Ra conference may 2017

1. Rheumatoid Arthritis (RA)
Karina Vilá, MD
Rheumatologist

2. Definition
Epidemiology
Risk Factors
Pathophysiology
Signs and symptoms including extra-articular manifestations
Complications
Diagnosis
Treatment

3. Definition
• A chronic, systemic,
inflammatory
autoimmune disease
• Most common form of
inflammatory disease
that affects diarthrodial
joints, causing a painful
swelling
• It can lead to bone
erosion and irreversible
joint deformity and
disability
Epidemiology
• Female:male – 3:1
• Age of onset – 35 to
50 years old
• Prevalence – 1 per
100 patients
• Incidence – 0.5 per
1000 persons per
year in the U.S.

4. AgeFamily
GenderImmune system
Gender
Women are more
likely to develop RA
than men are.
Age
RA can occur at any
age, but it most
commonly begins
between the ages of
40 and 60.
Family History
Cases of RA in the
family may increase
the risk of the
disease
Immune System
RA occurs when the
immune system
mistakenly attacks
body’s tissues

5. • The pathogenesis of RA is not completely understood. An external trigger (eg, cigarette smoking,
infection, or trauma) that triggers an autoimmune reaction, leading to synovial hypertrophy and chronic
joint inflammation along with the potential for extra-articular manifestations, is theorized to occur in
genetically susceptible individuals.
• Synovial cell hyperplasia and endothelial cell activation are early events in the pathologic process that
progresses to uncontrolled inflammation and consequent cartilage and bone destruction. Genetic
factors and immune system abnormalities contribute to disease propagation.
• CD4 T cells, mononuclear phagocytes, fibroblasts, osteoclasts, and neutrophils play major cellular roles
in the pathophysiology of RA, whereas B cells produce autoantibodies (ie, RFs). Abnormal production of
numerous cytokines, chemokines, and other inflammatory mediators (eg, tumor necrosis factor alpha
[TNF-a], interleukin [IL]-1, IL-6, IL-8, transforming growth factor beta [TGF-ß], fibroblast growth factor
[FGF], and platelet-derived growth factor [PDGF]) has been demonstrated in patients with RA.
• Ultimately, inflammation and exuberant proliferation of the synovium (ie, pannus) leads to destruction
of various tissues, including cartilage, bone, tendons, ligaments, and blood vessels. Although the
articular structures are the primary sites involved by RA, other tissues are also affected.

6. Polyarticular
(>4 joints)
Systemic
• Swelling and tenderness of
small peripheral joints
(metacarpophalangeal (MCP)
joints, proximal
interphalangeal (PIP) joints of
the fingers, interphalangeal
joints of the thumbs,
metatarsophalangeal (MTP)
joints and wrists)
• Larger peripheral joints may
become affected - ankles,
knees, elbows and shoulders
• Firm bumps of tissue under
the skin (nodules)
• Fever, weight loss
or fatigue
• Morning stiffness
that may last for
hours ≥1 hour
• Limited range of
motion

8. • Clinical evaluations should be done periodically as a
response to new symptoms.
• Monitor the patient for the conditions below and if any
co-morbidities arise refer to a specialist.
• ACR
• Uveitis/scleritis
• Lung involvement
• Renal
• Vasculitis
• Perciarditis
Episcleritis Vasculitis
Perciarditis

9. Osteoporosis Heart problems
Carpal tunnel syndrome Lung disease
• RA along with some
medications can increase the
risk of osteoporosis
•RA can increase the risk of
hardened and blocked arteries,
as well as inflammation of the
sac that encloses the heart
• If RA affects the wrists, the
inflammation can compress the
nerve that serves most on hand
and fingers
• RA have an increased risk of
inflammation and scarring of
the lung tissues, which can lead
to progressive shortness of
breath

10. Systemic connective tissue disorders
• Systemic lupus erythematosus (SLE)
• Mixed connective tissue disease (MCTD)
• Sjögren’s syndrome
Seronegative spondyloarthropathies
• Psoriatic arthritis (PsA)
• Ankylosing spondylitis (AS)
• Reactive arthritis
Infectious asthritis
• Lyme-associated arthritis
• Hepatitis C-associated arthritis
• Parvovirus B19-associated arthritis

11. • Revised ACR/EULAR 2010 classification criteria for RA
Source: American College of Rheumatology, Celltrion, EULAR
The new 2010
classification system
redefines the current
RA paradigm by
focusing on the
features at earlier
disease stages that
are associated with
persistent and
erosive disease,
rather than defining
the disease by its
late-stage features.

