ARTHRITIS - RHEUMATOID

DIAGNOSTIC CRITERIA

Definition : A chronic systemic inflammatory disease with a predilection for joint involvement with st tissue swelling or effusion, non-articular manifestations and serum rheumatoid factor raised in up 80% of patients.

1. Greater prevalence in women. Cause multi-factorial with genetic susceptibility. Insidious onset, involving mostly proximal inter-phalangeal joints of fingers, toes, wrists, elbows, knees, and ankles, and related peri-articular tissue. With morning stiffness lasting more than an hour. Less commonly mono-articular.
2. Symmetric, involvement, Progression to larger joints and deformities.
3. Systemic manifestations like fever, malaise, weight loss. Extra articular manifestations like lymphadenopathy, pleural effusions, anaemia, splenomegaly, ocular disease, entrapment neuropathies.
4. Rheumatoid factor usually present, I in 80 detectable in 70-80% of cases! Elevated ESR.
5. X-rays show juxta articular joint erosions.

Prognosis: Progressive decline in function is the usual course, but a great deal could be done by

1. comprehensive medical management. About half of those affected disabled in 10 years. Good prognosis or patients who are sero-negative, with good functional status during active phase. Much poorer
2. prognosis for those with sero-positivity, have poor functional status and the disease persisting beyond 2 years. They die 10-15 years earlier than those without arthritis.

MANAGEMENT

General Principles (See algorithm)

1. The goal of therapy in Rheumatoid arthritis is reduction of inflammation and pain, preservation of function, and prevention of deformities. The therapeutic strategy of the specialists has shifted from /go slow, go low’ to ‘early aggressive treatment’, as it has been found that structural damage occurs early in the disease process, and the synovial inflammation is continuous and persists throughout. The ‘cold, burnt-out case’ does not exist. Pointers to a severe disease would be the extent and severity of joint involvement, presence of non-articular manifestations, sero-positivity with high titre, raised ESR and C-reactive protein values, normocytic normochromic anaemia, and thrombocytosis.
2. Recent trend in management is to treat a ‘slowly progressive case’ (determined on above-quoted criteria) with NSA IDs with periodic assessment. Inadequate response would call for addition of low dose steroid and a ‘safer’ Disease Modifying Anti Rheumatic Drug (DMARD) like Chioroquine.
3. An aggressive case calls for initial NSAIDs combined with low dose steroid and Methotrexate. Low dose steroid (5-7.5 mgm prednisone daily) found to retard progression of bone erosion. Pulse doses of steroids (Methyl prednisolone 1 gm IV or depot-methyl prednisolone (80-120mg) IM, on 3 consecutive days monthly have been found to control flares of synovitis better, reduce side effects and also prevent the need for increasing doses of prednisolone over periods of time. Inadequate response would call for other DMARDs, Immunosuppressive and other investigational agents. The care of a case with aggressive advance is difficult and requires many skills and should always be under the care of a Rheumatologist.
4. Penicillamine and gold are sometimes used in cases with troublesome extra -a rticularmanifestations like vasculitis.
5. Intra-articular injections of steroids like Triamcinolone into I or 2 joints under perfect asepsis, bring excellent relief from pain, increase mobility and reduce deformity.
6. Recently US FDA has approved biologic agents, inhibitors of Tumour Necrosis Factor alpha (TNFalpha) Etanercept and Infliximab (that reduce inflammation and bone resorption like DMA RDs) for use in RA. They appear promising, are relatively safer than methotrexate, but are expensive and are given parenterally. More experience will delineate their place in management.
7. These anticytokines appear indicated for advanced DMA RD resistant disease or for rapidly advancing aggressive disease.

General Measures

• • Supportive therapy with good nutrition, exercises for ensuring muscle strength and mobility, anabolic steroids, protein and vitamin supplements.
  • Can remain active but should avoid physical stress during active phase.
  • Active physiatrist support.
  • Reduction of joint stress.
  • Treatment of associated depression and sleep disorders.
  • Treatment of sicca symptoms (in Sjogren’s syndrome) with artificial tears and saliva.

Patient Teaching

1. 1. 1. Importance of noharmacologic measures.

Understanding of possible toxic effects of drugs being consumed, and the absolute necessity for clinical and laboratory monitoring.