RHEUMATOID ARTHRITIS

dr. Ketut Suryana, SpPD-KAI

Medical Faculty, Warmadewa University

To make the diagnosis dan its managements To explain the terminology To explain the etiopathogenesis To explain the pathologic abnormality To inform the clinical symptoms and signs To explain the criteria of diagnosis To perform the general management

RHEUMATOID ARTHRITIS (RA)

RA : - an autoimmune diseases - systemic inflammatory

- the affect predominantly at the joints.

Etiologic factor : unclear - Genetic factor (HLA-DR4)

- Arthritogenic agents (bacteria, virus)

Pathologic : erosive synovitis, peripheral joints , symmetric and chronic Extra articular pathologic : rare

EPIDEMIOLOGY
Age :

Mostly in 30-40 yrs Increasing in older patients US Health Examination (1960-62) 0.3% age< 35 th 10.0% age> 60 th
Sex :

Women : Man (2,5 :1)

Another factors :

Social status, education, & Psycho-stress

ETIOLOGIC FACTOR
Unclear Suggested
Genetic factor,
HLA DR-4

Environment Arthritogenic agents (bacteria, virus)

Genetic factors
(HLA DR4)

Arthritogenic
(Bacteri,virus)

Autoimmune
Humoral immunity (RF) Cellular immunity Inflamatory mediators, cytokines

SYNOVITIS

Humoral Immunity (RF) in RA

Antigen B lymphocyte Synovium Ig G Production Ab 1 / Ag 2 (abnormal) FR Production Ab 2

Ag 1

(Ag2 + Ab2)

Immune complex Complemen activation

Arthritis

Synovium inflammation

Rheumatoid Factor (RF)

An auto antibody to antibody An Ab that bind to Fc portion of IgG molecule 75-80 % in RA High titer in severe case of RA May be present in other disesas 3% in normal population

Phatologic Inflammation of RA

PATHOLOGIC
Synovium inflammation (synovitis) with hypertropic, and villi proliferation tumor-like proliferation (pannus) to damage cartilage, bone and tendon

CLINICAL MANIFESTATION OF RA
History : pain, swelling and morning stiffness of small peripheral joint Often with general symptom ,(general fatigue, Symmetrical arthritis in small peripheral joint Extra articuler manifestation : rare

Arthritis in small peripheral joints

Early sign : tenderness and swelling mono articular and asymmetric Within a week or few month symmetrical arthritis (warm, pain, tender, without local heat) Joints : wrist, MCP, PIP, small joint s of the feet, etc Late stage : joint deformity Swan neck deformity

Rheumatoid Arthritis of hand

Early onset of RA

Late stage of RA

EXTRA ARTICULAR MANIFESTATION OF RA

Skin Rheumathoid nodul in pressure areas (rare in Indonesia) Vasculitis (purpura, echimosis, necrosis of nail, ulcer or gangren) Eye Kerato-conjungtivitis sicca (Sjogrens Syndrome) Scleritis, episcleritis

EXTRA ARTICULAR MANIFESTATION OF RA (cont)

Lung
Instertitial Pnemonitis

Pleural effusions, fibrosis

Cardiovascular
Pericarditis , myocarditis

Nodul reumathoid in myocard atau palve

Hematology
Mild Anaemia (on chronic disease)

Feltys Syndrome (granulocytopenia,splenomegaly &

recurrent infection)

Rheumatoid nodule

DIAGNOSTIC INVESTIGATIONS

Laboratory Test
Anemia (nn) ESR or CR (Good indication of inflamation) Lymphocyteosis Rheumatoid Factor positip (85%) Electrophoresis (increasing of Ig) )

DIAGNOSTIC INVESTIGATIONS
Imaging / X Ray
Normal (in early onset) Soft tissue swelling Periarticular osteopenia Marginal or central erossion and cysts

CRITERIA of RHEUMATOID ARTHRITIS

(The American Rheumatism Associations, 1987 revised criteria) 1. Morning stiffness ( 1 jam) 2. Arthritis of 3 joints or more 3. Arthritis of hand joints 4. Symetrical Arthritis 5. Rhematoid nodule 6. Serum Rheumatoid Factor 7. Typical radiologic changes of RA Rheumatoid Arthritis : 4 criterias or more, Note : Criteria 1 through 4 must have been present for at least 6 weeks

MANAGEMENT OF RA
Early Diagnosis and early treatment The goal : to achive the remission Patient Education and motivation To suppress the inflamations To perform maximal joint function To protect joint damage The tool : Education Physical rehabilitation Medications Surgical therapy Other : alternatif treatmant By the teams (Ruematologist/Internist, Orthopedist, Physioterapist, Psychiater, Social worker and Family)

MEDICINAL THERAPY
Simptomatis NSAID Glucocorticoid Antiinflammatory dan immunosupressive effect Without disease modifying effect DMARDs (Disease Modifying Anti Rheumatic Drugs) Biologic response modifiers TNF alfa=antagonist, IL1-Ra

The choice of DMARDs

Traditional methode (Pyramida sytem) Combination of Multiple drugs:

Step-down Bridge
Start with multiple drugs (oral Steroid, methotrexate, Sulfasalazine, Chloroqiun, etc) Start with multiple drugs (step by step, stop the most dangerous drug and the last, chloroquin) Continuous until several month-years.

DMARD FOR RHEUMATOID ARTHRITIS THERAPY

Drugs Hydroxychloroquine Onset 2-4 mont Dose 200 mg; 2x/day Side effects Rash, diarrhea, retina toxicity Rash, myelosuppression, GI intolerance GI symptoms, stomatitis, rash, alopesia, myelosuppression, liver and lung impairment

Sulfazalacine
Methotrexate

1-2 mont
1-2 mont

1000 mg; 2-3x/day

7,5-17,5 mg/wk

Azatioprine

2-3 mont 3-6 mont

50-150 mg/day 250-750 mg/hr

Mielosuppression, liver impairment, flu-like illness, GI symptoms

Myelosuppression. stomatitis, dyspepsia, proteinuria, autoimmune disorder, rash

D-penisillamine