medications fail to prevent or slow joint damage, you and your doctor may
consider surgery to repair damaged joints. Surgery may help restore your
ability to use your joint. It can also reduce pain and improve function.
Rheumatoid arthritis surgery may involve one or more of the following
procedures:
• Synovectomy. Surgery to remove the inflamed lining of the joint (synovium)
can be performed on knees, elbows, wrists, fingers and hips.
• Tendon repair. Inflammation and joint damage may cause tendons around
your joint to loosen or rupture. Your surgeon may be able to repair the
tendons around your joint.
• Joint fusion. Surgically fusing a joint may be recommended to stabilize or
realign a joint and for pain relief when a joint replacement isn't an option.
• Total joint replacement. During joint replacement surgery, your surgeon
removes the damaged parts of your joint and inserts a prosthesis made of
metal and plastic.
• There is no cure for RA, but treatments can improve symptoms and
slow the progress of the disease.
• The goals of treatment are to minimize symptoms such as pain and
swelling, to prevent bone deformity (for example, bone erosions visible
in X-rays), and to maintain day-to-day functioning.[75] This is primarily
addressed with disease-modifying antirheumatic drugs (DMARDs) -
Common DMARDs include methotrexate (Trexall, Otrexup,
others), leflunomide (Arava), hydroxychloroquine (Plaquenil) and
sulfasalazine (Azulfidine).
• dosed physical activity; analgesics and physical therapy may be used to
help manage pain.
 RHEUMATOID ARTHRITIS DRUG GUIDE
• You may take rheumatoid arthritis medications alone, but they are
often most effective in combination. These are the main types of RA
medications:
• Disease-modifying anti-rheumatic drugs (DMARDs)
• Biologic response modifiers (a type of DMARD)
• Glucocorticoids
• Nonsteroidal anti-inflammatory medications (NSAIDs)
• Analgesics (painkillers)
Examples

of
DMARDs:
Examples

of

corticosteroids:
Examples

of

biologic

response

modifiers:
Examples of NSAIDs:
Examples of analgesics: