Management of
Rheumatoid Arthritis
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1. Morning
stiffness
Morning stiffness in and around the joints, lasting at least 1
hour before maximal improvement at any time inthe disease
course.
2. Arthritis in at
least three
joint Areas*
Soft tissue swelling or fluid observed by a physician, with
swelling at current examination or deformity and a
documented history of swelling.
3.Arthritis of
Swelling of wrist, MCP, or PIP with swelling at current
examination or deformity and a documented history of
swelling.
4. Symmetric
arthritis
Simultaneous involvement of the same joint areas (defined in
2) on both sides of the body (bilateral involvement of PIPs,
MCPs, or MTPs is acceptable without absolute symmetry)
with swelling at current examination or deformity and a
documented history of swelling.
5. Rheumatoid
nodules
Over bony prominences or extensor surfaces, or in periarticular regions
6.Rheumatoid
factor
Detected by a method positive in less than 5% normal
controls at current examination or documented to have been
positive in the past by any assay method.
7. Radiographic
changes
Typical of RA on posteroanterior hand and wrist radiographs
which must include erosions or unequivocal bony
decalcification localized to or most marked adjacent to the
involved joints (osteoarthritis changesalone do not qualify).
hands
*Note: At least four criteria must be fulfilled for classification as RA.
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Autoimmune/Genetic factors?
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Other factors
Silica Dust Exposure
Increased risk for RA in smokers
Infections?-(EBV)
Dietary Factors? red meat
? intake of fruit and oily fish may protect against RA
(Mediterranean diet)
?Interactions between genes and environment
and stochastic factor contributions
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Other nutrient factors
Lower intakes of vitamin C, fruit and
vegetables (high consumption of the
antioxidants cryptoxanthin and zeaxanthin)
increased the risk of inflammatory polyarthritis
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Articular and Peri-articular
Manifestations
 Duration of signs and symptoms at more than 3
months was the strongest predictor of RA
 Duration of signs and symptoms at more than 3
months was the strongest predictor of RA
 Slow, insidious disease onset (70%)
 Intermediate onset (20%)
 Sudden acute onset (10%)
 Complain of pain, stiffness, and swelling of their
peripheral joints
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Clinical Findings
 Examination of the joints reveals tenderness to
palpation, synovial thickening, joint effusion,
redness and warmth
 May show decreased range of motion, ankylosis,
and subluxation
 Upper limb (50%)
multiple joints affected (30%)
hand only (25%)
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Clinical Findings
Symmetrical joints involvement (85%)
Joints most commonly affected areThe proximal interphalangeal (PIP) and
metacarpophalangeal (MCP) joints of the
hands and wrists, followed by
The metatarsophalangeal (MTP) joints of the
feet, ankles, and shoulders.
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Radiograph of the left
hand. Soft tissue
swelling is present
around the MCP joints
and wrist with diffuse
narrowing of
MCP, PIP, and
radiocarpal joint
spaces.
Erosions are seen at
the first CMC joint and
distal ulna.
Periarticular
osteopenia surrounds
all of the articulations.
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Radiograph of the left wrist
reveals soft-tissue swelling
with narrowing about the
radial carpal joint
associated with early
reactive sclerosis involving
the radial articular surface.
There is widening of the
distal radial–ulnar joint and
cysts are present within the
carpal navicular and distal
ulna.
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An MRI of the left wrist of
the same patient multiple
bony erosions in the ulna,
lunate, triquetrum, and
distal radius.
Complete loss of articular
cartilage is with slight
ulnar shift
Exuberant synovial
proliferation with inflamed
synovium is seen to enter
the large erosion within
the distal ulna, illustrating
the extensive synovitis
that is missed on
conventional radiography
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Diffuse swelling of the hand with
polyarthritis of the MCPs, PIPs, and wrists
seen in remitting seronegative symmetric
synovitis with pitting edema
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Extra-Articular
Manifestations
Rheumatoid Nodules
Anemia of chronic
disease,
lymphadenopathy
Vasculitissensorimotor
neuropathy, nail-fold
infarcts, leg ulcers,
purpura, and digital
gangrene
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Treatment of Early Arthritis
Nonsteroidal Anti-Inflammatory Drugs- do not
alter the course of the arthritis and its outcome
GlucocorticoidsDisease-Modifying Antirheumatic Drugs
Methotrexate- favorable risk–benefit ratio, is (as
in established RA) regarded to be the drug of
first choice
hydroxychloroquine or sulfasalazine
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QOL assessment
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Mobility
Self-care
Usual activities
Pain/discomfort
Anxiety/depression
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Specific drugs: Methotrexate
Anti folic acid- inhibition of proliferation of cells
responsible for synovial inflammation
Decreases markers of inflammation, including
the erythrocyte sedimentation rate and c-reactive
protein (CRP)
Adverse Effects-low-dose weekly-7.5 to 10 mg
anorexia, nausea, vomiting, and diarrhea(10%)
Hematologic-leukopenia (3%)
? cirrhosis and liver failure (1/1000)
acute interstitial pneumonitis
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“MTX is currently considered a first-line agent
in the treatment of RA, and the “anchor drug”
for combination therapy with other DMARDs
and biologic agents. It has become the
standard of care and the most widely used
drug in the treatment of RA.”
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Leflunomide
A second choice DMARD to be used after
methotrexate
has a long half-life (2 wks)
dose:20 mg daily
lefl unomide, sulfasalazine, and methotrexate
reduced radiologic progression
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Other Drugs
Antimalarials
Sulfasalazine
Tetracyclines
Gold Salts
D-penicillamine
Azathioprine
Cyclosporine
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