Clinical Therapeutics: Eva Fe R. Columna M D - 3 B

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Clinical Therapeutics

EVA FE R. COLUMNA
MD-3B
Case 17

A 38-year old woman presents to your office complaining


of chronically swollen finger joints over the past 6
months. She tells you that the swelling and pain are usually
most severe in the morning, but do resolve within a
couple of hours. PE reveals swelling of the PIP and
MCP joints of both hands, ulnar deviation of the
fingers, swan-neck deformity, and subcutaneous
nodules over both of her elbows. When lab results
reveals the presence of specific IgM antibody directed
against the Fc fragment of IgG, you suspect that a
biopsy of her affected joints might demonstrate a pannus.
Diagnosis

RHEUMATOID
ARTHRITIS
RHEUMATOID ARTHRITIS (RA)

It is a chronic multisystem disease of unknown


etiology characterized by persistent inflammatory
synovitis, usually involving peripheral joints in a
symmetrical fashion. Blood vessels, skin, heart, lungs
nerves, and eyes may also be affected.
Epidemiology:
 Affects 1% of the world's population
 women are affected approximately three times more
often than men
 onset: 30-50
Etiology

The exact causes of rheumatoid arthritis are


unknown. Rheumatoid arthritis is most likely
triggered by a combination of factors, including an
abnormal autoimmune response, genetic
susceptibility, and some environmental or biologic
trigger, such as a viral infection or hormonal
changes.
Pathogenesis Arthritogenic antigen

T cells and B cells are


Rheumatoid factor
activated

Release of cytokines

Persistent synovitis

Pannus formation

Lysis of articular cartilage

Fibrous and bony ankylosis


Clinical Manifestations
Articular Manifestations
 Symmetrical polyarthritis of peripheral joints with pain, tenderness
and swelling
 Morning stiffness of > 1 hour duration
 PIP and MCP are frequently involved
 Characteristics changes of the hand:
 Z deformity - radial deviation of wrist with ulnar deviation of fingers
and palmar subluxation of proximal phalanges
 Swan-neck deformity – hyperextension of the PIP joint with
compensatory flexion of the DIP joint
 boutonnière deformity - flexion contracture of the PIP joint with
extension of the DIP joint
 hyperextension of the first interphalangeal joint and flexion of the first
metacarpophalangeal joint with a consequent loss of thumb mobility
and pinch
boutonnière Swan neck deformity
deformity

Z deformity
 Extraarticular Manifestations:
 Cutaneous – rheumatoid nodules and vasculitis
 Pulmonary - pleural disease, interstitial fibrosis,
pleuropulmonary nodules, pneumonitis, and arteritis
 Ocular – episcleritis and scleritis
 Hematologic - anemia, Felty’s syndrome
 Cardiac – pericarditis, myocarditis
 Neurologic – myelopathies secondary to cervical spine
disease, entrapment
Diagnosis

1987 Revised Criteria for the classification of Rheumatoid Arthtritis


1. Guidelines for classification
a. Four of seven criteria are required to classify a patient as having
rheumatoid arthritis (RA).
b. Patients with two or more clinical diagnoses are not excluded.
2.Criteria
  a. Morning stiffness: Stiffness in and around the joints lasting 1 h before
maximal improvement.
  b. Arthritis of three or more joint areas: At least three joint areas, observed
by a physician simultaneously, have soft tissue swelling or joint effusions, not
just bony overgrowth. The 14 possible joint areas involved are right or left
proximal interphalangeal, metacarpophalangeal, wrist, elbow, knee, ankle,
and metatarsophalangeal joints.
  c. Arthritis of hand joints: Arthritis of wrist, metacarpophalangeal joint,
or proximal interphalangeal joint.
  d. Symmetric arthritis: Simultaneous involvement of the same joint areas
on both sides of the body.
e. Rheumatoid nodules: Subcutaneous nodules over bony prominences,
extensor surfaces, or juxtaarticular regions observed by a physician.
 f. Serum rheumatoid factor: Demonstration of abnormal amounts of
serum rheumatoid factor by any method for which the result has been
positive in less than 5% of normal control subjects.
 g. Radiographic changes: Typical changes of RA on posteroanterior hand
and wrist radiographs that must include erosions or unequivocal bony
decalcification localized in or most marked adjacent to the involved joints.

 
Criteria a–d must be present for at least 6 weeks.
Criteria b–e must be observed by a physician
Laboratory Findings
No tests are specific for RA
 (+) Rheumatoid Factor
 (+) anti-CCP
 Elevated ESR
 Synovial Fluid Analysis
Measure Normal Inflammatory
Volume (ml) <3.5 >3.5
Clarity Transparent Translucent to opaque
Color Clear Yellow
WBC / mcL <200 2000-75000
PMN leukocytes <25% >50%
Culture Negative Negative
Differential Diagnosis

Rule in Rule out

Osteoarthritis Chronic swollen fingers Older people


Pain resolves MCP involvement is
rare
DIP joints are typically
affected

Gouty Arthritis Joint swelling Asymmetric


(+) nodules distribution of affected
joints
Pain most commonly
occurs at night
(+)  monosodium
urate (MSU)
Treatment

The goals of drug treatment for rheumatoid


arthritis include:
 Relief of pain
 Reduction of inflammation

 Protection of articular structures


 Maintenance of function

 Control of systemic involvement


Pharmacologic Non-Pharmacologic
Management Management

 Nonsteroidal Anti-
Patient Education
Inflammatory Drugs (NSAIDs) 
 Disease-Modifying Anti- Exercise
Rheumatic Drugs (DMARDs)  Physical therapy
 Biologic Response
Modifiers (Biologic DMARDs) Surgery
 Corticosteroids
 Immunosuppressive Therapy
Prognosis/Mortality

The course of the disease varies greatly. Some people


have mild short-term symptoms, but in most the
disease is progressive for life.
Poor Prognostic Factors:
 Persistent synovitis
 Subcutaneous Rheumatoid nodules
 (+) Rheumatoid factor
 Elevated ESR and C-reactive protein
 Family history of RA
RA is known to reduce the lifespan of patients by
anywhere from 3 - 12 years.

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