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Rheumatoid Arthritis

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Rheumatoid Arthritis

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Rheumatoid arthritis -Chronic progressive , systemic inflammatory disease characterized by the progressive destruction of synovial joints

Most common autoimmune inflammatory arthritis in adults Prevalence of about 0.5 to 1 % in Western population Developing countries have a lower prevalence Women are affected 2-4 times more common than men Incidence increases with age with a peak onset in 4th and 5th decades Aetiology is poorly understood- possibly multifactorial Amongst environmental factors smoking has now emerged as a clear external risk Bone erosion Cartilage destruction- hallmark of RA

Rheumatoid arthritis  causes significant disability- patients experience difficulty performing ADLs ( activities of daily life ) Has a significant impact on health related quality of life Approximately 1/3rd of people stop work because of RA within 2 yrs of its onset ( NICE 2009 ) Systemic effects of RA contribute to a 5-15 yr reduction in life expectancy ↑ mortality rate ( 2.4 and 2.5 /100 person-yrs for men and women )

Presentation-Joint pain swelling stiffness , affects commonly
○ wrists 
○ proximal interphalangeal jt
○ metacarpophalangeal jt
○ metatarsophalangeal jt
 AM stiffness or stiffness after inactivity – lasting over 30 mins
 Systemic symptoms as
○ weight loss
○ fatigue
○ malaise Swelling of three or more joints Tenderness largely along the joint line Boggy swelling due to synovitis may be visible A positive squeeze test- sensitivity 40-80 % but specificity 84 % in early disease

American College of Rheumatology ( ACR ) / European League Against Rheumatism ( EULAR ) 2010 rheumatoid arthritis classification criteria 1 Large joint 2-10 Large joints 1-3 Small joints ( large joints not counted ) 4-10 Small joints ( large joints not counted ) > 10 Joints ( atleast one small joint ) Negative RF and negative ACPA Low positive RF or low positive ACPA High positive or high positive ACPA Normal CRP and ESR Abnormal CRP or abnormal ESR

Early recognition and referral is the key
 Structural damage ( irreversible ) can occur early in the disease » prompt treatment has been shown to reduce inflammation thereby limiting structural damage
 Clear evidence exists that response to DMARD therapy is related to duration of symptoms prior to diagnosis
 Patients treated late ( for eg not within 6 months ) suffer considerable greater disability compared to patients treated early
 Window of opportunity – construct for treatment
 Several studies have shown that very early phase of disease
( < 3months ) may be pathologically distinct to established RA – this phase may represent a therapeutic window during which the disease is particularly amenable to anti-inflammatory therapies

Refer people with persistent synovitis with an unknown cause to a rheumatologist

Refer urgently within 2 weeks if any of the following present
○ small joints of the hand and feet affected
○ more than 1 joint is affected
○ there has been a delay of 3 months or longer between onset of symptoms and the person seeking medical adv
 Do not delay referral if blood tests are normal or have not returned from laboratory
 Offer paracetamol + – codeine ( prescribed separately ) for pain relief
 If pain not controlled – offer 
○ NSAID such as Ibuprofen , naproxen or a diclofenac + PPI OR
○ Coxib ( eg celocoxib or etoricoxib ) and a PPI
○ Do not offer steroids in primary care

Investigations FBC- Anaemia is common usually normochromic normocytic
Thrombocytosis CRP/ESR Inflammatory markers can be usually but not always elevated Urea and electrolytes 
Potential treatment can affect renal function LFTs AlkPo4 and GGT may be mildly elevated ANA May suggest connective tissue disease as SLE
+ve in up to 30 % of people with RA who are also RhF +ve
Weakly positive in up to 10 % healthy people Rheumatoid factor 

Prompt treatment limits structural damage Frequent delay 
in referral and rheumatology 
services struggle 
to see patients 
within 3 week of 
referral

References Biologics for rheumatoid arthritis : an overview of Cochrane reviews Jasvinder A singh et al Cochrane Musculoskeletal Group April 2009 Gunasekera WMA, Kirwan JR. Rheumatoid arthritis: previously untreated early disease. Systematic review 1124. BMJ Clinical Evidence Guideline Summary NGC : 009497 Rheumatoid arthritis : diagnosis , management and monitoring Medical Services Commission , British Columbia Sep 2012 Practice » Easily Missed ? Rheumatoid arthritis BMJ 2016 ;352:i387 Clinical guideline for the diagnosis and management of early rheumatoid arthritis The National Health and Medical Research Council ( NHMRC ) Australia June 2009 Rheumatoid arthritis – everything NICE says in an interactive flowchart accessed via http://pathways.nice.org.uk/pathways/rheumatoid-arthritis#content=view-node%3Anodes
-when-to-refer-for-specialist-opinion Colebatch AN, Edwards CJ, Østergaard M, et al EULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis Annals of the Rheumatic Diseases 2013;72:804-814. 2015 American College of Rhematology Guideline for the treatment of Rheumatoid Arthritis Jasvinder A.Singh et al Arthritis Care and Research DOI 10.1002/acr.22783 Diagnosis and Management of Rheumatoid Arthritis Am Fam Physician .2011 Dec 1;84 (11 ) : 1245-1252 CKS NHS Rheumatoid Arthritis August 2013 Primary Care Management of Rheumatoid Arthritis : Making the Diagnosis and Optimizing Outcomes RAPID Rheumatoid Arthritis Primary Care Initiative Diagnosis and management of rheumatoid arthritis Gerald Tracey Prescribing in Practice June 2017 http://www.arthritisresearchuk.org/arthritis-information/inflammatory-arthritis-pathway/step-one.aspx Early treatment cuts disability in rheumatoid arthritis , UK study suggests BMJ 2017 ; 357 :j 1948

 

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