Rheumatoid Arthritis

Clinical Description

Chronic systemic inflammatory disease characterized by a symmetrical, deforming, peripheral polyarthritis.

Signs and Symptoms

• Arthritis: Symmetrical, polyarthritis of MCPs, PIPs of hands and feet → pain, swelling, deformity, Swan neck, Boutonniere, Z-thumb, Ulnar deviation of the fingers, Dorsal subluxation of ulnar styloid
• Morning stiffness >1hour
• Improves with exercise
• Larger joints may become involved
• Nodules
• Commonly elbows also fingers, feet, heal
• Firm, non-tender, mobile or fixed

Diagnosed when any 4 out of the following findings are present

• Morning stiffness >1h (lasting >6wks), Arthritis ≥3 joints, Arthritis of hand joints, Symmetrical, Rheumatoid nodules, +ve RF, Radiographic changes

Investigations

• Anti-CCP: 98% specific (Ag derived from collagen)
• Rheumatoid Factor +ve in 70%
• ANA: +ve in 30%
• FBC (anaemia, ↓PMN, ↑platelet),
• ↑ESR
• ↑CRP
• Radiography

Treatment

Treatment objectives

• relief symptoms
• modulate immunity with DMARDs as soon as possible

Non-pharmacological

• Regular exercise
• Physiotherapy
• Occupational therapy: aids, splints
• Surgical: ulna stylectomy, joint prosthesis

Pharmacological

Principles:

• Disease Modifying Anti-Rheumatoid Drugs (DMARDs): use early
• Steroids: IM, PO or intra-articular for exacerbations
• Prednisolone 0.5-1 mg/kg body weight 24hourly
• Take corticosteroids with food and Omeprazole 20mg 12hourly to prevent gastric ulcers
• NSAIDs: good for symptom relief
• Diclofenac 50 mg 8 hourly PO or 100 mg 12 hourly as required
• Ibuprofen 400mg 12 hourly
• Add Omeprazole 20mg 12hourly to the steroids to prevent gastric ulcers

Consider addition of Paracetamol 1g 6 hourly or Tramadol 50 to 100 mg 12 hourly to help relieve acute pain

• Prevent osteoporosis and gastric ulcers

DMARDs

• 1st line for treating RA
• Early DMARD use associated with better long-term outcome
• All DMARDs can → myelosuppression → pancytopenia

Main agents (discuss with a specialist before initiating these drugs)

• Methotrexate 7.5 to 25 mg PO weekly : It is generally continued indefinitely
• (SE: hepatotoxic, pulmonary fibrosis, anaemia and leucopenia)
• Give it together with Folic acid 5 to 15mg daily
• Sulfasalazine 500 mg daily, increased by 500 mg every week to 2-3 grams daily in divided doses
• (SE: hepatotoxic, SJS, ↓ sperm count)
• Preferred agent in pregnancy
• Hydroxychloroquine 200 – 400 mg daily. Maximum dose of 6.5 mg/kg per day
• (SE: retinopathy, seizures)
• Regular eye checkup needed

Combination triple therapy (methotrexate plus sulfasalazine plus hydroxychloroquine).

Other Agents (discuss with a specialist before initiating these drugs)

• Leflunomide (SE: ↑ risk of infection and malignancy)
• Gold (Gold sodium thiomalate 10mg/ml )(SE: nephrotic syndrome)
• Penicillamine (SE: drug-induced lupus, taste change)
• Biologicals
• Anti-TNF (SE: ↑ infection (sepsis, TB), ↑ AI disease, ↑ Ca)
• Severe RA not responding to DMARDs
• Screen and treat for TB first

Complications

• De Quervain’s Tenosynovitis
• Atlanto-axial subluxation
• Immune
• AIHA
• Vasculitis
• Amyloid
• Lymphadenopathy
• Cardiac: pericarditis and pericardial effusion
• Carpal Tunnel Syndrome
• Pulmonary
• Fibrosing alveolitis (lower zones)
• Pleural effusions (exudates)
• Ophthalmic
• Epi-/scleritis
• Raynaud’s
• Felty’s Syndrome (RA + splenomegaly + neutropenia)

When to refer a rheumatoid arthritis patient

• Presence or suspicion of complications listed above
• No response to DMARDs
• Suspicion of life-threatening drug side effects