RHEUMATOID ARTHRITIS- Extra-articular manifestations and management

Andrea R S

Extra-articular manifestations

CUTANEOUS AND VASCULAR Rheumatoid nodules- Occur usually in seropositive

patients at sites of frictions like extensor surface of forearm, sacrum, achiles tendon and toes.

Rheumatoid vasculitis Vary from benign nailfold infarcts to

widespread cutaneous ulceration and skin necrosis

Ocular involvement

Cardiac and pulmonary Granulomatous lesions can cause

heart block, cardiomyopathy, coronary artery occulusion.

Serositis is commonly assymptomatic but may present as pleurisy or breathlessness.

Pulmonary fibrosis can cause dyspnea

Neurological involvement Rheumatoid arthritis tends to spare

CNS but vasculitis can cause peripheral neuropathy

Peripheral entrapment neuropathy Cervical cord compression

Hematological Anemia,thrombocytopeniaMusculoskeletal Muscle wasting,osteoporosis,bursitisAmyloidosis-presents as nephrotic

syndrome

LAB INVESTIGATIONS

BLOOD TESTS AND RADIOGRAPHYBLOOD RADIOGRAPHYRheumatoid factor PLAIN X-RAYACPA USGESR and CRP MRI

RHEUMATOID FACTOR Not specific for RA as its found in 5%

of healthy people Can be of prognostic value as people

with high titres tend to have more severe and progressive disease with non articular manifestation

ACPA-Anti citrullinated peptide antibodies

As better specificity than RF Presence of ACPA is most common in

persons with aggressive disease with tendency to develop bone erosions

Useful to confirm the diagnosis

RADIOGRAPHY Plain x-ray of hands,wrist and feet Ultrasound and MRI-not routinely

done Main value is in patients with

symptom suggestive of inflammatory arthritis

DAS28 Count number of tender joints Count number of swollen joints Measure ESR Ask patient to rate global activities

of arthritis during the past week from 0(no symptom) to 100(very severe)

Enter data into an online calculator or work out using formula

To establish diagnosis- Clinical criteria ESR and CRP Rheumatoid factor and ACPA USG and MRI To monitor disease activity and drug

efficacy Pain Early morning stiffness Joint tenderness Joint swelling DAS28 USG ESR and CRP

To monitor disease damage X-ray and functional assesment To monitor drug safety Urinanalysis Complete blood count Liver function test Urea, creatinine

MANAGEMENT

MEDICAL Disease modifying anti rheumatoid

drugs(DMARD’s) Corticosteroids Biological therapies NSAID’sSURGICALGENERAL MEASURES

Drug Mechanism

Dose Side effects

Monitoring requirement

Monitoring frequency

Methotrexate

Inhibits DNA synthesis and cell division

5-25mg/wk

GI upset, stomatitis, rash, alopecia,hepatotoxicity, acute pneumonitis

Complete blood count,LFT

Initially monthly then every 3 months

Sulfasalazine

unknown 2-4mg/day

Nausea, GI upset,hepatitis,rash

CBC,LFT Monthly for 3mnths and then 3-monthly

Hydroxychloroquine

unknown 200-400mg/day

Rash,nausea,diarrhoea,corneal deposits,retinopathy

Visual acuity,fundoscopy

12 monthly

Leflunomide Blocks Tcell division

10-20mg/day

Nausea,GI upset,rash,hepetitis

CBC,LFT

2-4 weekly

D-penicillamine

unknown 250-750mg/day

Rash, stomatis,metallic taste,thrombocytopenia,proteinuria

CBC,urine

Initial 1-2/wk then 4-6/wk for maintenance

Gold unknown 50mg/mnth IM injection

Rash,stomatitis,proteinuria

CBC,urine

Each injection

Cyclosporine Blocks Tcell activation

150-300mg/day

Nausea,renal impairement,hypertension

CBC,urine,BP,LFT

2-4times a week

Corticosteroids Primary role-is in the induction of

remission in patients with early RA who are starting synthetic DMARD treatment

High dose oral prednisolone(60mg/day) initially to reduce and stop this gradually over 3 months as DMARD’s start to take effect

Low dose prednisolone every 6-8 weeks

Side effect-osteoporosis

Biological therapy Although well tolerated they increase

the risk of serious infection due to suppression of immune system. Better than DMARD’s but cost is high

Agent dose Side effectAnti TNF-αEtanerceptInfliximabAdalimumab

50mg every week SC3mg/kg every 8wks IV40mg every 2 wks SC

Infusion reaction, increased risk of infection, reactivation of TB

Anti B cell therapyRituximab

1000mg IV repeat after 2wks

Infections ,infusion reaction

T-cell activation inhibitorAbatacept

125 mg SC once a wk infection

Anti –IL6Toclizumab

8mg/kg every 4 wks IV

Infection, infusion reaction

Anti-IL1Anakinra

100mg daily SC Infection,infusion reaction

Surgery-synovectomy of wrist or finger tendon sheath

Later stage when joint damage has occurred arthroplasty is done

General measures-physical rest,analgesics,NSAID’s,passive exercise

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