Rheumatoid arthritis ppt By Shaista Sumayya

Rheumatoid arthritis (RA) is a chronic, progressive inflammatory disorder of unknown etiology characterized by polyarticular symmetric joint involvement and systemic manifestations.

1. RHEUMATOID ARTHRITIS PRESENTATION BY: SHAISTA SUMAYYA PHARM D SULTAN UL ULOOM COLLEGE OF PHARMACY, HYDERABAD GUIDED BY : DR. S.P.SRINIVAS NAYAK, ASSISTANT PROFESSOR, SUCP, HYD

2. DEFINITION Rheumatoid arthritis (RA) is a chronic, progressive inflammatory disorder of unknown etiology characterized by polyarticular symmetric joint involvement and systemic manifestations.

3. PATHOPHYSIOLOGY

4. CLINICAL PRESENTATION:

5. RISK FACTORS Factors that may increase your risk of rheumatoid arthritis include: Gender .  Women are more likely than men to develop rheumatoid arthritis. Age .  Rheumatoid arthritis can occur at any age, but it most commonly begins in middle age. Family history .  If a member of your family has rheumatoid arthritis, you may have an increased risk of the disease. Smoking .  Cigarette smoking increases your risk of developing rheumatoid arthritis, particularly if you have a genetic predisposition for developing the disease. Smoking also appears to be associated with greater disease severity. Environmental exposures .  Although poorly understood, some exposures such as asbestos or silica may increase the risk of developing rheumatoid arthritis. Emergency workers exposed to dust from the collapse of the World Trade Center are at higher risk of autoimmune diseases such as rheumatoid arthritis. Obesity .  People — especially women age 55 and younger — who are overweight or obese appear to be at a somewhat higher risk of developing rheumatoid arthritis.

6. EULAR RA CLASSIFICATION CRITERIA

7. INVESTIGATIONS

8. TREATMENT NON PHARMACOLOGICAL : Diet Exercise Stress reduction SURGERY : Synovectomy Arthroscopic surgery Osteotomy Arthroplasty Arthrodesis

9. PHARMACOLOGICAL

10. MEDICATIONS

11. How to differentiate between RA and Ankylosing spondylitis Rheumatoid arthritis Most common in females (35-50yrs) Pain in knuckles, hands, small joints – deformity occurs if therapy is not given CSR, CRP elevated Positive rheumatoid factor Positive anti citrullinated antibody Ankylosing spndylitis Young males(20-40yrs) Patient complaints of backache in the morning Sacro - ileac joint inflammation Buttock pain Bamboo spine Pain at rest – goes away on exercising HLA B27 positive

12. Management: Before start of therapy : CBC Sr creatinine – should be normal LFT – SGOT, SGPT should be normal Viral markers Chest x ray – ask history of TB Rheumatoid factor ESR/CRP After start of therapy : Monitor CBC, serum creatinine, LFT, ESR every 3 months

13. DRUG OF CHOICE FOR RA METHOTREXATE DOSE : 10mg/week – 25mg/week Start with 10mg/week MTX shows response after 6-12 weeks Patient needs to report after 2-4 weeks with LFT If patient has tolerated the dose then increase dose @5mg/week upto 25mg/week DECIDING THE DOSE : based on Swollen joints Tender joints Erythema and difficulty in movement

14. FORM OF THERAPY Below 15mg/ wk – oral Above 15mg/ wk – subcutaneous preferred Intrathecal for single joint involvement – usually given in cancer HOW LONG TO GIVE THE THERAPY? 3-5 yrs minimum duration of therapy Patients with response to MTX cures with more frequency ADR OF MTX : GI (stomatitis, nausea/vomiting, diarrhea ), myelosuppression (thrombocytopenia, leukopenia), hepatic (elevated enzymes, rarely cirrhosis), pulmonary (fibrosis, pneumonitis), rash

