PBL Day 3

1. Complications of RA (rheumatoid vasculitis, unstable cervical spine)

Rheumatoid Vasculitis Rheumatoid vasculitis is skin condition that is a typical feature of rheumatoid arthritis, presenting as peripheral vascular lesions that are localized purpura, cutaneous ulceration, and gangrene of the distal parts of the extremities. What is rheumatoid vasculitis? Vasculitis is a serious complication of rheumatoid arthritis. While rheumatoid arthritis affects the body's joints, vasculitis is a condition in which blood vessels become inflamed. When blood vessels become inflamed, they may become weakened and increase in size, or become narrowed, sometimes to the point of stopping blood flow. The blood vessels most often involved are arteries that bring blood to the skin, nerves, and internal organs. Veins can also be involved. What are the symptoms of rheumatoid vasculitis? When vasculitis involves the small arteries and veins that nourish the skin of the fingertips and skin around the nails, small pits in the fingertips or small sores causing pain and redness around the nails can occur. Involvement of somewhat larger arteries and veins of the skin can cause a painful red rash that often involves the legs. If the skin is very inflamed, ulcers can occur and infection becomes a complicating risk. Vasculitis that injures the nerves can cause loss of sensation, numbness and tingling, or potentially weakness or loss of function of the hands and/or feet. The rare vasculitis of larger arteries can cause complete absence of blood flow to tissue sites supplied by the affected vessel (termed occlusion, resulting in infarction), which can cause gangrene of fingers or toes, stomach pain, cough, chest pain, heart attack, and/or a stroke if the brain is involved. This form of systemic vasculitis can also be accompanied by general symptoms such as fever, loss of appetite, weight loss, and loss of energy. Which patients with rheumatoid arthritis get vasculitis? Rheumatoid vasculitis most often occurs in people with at least 10 years of severe disease. In general, people who get vasculitis have many joints with pain and swelling, rheumatoid nodules, high concentrations of rheumatoid factor in their blood, and sometimes smoke cigarettes. They may also have an enlarged spleen and chronic low white cell count, a condition known as Felty's Syndrome. Less than five percent of people with rheumatoid arthritis get skin vasculitis. Fortunately, far fewer people get vasculitis of larger arteries. There is evidence to support that since the introduction of effective treatments for rheumatoid arthritis, the occurrence of rheumatoid vasculitis is far less common. What causes rheumatoid vasculitis? The cause of rheumatoid vasculitis is not known. An abnormally active immune system (the body's defense system) appears to play an important role in blood vessel inflammation. Evidence linking the immune system to vasculitis includes:

High levels of rheumatoid factor The presence of other proteins in the blood (called immune complexes) Lower levels of proteins in the blood (called complement), which are used up when inflammation occurs. The appearance of inflamed blood vessels under the microscope, which shows immune cells within the wall of the vessel. How is a diagnosis of rheumatoid vasculitis made? The doctor will suspect the diagnosis based on symptoms of rash, numbness or tingling of the hands or feet, skin ulcers, cough and shortness of breath, chest pain, abdominal pain, or stroke symptoms. An electrical test of nerve function (EMG) is sometimes done to study the numbness and tingling sensations in the arms and legs. Biopsy of the skin or other symptomatic organs is sometimes necessary. How is rheumatoid vasculitis treated? Treatment depends upon the size of the vessel, the organs affected, and the overall severity of the vasculitis. Vasculitis involving the fingertips and skin around the fingernails, or that only causes a rash, is treated with pain control, antibiotic cream, and local protection. Many rheumatoid arthritis patients who experience this kind of vasculitis are not being effectively treated for their joint disease. Drugs that treat rheumatoid arthritis, can be started and often improve both the joint symptoms and the vasculitis. Because more serious rheumatoid vasculitis is rare, studies comparing an active drug to an inactive material (placebo) have not been published. Treatment recommendations for vasculitis that causes nerve damage, skin ulcers, and damage to internal organs rely on descriptions of series of patients with vasculitis and your doctor's previous experience. When this kind of vasculitis occurs, despite adequate treatment of joint disease, stronger treatments to control the immune system are used. When any of these treatments are used, very careful monitoring by a doctor is necessary. What is the long-term outcome from rheumatoid vasculitis? Skin involvement alone is usually not very serious. Vasculitis that involves the nerves and internal organs is more difficult to treat and usually occurs in people with very severe rheumatoid arthritis. For all of these reasons, it can potentially impact outcome and requires close medical follow-up. Unstable Cervical Spine Cervical myelopathy If you have had rheumatoid arthritis for some time, you are at increased risk of developing cervical myelopathy and you may need special assessment of your neck before any operation where you are put to sleep. This condition is caused by dislocation of joints at the top of the spine, which put pressure on the spinal cord. Although relatively uncommon, it is a serious condition that can greatly affect your mobility.

2. Treatment (physical therapy, exercise, education)

Physiotherapy A physiotherapist may help you improve your fitness and muscle strength, and make your joints more flexible. They may also be able to help with pain relief using heat or ice packs, or trancutaneous electrical nerve stimulation (TENS). A TENS machine applies a small pulse of electricity to the affected joint, which numbs the nerve endings and can help ease the pain of rheumatoid arthritis.

