PRESENTATION ON RHEUMATOID ARTHRITIS FOR EDUCATION

Presentation on Rheumatoid Arthritis

1. RHEUMATOID ARTHRITIS

2. INTRODUCTION Autoimmune conditions cause the body to produce an inappropriate immune response against its own healthy tissue. Rheumatoid arthritis (RA) is a common, chronic, progressive autoimmune condition that primarily affects the joint and synovium but can also have detrimental effects on organ systems throughout the body.

3. EPIDEMIOLOGY The annual incidence is about 40 individuals per 100,000 Worldwide. Women are twice as likely to develop the disease compared with men. RA can affect children age 16 years or younger; in these patients, the condition is referred to as juvenile RA.

4. ETIOLOGY The specific cause of RA is unknown. Genetic susceptibility. Environmental factors. Role of hormonal regulation.

5. PATHOPHYSIOLOGY

6. CLINICAL PRESENTATION JOINT INVOLVEMENT. Hands, wrists, ankles, and feet most commonly affected, Presence of warmth and swelling with or without pain especially in the smaller joints. Prolonged morning stiffness, often for longer than 30 minutes in duration. 2. EXTRA-ARTICULAR INVOLVEMENT. Fatigue and weakness. Rheumatoid nodules can be found in the joints.

7. DIAGNOSIS Medical History and Physical Examination. Blood test include Rheumatoid factor(RE), and Anti-CCP. Synovial Fluid analysis. Imaging Studies: X-ray, Ultrasound and MRI scans

8. TREATMENT NON-PHARMACOLOGIC TREATMENT Education and self management Physical Therapy and Exercise Occupational Therapy Weight Management Stress Management

9. PHARMACOLOGIC TREATMENT METHOTREXATE It is the Disease-Modifying Anti-rheumatic Drugs (DMARD). It can be taken as monotherapy or in combination with other DMARD. Methotrexate is a structural analogue of folic acid that inhibits dihydrofolate reductase. Dihydrofolate reductase is the enzyme responsible for reducing dihydrofolic acid to folinic acid, the active intracellular metabolite. Through this action, Methotrexate inhibits DNA synthesis and repair and cellular replication. Methotrexate is taken once weekly and is typically given in either tablet form or as a subcutaneous injection. Methotrexate is teratogenic and is therefore contraindicated in pregnancy and breastfeeding.

10. LEFLUNOMIDE Leflunomide, an oral DMARD that inhibits pyrimidine synthesis, can be used as monotherapy or in combination with other DMARDs to treat RA. Leflunomide has been shown to reduce signs and symptoms of RA, inhibit structural damage, and improve physical function. The typical maintenance dose used to treat RA is 20 mg daily; the dose can be decreased to 10 mg daily if patients are unable to tolerate higher doses. Leflunomide should not be used in pregnant or nursing mothers or in patients with severe hepatic impairment.

11. BIOLOGIC DISEASE-MODIFYING ANTIRHEUMATIC DRUGS Biologics agents are genetically engineered protein molecules that have varying mechanisms by which they decrease inflammation. They can be separated into two groups: TNF inhibitor biologics Non-TNF biologics Biologic agents can be used in combination with conventional DMARDs, but multiple biologics should not be used concomitantly due to additive immunosuppressive effects.

12. TNF INHIBITOR BIOLOGICS TNF inhibitors block the pro inflammatory cytokine TNF-α. Elevated levels of TNF-α are found in the synovial fluid of individuals with RA as well as other rheumatologic conditions. Etanercept , golimumab , certolizumab , and infliximab can take several weeks for clinical benefit to be noted and up to 3 months to achieve full clinical benefit. A major limitation to the use of TNF inhibitors is cost, as they are more expensive than conventional DMARDs

13. NON-TNF BIOLOGICS ABATACEPT Abatacept is a selective co-stimulation modulator that inhibits T-cell activation by binding to CD80 and CD86. This binding blocks the interaction between T cells CD28, thus inhibiting the activation of T cells. Activated T cells are found in the synovial fluid of patients with rheumatologic conditions such as RA and are thought to play a role in the disease Abatacept is typically initiated if disease activity persists in patients after conventional DMARD monotherapy and can be an alternative to TNF inhibitors with or without Methotrexate.

14. OTHER DISEASE-MODIFYING ANTIRHEUMATIC DRUGS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS NSAIDs inhibit prostaglandin synthesis and can provide anti inflammatory as well as analgesic effect. However, they do not slow disease progression and should not be used as monotherapy. NSAIDs can provide symptomatic relief of pain and stiffness and can be effective as adjuncts to DMARD therapy in patients with RA.

15. GLUCOCORTICOIDS Glucocorticoid have been used in the treatment of RA for their anti inflammatory and immune-modulating effects. Although these agents have been found to slow the progression of RA, glucocorticoid should not be used as monotherapy in the treatment of RA, particularly due to the potential for serious, long-term adverse effects.

16. REFERENCE Joseph T. DiPiro , Gary C. Yee, L. Michael Posey, Stuart T. Haines, Thomas D. Nolin, Vicki L. Ellingrod ., Pharmacotherapy a pathophysiologic approach.,11 th Edition., page- 1517-1536