Download - Inflamatory arthritis
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INFLAMMATORY ARTHRITISDr. Angelo Smith M.D
WHPL
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Rheumatoid Arthritis
• Definition – symmetric inflammatory joint condition characterized by pannus formation, joint erosion, and systemic inflammation
• Most common inflammatory arthritis, 1% of the population, 2:1 female to male ratio, peak incidence between ages 40 to 60
• Onset usually insidious over months
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• Genetic factors clearly important – HLA “shared epitope” is strongest risk factor, but also non-HLA genes such as PTPN22, STAT4, TNFAIP3
• Environmental factors – cigarette smoking increases both risk of disease and severity of disease, also risk in coal miners (Kaplan syndrome)
Predisposition
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Longitudinal Course of RA
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Joints Commonly Involved
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Pathogenesis
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• History and physical are majority of diagnosis – Symmetric pain and swelling in small joints of
hands, wrists, feet, ankles most common, followed by knees, elbows, shoulders
– Morning stiffness – better with activity– Constitutional symptoms – fatigue, even weight
loss are common, but fever is VERY RARE– Steady, progressive, additive onset is by far most
common presentation
Diagnosis
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Patterns of OnsetInsidious 55%-65% Joint stiffness, swelling,
pain, fatigue
Acute 8%-15% Fever, weight loss, fatigue, joint abnormalities present but often not prominent
Intermediate 15%-20% Systemic complaints morenoticeable than insidious onset
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Extra-articular features
• Rheumatoid nodules• Pleural effusions• Atherosclerosis (new, but probably testable)• Scleritis• Rheumatoid vasculitis (rare)• Felty’s syndrome (neutropenia, splenomegaly,
recurrent infection)
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• High ESR or CRP common but not required• Rheumatoid factor positive in about 50%– RF usually indicates more severe disease, greater likelihood
of extra-articular manifestations• Anti-CCP antibodies - relatively new (but very clinically
useful and testable!!)– Found in about 50% of patients without much overlap with
rheumatoid factor– Highly sensitive – positive test almost always indicates
disease (>90% specificity for RA, even in mixed autoimmune cohorts)
Laboratory
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• Classical findings of inflammatory arthritis:– Periarticular joint erosions– Periarticular osteopenia– Symmetric joint space narrowing
• Note that each of these is the opposite of OA!! – (erosions instead of spurs, osteopenia instead of
sclerosis, and symmetric instead of asymmetric joint narrowing)
X-ray
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Joint-space narrowing and erosion are seen in up to two thirds of patients within the first 2 to 5 years of disease
Early Radiographic Progression
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Rheumatoid arthritis
erosions on X-ray
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RHEUM. ARTHRITIS - Late changes
ADVANCED JOINT CHANGES:
Joint destruction Pain Deformity Instability
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• Early treatment with a disease modifying drug is standard of care
• Non-disease modifying– NSAIDs– Prednisone
• Disease modifying– Methotrexate – most common first line, usually around 15-
20mg/week with daily folate 1mg/day– Sulfasalazine, leflunomide also effective– Biological agents such as TNF-alpha blockers, abatacept,
rituximab, and tocilizumab are all second or third line
Treatment
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• Goal of treatment is clinical remission if possible
• Control of disease prevents bone erosions and subsequent deformity and loss of function
• All disease modifying drugs are immunosuppressive, non-biologics have risk of GI intolerance and hair loss, TNF blockers are associated with re-activation of tuberculosis and rarely an MS-like disease, other biologics are not currently in wide use
Treatment