Rheumatoid Arthritis

Department of Internal Medicine

Samuel Asselo MuranoYear VI

Wednesday, 5th April 2017

Case Study
A 26 year-old woman presents with a 3 week history of joint swelling
and stiffness.
PIPs, MCPs and wrists are involved symmetrically which you confirm
on exam. Stiffness in the morning is about 2 hrs.
She also has fatigue and low-grade fever.
She has no back pain or DIP involvement.
Rheumatoid Arthritis
Chronic inflammatory multisystem disease.
Main focus is the SYNOVIUM.
Hallmark: Inflammatory synovitis in a symmetric distribution.
Bone erosions, deformities.
Predominant cells: T lymphocytes.
Pro-Inflammatory cytokines that mediate inflammation: TNF-a, IL-1,IL-
6
Rheumatoid Arthritis
Radial deviation of the wrist with ulnar deviation of the digits. Z
deformity
Boutoniere deformity
Swan neck deformity
Goals of Treatment
The goals of therapy of RA are
Relief of pain
Reduction of inflammation
Protection of articular structures
Maintenance of function
Control of systemic involvement
Extra articular manifestation
Rheumatoid nodules
Rheumatoid vasculitis,
Pleuropulmonary manifestations: pleural disease, interstitial fibrosis,
pleuropulmonary nodules, pneumonitis, and arteritis.
Pericarditis
Neurologic manifestations: neuropathies of median, ulnar, radial
(interosseous branch), or anterior tibial nerves.
Eye: episcleritis,
Felty's syndrome consists of chronic RA, splenomegaly, neutropenia, and, on
occasion, anemia and thrombocytopenia.
Osteoporosis
Caplans Syndrome
Labaratory
Anti Cyclic Citrulinated Peptide
Anemia
ESR
Xrays
Synovial fluid Analysis
Treatment
NSAIDs
Cyclooxygenase 2 (COX-2) inhibiors.
Corticosteroids
MTX
Hydroxychloroquine
Tumor Necrosis Factor (TNF) inhibitors
i. Infliximab
ii. Adalimumab
iii. Etanercept
Methotrexate dosage
Start with 5 mg weekly.
Increase by 2.5 mg every 2 weeks till you are administering 15 mg
weekly.
Treatment progress
1. NSAIDs + Corticosteroids
2. Methotrexate (right away).
3. Remove 1 after 3 weeks. Maintain on 2 and Administer NSAIDs only
when needed i.e joint pain.
4. If MTX failed or patient developed complications, put on
hydroxychloroquin or TNF inhibitors.
5. When using TNF inhibitorsbe on alert for Pulmonary TB.