Management of rheumatoid arthritis

An overview of the current approach to the diagnosis and treatment of rheumatoid arthritis

1. Management of Rheumatoid Arthritis Presenter – Dr A E Bassey Supervisor – Dr E O Oguche

2. Outline Introduction Aetiology Pathophysiology Differential diagnoses Management Clinical evaluation Investigation Treatment Medical Surgical Complications Prognosis Current trends Conclusion

3. Introduction RA is the commonest inflammatory arthritis. It is a systemic autoimmune disease that can lead to tremendous disability and reduction in quality of life Early diagnosis and aggressive treatment have been shown to slow down dx progress, diminish complication rate and improve life expectancy

4. Introduction Age peak = 30-50yrs Sex = M:F - 1:3 Race = Caucasian > African Global prevalence = 1-2% Locally, Mean age = 41.4-46.9% M:F = 1:2.4 – 1:6.1

5. Aetiology Unknown Genetic susceptibility HLA-DR4 = <30% in gen. population but in RA population prevalence is 70%

6. Pathophysiology Antigen in synovium (postulated) for which autoantibodies are produced HLA-DR4 in cell surface of APCs present the unidentified antigen to CD4 lymphocytes causing CD4 activation. CD4 activation – B-cell activation – Autoantibodies – RF, Anti-CCP antibodies Memory cell Elaboration of chemokines TNF, IL1, IL6 – chemotaxis of PMNs, macrophages – acute articular synovitis and tenosynovitis, enhanced by Immune complexes Synovitis xtised by vascular proliferation, synoviocyte hyperplasia and subsynovial inflammatory cell infiltration (This is the pannus).

7. Pathophysiology Cartilage damage caused by By proteolytic enzymes, prostaglandins, cytokines Direct invasion by Pannus Tendon damage caused by As for cartilage Bone damage Pannus invasion Osteoclastic resorption Secondary OA

8. Pathophysiology Stages Pre-clinical Synovitis Destruction Deformity

9. Pathophysiology Extra-articular manifestations Rheumatoid nodules Lymphadenopathy Splenomegaly Myopathy Neuropathy Vasculitis Organ affectation

10. Differential Diagnoses Polyarticular OA Gout CPPD disease Ankylosing spondylitis Reactive arthritis

11. Management – clinical evaluation Hx Usually female, 4 th decade, presents with Symmetrical pain and swelling of MCPJ and PIPJ both hands (DIPJ spared), assoc. with morning stiffness lasting >30mins. There may be a preceding hx of longstanding muscle weakness and general feeling of being unwell. Progresses to involve wrist, feet, knees, shoulders Exam Hand MCPJ, PIPJ swollen and tender May be rheumatoid nodules Ext anf flexor tendons are tender, thickened and produce crpitation on passive finger mov’t . May also trigger If advanced – Z-deformity, Swan neck deformity, Boutonniere deformity

12. Management – clinical evaluation

13. Management – clinical evaluation Feet Valgus feet MTPJ subuxation Clawed toes Shoulder Central glenoid erosion Hip Protusio acetabuli C-spine Basilar invagination Atlantoaxial subluxation Subaxial subluxation

14. Management - Investigation Xrays Early: ST swelling, periarticular osteopenia Periarticular erosion Joint space narrowing Deformity USS/MRI Becoming more useful in early dgx by detecting synovitis and early erosions FBC – normocytic, normochromic anaemia . ESR+ CRP are raised RF, Anti-CCP

15. Management - Treatment Multidisciplinary – Rheumatologist, Ortho, PT, Occupational therapist, Orthotist, Social worker Mainstay of treatment is medical Treatment principles Rapid control of inflammation – Pharmacologic Control of pain Physical therapy – maintain muscle tone, overcome stiffness & prevent contractures Short-term orthotic splintage to combat joint instability Surgery - correct deformities, restore joint stability, reconstruction or fusion procedures

16. Management - Treatment Rapid control of inflammation 1 st line – Corticosteroids ± DMARDs (Methotrexate is currently DMARD of choice) 2nd line – Biologic therapy: TNF inhibitors, IL1 inhibitors, T-cell inhibitors, B-cell inhibitors Pain control by NSAIDs – helps improve joint mobility

17. Management - Treatment Rheumatoid nodules: commonest extra-articular manifestation of RA, and pathognomonic of the dx. Seen in only 25% Rx: Steroid injection, if no response or already formed sinus the excision is done Ulnar deviation of MCPJ Rx: If joint preserved – synovectomy + ext tendon centralization. If joint damaged – MCPJ arthroplasty or fusion Boutonniere deformity: attenuation of dorsal capsule of PIPJ and central slip of ext tendon  increased PIP flexion  lateral bands ext tendon sublux volar to axis of PIP rotation pulling it into further flexion and DIP into extension Rx: Splintage if flexible, if fails then imbrication of central slip. Fixed deformity – PIP arthroplasty or fusion

18. Management - Treatment Swan neck deformity: FDS & volar plate attenuation for PIP synovitis  loss of volar support for PIP  Lateral bands sublux dorsal to PIP axis of rotation  PIP pulled into hyperextension Rx – Splintage if flexible, if fails FDS tenodesis Cervical conditions: majority have no neurologic derangement. Spinal fusion if there’s neuro deficit

19. Complications Fixed deformity Infection Vasculitis Amyloidosis

20. Prognosis Poor factors – young age, female, polyarticular, high BMI, smoking, erosions at presentation, high RF, High anti-CCP. Elevated ESR & CRP Following initial synovitis 10% recover 60% run long course 20% have rapid dx 10% be completely disabled

21. Current trends Rapid and aggressive treatment once diagnosis is made Expanding biologic therapy

22. Conclusion RA has no cure, but with proper and timely treatment via a multidisciplinary approach outcomes can be significantly improved

23. THANK YOU

24. References Blom A, Warwick D, Whitehouse M. Apley and Solomon’s System of Orthopaedics & Trauma. 10th Ed. Florida: CRC Press, 2018. Chapter 3: Inflammatory Rheumatic Disorders; p. 65-72. https://www.orthobullets.com/basic-science/9085/rheumatoid-arthritis Adelowo OO, Ojo O, Oduenyi I, Okwara CC. Rheumatoid arthritis among Nigerians: the first 200 patients from a rheumatology clinic. Clin Rheumatol. 2010 Jun;29(6):593-7. Ohagwu K, Olaosebikan H, Oba R, Adelowo O. Pattern of rheumatoid arthritis in Nigeria; Study of patients from a Teaching Hospital. Afr J Rheumatol. 2017:5(2)