Rheumatoid arthritis
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Prof. Kuryata O.V.
Dnipropetrovsk Medical Academy
Department of internal medicine 2 and
phtisiology
Rheumatoid arthritis
chronic systemic disease of connective tissue
with progressive symmetrical erosive and
destructive lesions mainly peripheral joints and
characteristic extra-articular manifestations.
Statement 00456. Rheumatoid arthritis
Rheumatoid arthritis
is the most common form of inflammatory joint
disease and affects about 1% of the population.
The annual incidence is about 0.02%.
RA patients comprise 15-20% of the total
population of people with disabilities.
Statement 00456. Rheumatoid arthritis
RA stages
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early (asymptomatic) stage is characterized by vascular and cell
activation ;
advanced (fast development of chronic inflammation) stage
shows disruption of angiogenesis, activation of endothelium,
cell migration, infiltration of synovial tissue by activated CD4+
T cells , formation of rheumatoid factor or other auto-antibodies,
immune complexes. Synthesis of "pro-inflammatory" cytokines
, prostaglandins, metalloproteinases , collagenase.
Late stage is characterized by somatic mutations and defects in
apoptosis of synovial cells
Statement 00456. Rheumatoid arthritis
Stages of rheumatoid arthritis
Synovial
inflammation
RF
Плазматическая
клетка
Синовия
Th2
Макрофаг
Th0
IFN-
IL-12
B cell
Destruction
joints
IL-4
IL-10
IL-4
IL-6
IL-10
Interferon-
CD4 + T cell
CD11
CD69
OPGL
CD69CD11
Остеокласт
Фибробласт
Хондроцит
Продукция металлопротеаз и
др. Эффекторных молекул
Миграция ПМЯЛ
Эрозии кости и хряща
Loss of function
TNF-
IL-1
IL-6
Symmetrical swelling of the proximal interphalangeal and
metacarpophalangeal joints is a classic variant of the onset of
rheumatoid arthritis. Archive of the department.
Boutonniere deformation of 4th and 5th fingers with ulnar deviation of the fingers
on the right hand
The archive of the department
Assessment of joint function
The archive of the department
Extra-articular manifestations of RA
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1 - General
fever
lymphadenopathy
Weight loss
weakness
2 - Skin
palmar erythema
subcutaneous nodules
vasculitis
3 - Eye
episcleritis
scleritis
Nodules on the choroid and retina
4 - Histopathological
Felty's syndrome
Syndrome of large granular
lymphocytes
lymphoma
5 - Lung
pleurisy
nodules
interstitial fibrosis
obliterating bronchiolitis
6 - Cardiovascular
pericarditis
myocarditis
vasculitis of the coronary
vessels
nodules on the valves
7 - neuromuscular
pinched nerves
peripheral neuropathy
multiple mononevrit
8 - Other
Sjogren syndrome
amyloidosis
Adapted from Perederiy V.G, Tkach S.M.
Internal Medicine Essentials. Vol. 2.
Clinical suspicion of RA
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The presence of at least 3 swollen joints
The involvement of metacarpophalangeal and
metatarsophalangeal joints
A positive test is "compression"
Morning stiffness for at least 30 minutes.
Erythrocyte sedimentation rate of 25 mm / h
Statement 00456. Rheumatoid arthritis
Adverse prognostic features of RA
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Onset of the disease at a young age
High titers of RF
Increased erythrocyte sedimentation rate
Swelling of the joints for more than 20
Extra-articular manifestations of RA
The presence of anti-CCP-AT
Statement 00456. Rheumatoid arthritis
The goals of treatment of RA
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Reducing pain and stiffness
Achieving control of inflammation
Saving a patient's ability to perform everyday
functions
Prevention of joint destruction
Achieving remission
The algorithm of the management of RA
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Early diagnosis of RA
Appointment fast efficient PSU (individually)
The combination of BP, NSAIDs, corticosteroids (if
necessary)
Educating the patient
Regular monitoring of the disease and the side effects
of therapy
Adjustment of therapy (drug dose)
Radiography (MRI) of the hands and feet at least 1
time in 2 years
Timely application of surgical treatments
Systemic drug treatment
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NSAIDs
Disease-modifying drugs
Steroids
Biological drugs
Disease-modifying drugs
Drug
Time of the development
of the effect
Dosage
Hydroxychlorochine
2-6 months
200 mg/day
Sulfasalazine
1-2 months
1000 mg 2-3 times per day
Methotrexate
1-2 months
7.5-20 mg/week ID or IM
Leflunomide
4-12 weeks
10-20 mg/day
Gold
3-6 months
25-50 mg every 2-4
weeks, IM 3 mg bid per os
Cyclosporine А
2-4 months
2.5-4 mg/kg/day
Adapted from Perederiy V.G, Tkach S.M. Internal Medicine Essentials. Vol. 2.
NSAIDs
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Assigned to all patients with active RA
Have analgesic and anti-inflammatory effects
Evaluating the effectiveness of the drug in 1-2 weeks.
Do not alter the course of the disease
Do not prevent joint destruction
Combination of two or more NSAIDs increases the
risk of side effects
NB!
The most important requirement for the
treatment of RA is an early start to the basic
treatment, immediately after the diagnosis,
preferably not later than 3 months. from the
onset.
Indications for the use of
systemic corticosteroids.
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"Bridge therapy" to get the effect of basic
drugs
Ineffectiveness or intolerance to NSAIDs and
basic drugs
The presence of vasculitis and vistseritov
Pseudosepticus version of RA
Still's syndrome and Felty syndrome
RA treatment algorhythm, based on EULAR 2010
recommendations
Phase І
МТХ + TNF inhibitor
Adverse prognostic factors
Clinical diagnosis of RA
no
Start MTX
yes
Contraindications to MTX?
±
Short course of steroids in
high or low doses
±
Start from leflunomide,
sulfasalazine or gold
The goal of treatment after
3-6 months
Not achieved
Go to phase II
Smolen J.S. et al., Ann Rheum Dis, 2010;69:964-975
Achieved
Continue
treatment
RA treatment algorhythm, based on EULAR 2010
recommendations
Phase ІІ
No effect or side effects from treatment in phase
I
да
Adverse prognostic factors (positive RF/antiCCP, high activity index, early development of
bone erosions)
Add biological agen (TNF
inhibitor)
Not achieved
The goal of the treatment
after 3-6 months
Not achieved
Go to phase III
Smolen J.S. et al., Ann Rheum Dis, 2010;69:964-975
нет
Start other drug-modifying drug:
Leflunomide, sulfasalazine, MTX,
gold +/- steroids
The goal of the treatment
after 3-6 months
Achieved
Continue
treatment
Criteria for Quality of Care
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Morning stiffness is not perevshuye 15 min.
No weakness.
No pain in joint
There is no pain on palpation or joints of hands.
No soft tissue swelling around the joints or tendon sheaths.
ESR less than 30 mm / hr in women and 20 mm / h with
her ​husband.
In the presence of 5 or more criteria suggest clinical remission
of RA in the presence of symptoms:
- Active vasculitis
- pericarditis
- pleurisy
- myositis
Questions:
1. The main pathophysiological stages of rheumatoid arthritis
2. Diagnostic criteria of rheumatoid arthritis.
3. Drug-modifying treatment of rheumatoid arthritis.
In case of any questions on the lectures you can contact the lecturer via
email:
dsma.internalmedicine2.eng@gmail.com
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