15. COMBINATION THERAPY Given when there is active disease even when MTX is ≥15mg/ wk for 8-12 weeks TRIPLE THERAPY : MTX+ sulfasalazine(1-2g/day)- start with 500mg/day + hydroxychloroquine (200-400mg/day) Given to patients who didn’t respond to MTX alone OR Leflunomide (100mg daily for 3 days then 10-20mg daily)+ sulfasalazine+hydroxychloroquine Leflunomide stays in circulation for upto 2yrs even after stoppage of therapy Teratogenic drug . Hence should be given to patients who are above 40yrs or use chelating agents – 11 day course with cholestyramine Monitor BP and peripheral neuropathy

16. SECOND CHOICE OF DRUG

17. IMPORTANT POINTS REGARDING BIOLOGICS Biologics always given in combination with MTX in RA Increase the risk of infections Screen for latent TB and hepatitis B before therapy There should be no infections before, while or after starting the therapy Patient should be asked to report slightest infection Vaccinate for influenza If patient already has an infection, treat the infection before starting therapy Given for a short course of 3-9 months High cost

18. ANEMIA IN RA RA can cause anemia- anemia of chronic disease If MTX is given, give folic acid to manage anemia If MTX is causing Hb drop >1-2g/dl – discontinue MTX HEPATITIS IN RA : Hydroxychloroquine + sulfasalazine Donot give biologics RENAL DYSFUNCTION : If sr. creatinine is >30ml/min low dose MTX is given If sr. creatinine is <30ml/min, sulfasalazine+ low dose hydroxychloroquine

19. HIV+ RA : Antiviral drugs+low dose hydroxychloroquine+sulfasalazine /low dose MTX Avoid biologics

20. USE OF STEROIDS IN RA Lowest dose – prednisolone ≤ 7.5mg/day Lowest duration - ≤ 3 months Used as initial therapy with MTX INTRAARTICULAR STEROIDS : Given for single joint pain , especially knee

21. VITAMIN SUPPLEMENTS Folic acid Vitamin D- given as weekly therapy for 8-10 weeks, then given as monthly therapy Calcium- initially 1g/day, later 500mg/day Vitamin B12

22. MANAGEMENT OF RA DURING PREGNANCY BEFORE PREGNANCY : Discontinue MTX atleast 3 months before pregnancy - teratogenic If pregnancy is confirmed – discontinue MTX Controlled disease for atleast 6 months DURING PREGNANCY : 1 st trimester – hydroxychloroquine ±sulfasalazine 2 nd trimester – hydroxychloroquine + sulfasalazine 3 rd trimester – hydroxychloroquine + steroids SOS POST DELIVERY : Hydroxychloroquine

23. COMPLICATIONS OF RA Rheumatoid arthritis increases your risk of developing: Osteoporosis .  Rheumatoid arthritis itself, along with some medications used for treating rheumatoid arthritis, can increase your risk of osteoporosis — a condition that weakens your bones and makes them more prone to fracture. Rheumatoid nodules .  These firm bumps of tissue most commonly form around pressure points, such as the elbows. However, these nodules can form anywhere in the body, including the lungs. Dry eyes and mouth .  People who have rheumatoid arthritis are much more likely to experience Sjogren's syndrome, a disorder that decreases the amount of moisture in your eyes and mouth. Infections .  The disease itself and many of the medications used to combat rheumatoid arthritis can impair the immune system, leading to increased infections. Abnormal body composition .  The proportion of fat to lean mass is often higher in people who have rheumatoid arthritis, even in people who have a normal body mass index (BMI). Carpal tunnel syndrome .  If rheumatoid arthritis affects your wrists, the inflammation can compress the nerve that serves most of your hand and fingers. Heart problems .  Rheumatoid arthritis can increase your risk of hardened and blocked arteries, as well as inflammation of the sac that encloses your heart. Lung disease .  People with rheumatoid arthritis have an increased risk of inflammation and scarring of the lung tissues, which can lead to progressive shortness of breath. Lymphoma .  Rheumatoid arthritis increases the risk of lymphoma, a group of blood cancers that develop in the lymph system.

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