Lec 44- RA Flashcards
What is it
- Most common autoimmune disease
- Chronic, progressive, system inflammatory disorder (including cardiovascular system)
- Affects synovial joints
- Many non-articular manifestations, some of which decrease life expectancy
- Causes significant disability
Who is affected
- 1% of UK population
- Decrease in past few years
- 2-3 times more common in women
- Increased prevalence with age
- Peak incidence 30-50 years
What causes RA
- Unknown
- Genetic
- Hormones
- Cigarettes
- Infection
How does it present
- Typically- slowly progressive, symmetrical peripheral polyarthritis, evolving over few weeks or months
- Pain and stiffness of the small joints of hands and feet; patients fell tired and unwell
- Also writes, elbow, shoulders, knees and ankles
- Joints are warm and tender, with swelling; stiffness especially morning; limited moment and muscle wasting
- Occasionally mono arthritis
- Occasionally very sudden
RA in hands
- Early disease- swelling and early joint damage
- Late disease- deformity and contractures
Co-morbities
- MI, HF, CVA, CVD, HTN
- Lymphoma and lymphorproliferative diseases
- Lung cancer, skin cancer
- Infections (disease and treatment)
- Depression, GI disease, osteoporosis, psoriasis, renal disease (disease and treatment)
Pathophysiology- much simplified
- Widespread inflammation of synovium- thickens
- Infiltration by inflammatory cells
- Synovium spreads onto the cartilage surface (pannus) damaging it
- Cartilage thins; underlying bone exposed -> damage (osteoclasts stimulated)
- Key inflammatory cells include T cells, B cells, macrophages and plasma cells.
- Key inflammatory mediators: Cytokines: IL-6, IL-1 and TNFa
- AutoAbs such as rheumatoid factor and citrullainated peptides activate the complement system ā> stimulates macrophages
How is RA diagnosed
-Patient history
-Presenting symptoms/clinical examination
-American college of Rheumatology classification criteria- poor sensitivity for early disease
CLINICAL TESTS
-increase ESR and CRP
-Increased platelet count
-Rheumatoid factor- IgM present in 75-80% of patients with RA (seropositive) and 5% of patient without RA
-Anti-cyclic citrullinated peptides (anti-CCP) Abs is more specific (90-96%
-Anaemia of chronic disease (norm chromic, normocytic)- will not respond to Fe treatment
-Radiology- X-ray, MRI, Ultrasound
Monitoring disease
-Symptoms and clinical markers (CRP)
-NICE refers to DAS28- disease activity score which has 4 parameters
1) Number of swollen joints out fo a total of 28 specific joints
2)Number of tender joints out of total of 28 specified joints
3)Erythrocyte sedimentation rate
4)Patients interpretation of wellbeing
Disease activity
High= >5.1
Moderate= 3.2-5.1
LOW= 2.6-3.2
Remission <2.6
Management
Multidisciplinary team
- Medical- shared care
- Specialist RA nurses
- Pharmacists
- Psychology
- Occupational therapy
- Physiotherapy
- Podiatry- patient education is very important
Management
-Early diagnosis is important
-Analgesics and NSAID only useful for:
+Symptoms relief including pain control
-Corticosteroids, DMARDs and biologics
+Slowing or prevention of joint damage
+Preserving and improving functional ability
+Acheiving and maintaining remission
Analgesics and NSAIDs
-Analgesics- adjunct for pain relief
+NSAIDs- analgesic and anti-inflammatory effect, but only provide symptomatic relief
-Use lowest dose possible and withdraw if possible once patient response to DMARD
-Side effects: GI (ulcers); Renal; CV (Na and water retention), increase risk of stroke and MI
Corticosteroids
- Inhibit cytokine release
- Rapid relief of symptoms/ decrease inflammation
- Long term oral steroids associated with long term side effects
- Oral therapy- bridging therapy until respond to DMARD (withdraw slowly)
- Intra-articular injection into target joint
Disease modifying anti-rheumatic drugs
- The sooner the better to prevent damage
- Ideally within 3 months of start of persistent symptoms
- NICE- first line treatment is a combination of DMARDs, unless inappropriate; if so mono therapy
- Regimen, unless C/Iād should contain- methotrexate
Biological response modifiers
- Huge change in management of RA in past decade
- Currently only used if DMARDs fail- NICE
- Specialist supervision
- Expensive
- Balance cost of treatment Vs cost of disability
