Rheumatoid arthritis

dr Bipul Borthakur

1. RHEUMATOID ARTHRITIS Dr BIPUL BORTHAKUR PROF Orthopaedics, SILCHAR ,ASSAM,INDIA

2. LEARNING OBJECTIVE DEFINITION EPIDEMIOLOGY PATHOPHYSIOLOGY CLINICAL FEATURES DIAGNOSIS TREATMENT PHYSIOTHERAPICAL IMPORTANCE

3. DEFINITION It is a chronic inflammatory systemic autoimmune disease characterized by destructive and proliferative changes in synovial membrane , periarticular structures , skeletal muscles , and perineural sheaths Joints are destroyed , ankylosed & deformed Associated with extraarticular manifestations ( involvement of other organs )

4. Joints affected Joints most frequently affected in RA include: Proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints of the hands Wrist joint Shoulder joint Elbow joint Knee joint Ankle joint Metatarsophalangeal (MTP) joints of the feet Distal interphalangeal (DIP) joints are typically spared

5. Extra-articular manifestations Secondary Sjögren’s syndrome Heart Pericarditis Myocarditis Endocarditis Valvular fibrosis Liver Enzyme abnormalities due to drug reactions or Sjögren’s syndrome Blood / blood vessels Mild anemia Vasculitis Felty’s syndrome

6. Eyes Keratoconjunctivitis Sicca syndrome Scleritis Episcleritis Keratitis corneal ulceration Choroiditis Retinal vacuities Episcleral nodules Lungs Pleuritis ± pleural effusions Pulmonary nodules Interstitial pulmonary fibrosis Skin Rheumatoid nodules Vasculitis Interstitial granulomatous dermatitis

7. EPIDEMIOLOGY Prevalence of RA is approximately 0.8 – 1.0 % in Europe and the Indian subcontinent Female : Male = 3 : 1 Prevalence is lower in South – east Asia ( 0.4 % ) Highest prevalence in the world is in Pima Indians ( 5 % )

8. PATHOPHYSIOLOGY In RA , the immune system’s antibodies attack the synovium which is the smooth lining of a joint Pain & inflammation in joint Synovial thickening occurs - Cartilage destruction Tendons & Ligaments - weaken and stretch Joint eventually loses it’s shape & configuration

9. AUTOIMMUNITY Defined as the failure of an organism in recognizing its own constituent parts as NON SELF , which allows an immune response against its own cells and tissues Any disease that results from such an aberrant immune response is termed an autoimmune disease

10. RISK FACTORS AGE > 60 YRS FEMALE SPECIFIC GENETIC TRAITS OBESITY SMOKING

11. GENETICS PRODUCTS OF HLA REGION OR CLASS 2 GENES OF MHC CONTROL BOTH IMMUNE RESPONSES AND SUSCEPTIBILITY TO RA HLA DRB4 POSITIVE PATIENTS – DEVELOP EROSIVE DISABLING DISEASE ONLY 1/3 – HLA DRB4 + ve

12. STAGES OF RA

13. CLINICAL FEATURES

14. Clinical spectrum

15. Poor prognostic factors Extra-articular signs and symptoms (e.g. Cutaneous ulcers, vasculitic rash, neuropathy, scleritis, subcutaneous nodules) Female gender Shared epitopes Poor functional status Involvement of multiple joints Early radiographic evidence of erosive changes Advanced age at onset of disease High RF titer

16. Poor prognostic factors Sustained elevation of acute-phase reactants (e.g. ESR) Low socioeconomic status/educational level High titre CCP antibody Smoking

17. DIAGNOSIS HISTORY & PHYSICAL EXAMINATION – SWELLING, FUNCTIONAL LIMITATIONS & DEFORMITY BLOOD TESTS ERYTHROCYTE SEDIMENTATION RATE [ESR] & CRP – to assess inflammation level in body ANEMIA RHEUMATOID FACTOR – associated with RA

18. RHEUMATOID FACTOR Antibody reactive against Fc fragment of IgG Not specific for RA: chronic infections, cirrhosis, malignancies, other rheumatic diseases. ANTI- CCP Antibodies to Cyclic Citrullinated Peptides Anti-CCP has high diagnostic specificity for RA (98%)

19. XRAYS GENERALLY HAND & FOOT XRAYS ARE TAKEN REVEALS SOFT TISSUE SWELLING, JOINT EROSIONS, OSTEOPOROSIS OF ADJACENT JOINTS – BONE CYST FORMATION & NARROWING OF JOINT SPACE