Occupational therapy If rheumatoid arthritis causes you problems with everyday tasks, or is making it difficult for you to move around, occupational therapy may help. An occupational therapist can provide training and advice that will help you to protect your joints, both while you are at home and at work. Some type of support for your joints, such as a splint, may also be recommended, or devices that can help open jars or turn on taps. Podiatry If you have problems with your feet, a podiatrist may be able to help. You may also be offered some type of support for your joints or shoe insoles that can ease pain. Complementary and Alternate Therapies Many people with rheumatoid arthritis try complementary therapies. In most cases, there is little or no evidence they are effective in the treatment of symptoms of rheumatoid arthritis. They include massage, acupuncture, osteopathy, chiropractic, hydrotherapy, electrotherapy and nutritional supplements including glucosamine sulphate, chondroitin and fish oil. Exercise, Joint Pain, and Rheumatoid Arthritis Not only can exercise help rheumatoid arthritis, its a vital part of rheumatoid arthritis treatment. When joints are stiff and painful, exercise might be the last thing on your mind. Yet with rheumatoid arthritis, exercising regularly is one of the best things you can do. People who exercise live longer, with or without rheumatoid arthritis. Regular exercise can actually reduce overall pain from rheumatoid arthritis. Exercise can keep bones strong. Thinning of the bones can be a problem with rheumatoid arthritis, especially if you need to take steroids. Exercise helps bones keep their strength. Exercise maintains muscle strength. Regular exercise improves functional ability and lets you do more for yourself. People with rheumatoid arthritis who exercise feel better about themselves and are better able to cope with problems. Natural Treatments for Rheumatoid Arthritis There are a variety of alternative therapies for rheumatoid arthritis. Let your doctor know if you're considering them. Heat and cold: The use of heat and cold is one of the best natural treatments to help ease rheumatoid arthritis joint pain. Cold compresses reduce joint swelling and inflammation. Heat compresses relax muscles and stimulate blood flow. Magnets: In people with osteoarthritis, the wear-and-tear type of arthritis, some preliminary studies have shown that magnets improved joint pain better than a placebo. However, its unclear if magnets might help rheumatoid arthritis. Acupuncture: The National Institutes of Health considers acupuncture an additional alternative treatment for arthritis. Studies have shown that acupuncture helps reduce pain, may lower the need for painkillers, and can help increase flexibility in affected joints. Mind/body therapy: Mind/body therapies can help with stress management and improve sleep and pain perception. Strategies include deep abdominal breathing, progressive muscle relaxation, visualization, meditation, and tai chi. Biofeedback: With biofeedback, you work with a therapist who helps you recognize feelings of increased tension and learn ways to calm yourself. This can help decrease feelings of pain.

Nutritional supplements: Keep in mind that even natural supplements can interact with medicines. Be sure your doctor is aware of all medicines and supplements you are taking. Research shows that omega-3 fatty acids in fish oil have an anti-inflammatory effect in the body. Several studies have shown that fish oil supplements may help reduce morning stiffness with RA. Some studies show that borage seed oil along with anti-inflammatory painkillers can reduce RA symptoms. These studies showed reductions of tender and swollen joints of RA after six weeks. 3. Medication (disease modifying anti-rheumatic drugs (DMARDs), anti-inflammatory

medication (NSAIDs), corticosteroids and cyclo-oxygenase II (COX-II) inhibitors, Tumour Necrosis Factor (TNF-) inhibitors)
http://www.hopkinsarthritis.org/arthritis-info/rheumatoid-arthritis/ra-treatment/ NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin, others) and naproxen (Aleve). Stronger NSAIDs are available by prescription. Side effects may include ringing in your ears, stomach irritation, heart problems and liver and kidney damage. Steroids. Corticosteroid medications, such as prednisone, reduce inflammation and pain and slow joint damage. Side effects may include thinning of bones, cataracts, weight gain and diabetes. Doctors often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication. Disease-modifying antirheumatic drugs (DMARDs). These drugs can slow the progression of rheumatoid arthritis and save the joints and other tissues from permanent damage. Common DMARDs include methotrexate (Trexall), leflunomide (Arava), hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine) and minocycline (Dynacin, Minocin, others). Side effects vary but may include liver damage, bone marrow suppression and severe lung infections. Immunosuppressants. These medications act to tame your immune system, which is out of control in rheumatoid arthritis. Examples include azathioprine (Imuran, Azasan), cyclosporine (Neoral, Sandimmune, Gengraf) and cyclophosphamide (Cytoxan). These medications can increase your susceptibility to infection. TNF-alpha inhibitors. Tumor necrosis factor-alpha (TNF-alpha) is an inflammatory substance produced by your body. TNF-alpha inhibitors can help reduce pain, morning stiffness, and tender or swollen joints. Examples include etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), golimumab (Simponi) and certolizumab (Cimzia). Potential side effects include increased risk of serious infections, congestive heart failure and certain cancers. Other drugs. Several other rheumatoid arthritis drugs target a variety of processes involved with inflammation in your body. These drugs include anakinra (Kineret), abatacept (Orencia), rituximab (Rituxan) and tocilizumab (Actemra). Side effects vary but may include itching, severe abdominal pain, headache, runny nose or sore throat.