12. • CR, a 40 year old woman noted bilateral hand discomfort for 4
months, followed 2 month later by bilateral foot pain when
walking.
• Self medicated with ibuprofen decided to visit her family
physician:
– Complains of stiffness after awakening (2 hours), which
improves gradually through the day
– Has difficulty turning faucets
– Sleep disturbed by pain

13. • Normal physical examination, except for:
– 3 swollen proximal interphalangeal (PIP) joints on the right hand and 4
on the left
– Feet tender to palpation without obvious synovitis
– Compression of metatarsophalangeal (MTP joints causes pain (positive
squeeze test)

14. • Laboratory values:
– ESR: Elevated
– CRP: Normal
– RF: Negative
– Anti-CCP: Positive
– ALT/AST: Normal
• X-ray of hands, feet and wrists
– Soft tissue swelling most apparent around PIP and MCP joints in the index and middle
fingers
Provisional Diagnosis
?

15. In a survey of 168 RA patients, there was a
median delay of 12 weeks before a patient
was assessed in primary care
A key reason RA patients are seen late by
rheumatologists is that patients delay talking
about symptoms with their PCP
Early identification of RA can improve the
long term outcome of the disease

16. 3
2
1
Steps
Refer
•Direct the patient to the
appropriate specialist
•Relay important patient
assessment information
Identify
•Identify the signs and
symptoms of RA
•Perform a clinical
examination
Evaluate
•Order baseline and diagnostic
lab/imaging tests
•Provide a provisional
diagnosis

17. • Rheumatoid arthritis can be difficult to diagnose in its early stages because
the early signs and symptoms mimic those of many other diseases.
Identify:
•Perform a physical exam to
check joints for swelling, redness
and warmth, reflexes and muscle
strength.
Evaluate:
• Order X-rays to track the progression of
RA in joints over time.
•Order ESR or sed rate test. People with RA
tend to have an elevated erythrocyte
sedimentation rate, which indicates
inflammatory process in the body.
•Order blood tests looking for RA factor and
anti-cyclic citrullinated peptide (anti-CCP)
antibodies.
•Perform preliminary diagnosis.

18. • There is no cure for RA.
• Medications can reduce
inflammation in joints in
order to relieve pain and
prevent or slow joint damage.
• Occupational and physical
therapy can teach how to
protect joints.
• Surgery may be necessary if
joints are severely damaged
by RA.

19. • Many drugs used to treat RA have potentially serious side effects.
NSAIDs
•Non-steroidal anti-
inflammatory drugs
relieve pain and reduce
inflammation.
•Side effects may include
ringing in 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.
•The goal is gradually
tapering off the
medication.
Disease-modifying anti-
rheumatic drugs
(DMARDs)
• Slow the progression of RA
and save the joints and other
tissues from permanent
damage.
• Include methotrexate,
hydroxychloroquine
(Plaquenil)
• Side effects vary but may
include liver damage, bone
marrow suppression and
severe lung infections.

20. Immunosuppressants
• Examples include
azathioprine (Imuran)
•Can increase susceptibility to
infection.
TNF-alpha inhibitors
• Tumor necrosis factor-alpha is an
inflammatory substance produced
by the 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
nausea, diarrhea, hair loss and an
increased risk of serious
infections.
Other drugs
•Target a variety of processes
involved with inflammation
in the body.
•Include anakinra (Kineret),
abatacept (Orencia),
rituximab (Rituxan),
tocilizumab (Actemra) and
tofacitinib (Xeljanz).
•Side effects vary but may
include itching, abdominal
pain, headache, runny nose
or sore throat.