20. 1987 Revised ACR Classification of RA Criterion Definition Morning stiffness Lasting ≥ 1 hour before maximal improvement Arthritis ≥ 3 joints Clinical evidence of soft tissue swelling or fluid in right or left PIP, MCP, wrist, elbow, knee, ankle, and MTP joints. Arthritis of hand joints 1 or more swollen areas in wrist, MCP, or PIP joint Symmetric arthritis Simultaneous involvement of same joint areas on both sides of body (bilateral involvement of PIP, MCP, or MTP joints is acceptable without absolute symmetry) Rheumatoid nodules Clinical evidence of subcutaneous nodules over bony prominences, extensor surfaces, or in juxta articular regions Serum RF Elevated rheumatoid factor measured by any method in which positive results are found in < 5% of normal subjects Radiographic changes Erosions or unequivocal body decalcification localized in or adjacent to involved joints on posteroanterior hand and wrist radiographs

21. 2010 ACR/EULAR classification criteria for RA A score of ≥6/10 is needed to classify RA Joint involvement Score 1 large joint 2-10 large joints 1 1-3 small joints (with or without involvement of large joints) 2 4-10 small joints (with or without involvement of large joints) 3 >10 joints (at least 1 small joint) 5 Serology (at least 1 test result is needed) Score Negative RF and negative ACPA Low-positive RF or low-positive ACPA 2 High-positive RF or high-positive ACPA 3

22. 2010 ACR/EULAR classification criteria for RA A score of ≥6/10 is needed to classify RA Acute-phase reactants (at least 1 test result is needed) Score Normal CRP and normal ESR Abnormal CRP or abnormal ESR 1 Duration of symptoms Score <6weeks >6 weeks 1

23. Principles of Therapy Early initiation of therapy Treat to target Combine medications to achieve remission

24. RA: Current Pharmacologic Options Symptomatic treatment of RA[ to reduce inflammation & pain] NSAIDs COX-2 inhibitors Analgesics DMARDs (Disease-modifying antirheumatic drugs) - impact the signs, symptoms, and disease progression of RA, as well as improve the quality of life and functionality of the patient. Corticosteroids have anti-inflammatory and immunoregulatory activity, but nominal disease-modifying capability.

25. RA: Disease Modifying therapies Traditional DMARDs Methotrexate Leflunomide Sulfasalazine Hydroxychloroquine Azathioprine Biological DMARDS TNF antagonists Etanercept Adalimumab Infliximab Certolisumab Golimumab Abatacept cyclosporine Rituximab Tocilizumab Tofacitinib

26. Methotrexate Most effective single DMARD (used as baseline therapy in most patients.) Typical dose is 15 mg/week.

27. PHYSIOTHERAPICAL IMPORTANCE IN RA PATIENT EDUCATION PSYCHO-SOCIAL INTERVENTIONS LIFESTYLE MODIFICATIONS NUTRITIONAL & DIETARY INTERVENTIONS

28. PATIENT EDUCATION Explaining the nature of the illness & how it occurs Treatment options available with pros & cons of each treatment Importance of blood tests and why some of the blood tests need to be done periodically during the treatment Importance of compliance with treatment Role of diet, exercise and fitness Education of the spouse or the care-giver is equally important

29. Psycho-social interventions Educational programmes Coping skills training Cognitive behavioural therapy

30. LIFESTYLE MODIFICATIONS REST EXERCISE – include muscle strengthening exercises [like isometric , isotonic, isokinetic] – to preserve the joint function Regular aerobic exercise [walking, swimming , cycling] – improve muscle function, joint stability, aerobic capacity WEIGHT REDUCTION- reduces the inflammatory markers- thereby decreasing the stress upon the joints involved- preventing joint destruction CARDIOVASCULAR RISK REDUCTION

31. NUTRITIONAL AND DIETARY INTERVENTIONS BALANCED DIET – less carbohydrates, more natural vegetables & fruits, adequate proteins, healthy fats – recommended to RA patients

32. NUTRITIONAL AND DIETARY INTERVENTIONS INCREASES RISK OF RA Red meat Coffee Low vitamin-C intake Obesity DECREASES RISK OF RA Alcohol – may decrease Tea Vitamin –D [may or maynot ]

33.     गुरूनहत्वा हि महानुभावान् श्रेयो भोक्तुं भैक्ष्यमपीह लोके | हत्वार्थकामांस्तु गुरूनिहैव भुञ्जीय भोगान् रुधिरप्रदिग्धान् || 5|| gurūnahatvā hi mahānubhāvān śhreyo bhoktuṁ bhaikṣhyamapīha loke hatvārtha-kāmāṁstu gurūnihaiva bhuñjīya bhogān rudhira-pradigdhān measning - It would be better to live in this world by begging, than to enjoy life by killing these noble elders, who are my teachers. If we kill them, the wealth and pleasures we enjoy will be tainted with blood.