Summary Rheumatoid arthritis

Rheumatoid Arthritis

 Chronic progressive inflammation causing joint destruction
 Increases morbidity and mortality

Epidemiology

 Onset aged 30-60
 40-50 people per 100,000
 2:1 F:M (world) and 3:1 F:M (UK)

Aetiology

 Infection, viral, immune system, diet, smoking and genetics

Pathophysiology

 Greatest impact of synovial joints (hands and feet)
 Symmetrical effect
 Synovium – protective fluid layer around joint
 Synoviocytes – macrophages or fibroblasts
 Symptoms:
 Increased blood flow – heat/redness
 Proliferation of synovial membrane – swelling
 Increased synovial fluid – swelling
 Muscle loss – loss of function
1. Synovitis - inflammation of the synovial membrane causing swelling and
reduced fluid
2. Pannus formation – bone and cartilage erodes and inflamed tendon
3. Fibrous ankylosis – fibrous connective tissue forms with loss of bone causing
immobility (less inflammation)
4. Bony ankylosis – no pain or swelling as bones fuse with connective tissue and
leading to osteoporosis

Clinical Features

 Pain
 Stiffness (prolonged in morning)
 Loss of function
 Fever, sweating and malaise

Diagnosis

 MCP or MTP squeeze test – pain suggests inflammation
 Bloods – raised ESR and CRP
 Rheumatoid factor (RF)
 Anti-CCP
 Decreased platelet and FBC
 X-ray, MRI and ultrasound
 ACR/EULAR criteria (>6) – joint involvement, serology (RF and ACCP), acute
phase reaction (CRP/ESR) and duration (>6 weeks)
 DAS (>2.6) – assess 28 joints, ESR, CRP and patient feeling
Management

,  Refer for specialist appointment
 Analgesics – not NSAIDs (no effect on disease)

NSAIDs

 Only effect pain not inflammation
 Mode of action – inhibit COX stopping conversion of arachidonic acid to PGG 2
 COX 1 – promotes renal blood flow, maintain stomach lining and alter platelet
aggregation
 Prostaglandins:
 PGI2 – dilates vascular smooth muscle, decreases platelet aggregation and causes
pain
 TXA2 – constricts vascular smooth muscle and increases platelet aggregation
 PGF2 – constricts respiratory smooth muscle
 PGD2 – dilates vascular smooth muscle and decreases platelet aggregation
 PGE2 – dilates vascular smooth muscle and increases pain
 Issues:
 CV risk – HT, HF and MI
 GI risk – inhibit gastro-protective prostaglandins
 Renal risk – increased sodium reabsorption (weight gain and oedema),
hyperkalaemia and acute renal failure
 COX 2:
 Advantages – reduced GI SEs
 Issues – withdrawing from market as increased thrombotic risk




Rheumatoid Arthritis II