21. • Education
• Physical therapies /exercises
• Surgery: May help restore the ability to use joints, reduce pain and correct
deformities.
Total joint
replacement: Surgeon
removes the damaged
parts of the joint and
inserts a prosthesis
made of metal and
plastic.
Tendon repair:
Inflammation and joint
damage may cause
tendons around the
joint to loosen or
rupture. Surgeon may
be able to repair the
tendons around the
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.
1 2 3

22. • Physiotherapy treatment is important in helping patients with RA manage
their disease.
• In conjunction with occupational therapists, physiotherapists can educate
patients in:
Performance of
therapeutic
exercises
Use of
assistive
devices
Joint
protection
strategies

23. • Rest and splinting, using compressive gloves, assistive
devices, and adaptive equipment, have beneficial effects in
managing RA symptoms and deformities.

24. Rest
The joints should be put into rest at a
functional position during the acute
stage of the disease: shoulder joint in
45⁰ abduction, both wrist joints in
20⁰ to 30⁰ dorsal flexion, fingers
slightly in flexion, hips at 45⁰
abduction without any flexion, knees
totally extended, and feet in a
neutral position.
Splinting
Orthosis and splinting are used to
diminish pain and inflammation, to
prevent development of deformities,
to prevent joint stress, to support
joints, and to decrease joint stiffness.
Various reports have shown benefits
of wrist splints in controlling
pain/inflammation and increases
hand grip strength by 20% to 25%.

25. • Patients have reported reduced joint swelling and increased well-being
however, there is no positive evidence regarding improved grip strength or
hand functions from using gloves.
• Gentle compression is beneficial because of the containment of joint
swelling and subsequent decrease of pain.

26. Examples
Loading over the hip joint may be reduced by
50% by holding a cane
Elevated toilet seats, widened gripping
handles, etc. might facilitate the daily life
Assistive Devices
Reduce functional deficits, diminish pain, and keep patients’ independence and self-efficiency
Occupational Therapy
Improves functional ability in patients with RA
Have beneficial effects on joint protection and
energy conservation in arthritic patients

27. Massage
Therapy
Improves
flexibility
Improves
general well
being
Diminish
swelling of
inflamed
joints
Decreases
stress
hormone
levels
Effective on
depression,
mood and
pain
Enhances
connection
with other
treatment
Dhondt and colleagues have reported that pain thresholds both at the massage site and at the
knee and ankle have decreased after applying oscillatory manual massage to the intervertebral
paraspinal region. This leads to the question of whether there are some changes in peripheral
nociceptive perception and central information in RA.

28. • Muscle weakness in patients with RA may occur because of immobilization
or reduction in activities of daily living.
• Maintenance of normal muscle strength is important not only for physical
function but also for stabilization of the joints and prevention of traumatic
injuries.

29. Whether the involvement of the joints is local or systemic
Stage of the disease
Age of the patient
Compliance of the patient with the therapy
ROM exercises, stretching, strengthening, aerobic
conditioning exercises, and routine daily activities may be
used as components of exercise therapy

30. Swimming,
walking, and
cycling with
adequate
resting periods
increase
muscle
endurance and
aerobic
capacity
Chronic stage
Should avoid
activities such
as climbing
stairs or weight
lifting
Active arthritis
Isometric
exercises
provide
adequate
muscle tone.
Moderate
contractures
should be held
for 6 seconds
and repeated
5-10 times
each day.
Acute arthritis

31. • In patients with RA, sociopsychological factors affecting the disease process
such as poor social relations, disturbance of communication with the
environment, and unhappiness and depression at work are commonly
encountered.
• All clinics that deal with the treatment of RA should provide education and
information to their patients about their condition and the various physical
therapy and rehabilitative options that are available to improve their quality
of life.

32. Improve our patient quality of life
Final Goal:
Early
Diagnosis
Prevent
irreversible
joint damage
Diminish
long term
complications
Improve outcome
and patient
functionality