RA, OA and Gout

p 

  is a chronic multisystem
disease of unknown cause characterized by a
symmetrical arthritis, with pain, swelling and
stiffness
p w
  is a degenerative joint disease, a
type of arthritis that is caused by the breakdown and
eventual loss of the cartilage, it represents failure of
the diarthrodial (movable, synovial lined) joint.
p  is a disease that involves the build-up of uric
acid in the body. Excess uric acid causes needle-
shaped crystals to form in the synovial fluid.
 Rheumatoid Arthritis:
p autoimmune disease that causes chronic
inflammation of the joints
p The symptoms can come and go, and each person
with RA is affected differently.
p Other people have times when the symptoms get
worse (flares’, and times when they get better
(remissions’.
p Others have a severe form of the disease that can
last for many years or a lifetime. This form of the
disease can cause serious joint damage.
p More often in women
p Often starts during the 4th & 5th decades of life.
athogenesis
 Rheumatoid Arthritis
p ¦

¦¦ F

persistent inflammatory synovitis, involving the
peripheral joint in a symmetrical distribution
p



potential to cause cartilage damage, bone
erosions and changes in joint integrity
 ONSET OF RHEUMATOID ARTHRITIS:
1. Insidious - in approximately 2/3 of patients,
systemic manifestations, including, fatigue,
anorexia, musculoskeletal symptoms may precede
overt symptoms of arthritis by months.
p In some patients, external events (major infections,
surgical procedures, trauma, or childbirth’ precede
the clinical onset.
p insidious onset followed by progression to
polyarticular involvement is the most common
course.
2. Acute ʹ occurs in approximately 10% of
patients
p rapid development of polyarthritis
accompanied by constitutional symptoms
including fever, lymphadenopathy and
splenomegaly
 Rheumatoid arthritis
SIGNS & SYMTOMS:
p Stiffness- morning stiffness is one of the
hallmark symptoms of rheumatoid arthritis
p Swelling ʹ synovial fluid enters into the joint,
hypertrophy of the synovium, thickening of
the joint capsule
p ain aggravated by movement ʹ most
common manifestation. Inflammation inside a
joint makes it sensitive and tender.
 SIGNS & SYMTOMS:
p Skin nodules
p Redness
p Warmth - in large joints especially the knee
 Rheumatoid Arthritis:
p This disease often occurs in more than one joint and
can affect any joint in the body.
p ands are most often affected
p Swelling and tenderness are usually noted first at the
metacarpophalangeal and proximal interphalangeal
joints Fusiform swelling at the proximal
interphalangeal joints is typical.
p Distal interphalangeal joints - usually spared.
p Grip strength - decreased because of pain and
mechanical derangement.
 Rheumatoid Arthritis:
The hand and wrist are common sites of synovitis in rheumatoid arthritis.
Marked swelling in the wrist and metacarpophalangeal joints is caused by
synovial proliferation. Modest ulnar deviation of the fingers is also
present.
 Rheumatoid Nodules:
p Rheumatoid nodules commonly form near the
extensor surface of the elbow. They can be fixed to
the underlying periosteum or can be freely mobile.
 Rheumatoid Nodules:
p Rheumatoid nodules are the most common extra-articular
manifestation, occurring in about 15% of patients.
p Subcutaneous
p Found in areas exposed to pressure -- over the extensor
surfaces of the forearm, the olecranon bursa, the knuckles,
the ischial regions, the Achilles tendon, and the bridge of the
nose . Also occur in viscera.
p Firm and are either freely movable or attached to connective
tissues
p Size - from a few millimeters to more than 2 cm in diameter
and often occur in clusters.
p Have a rubbery or gritty feel and can be indistinguishable
from gouty tophi on physical examination.
 ¦AUSES:
p Unknown
p Autoimmune
p Things that may cause rheumatoid arthritis
are:
1.Genes
2.Environment
3.Hormones
 DIAGNOSIS:
p physical exam
p x rays
p lab tests
p Rheumatoid arthritis can be hard to diagnose
because:
1. There is no single test for the disease
2. The symptoms can be the same as other kinds of
joint disease
3. The full symptoms can take time to develop.
 Treatment:
The goals of treatment are to:
p Take away pain
p Reduce swelling
p Slow down or stop joint damage
p Maintenance of function.
p ¦ontrol of systemic involvement.
p None of the therapeutic approach is curative, all
are palliative.
p
¦




     5  



¦ 
. se of aspirin, other 
  analgesics
2. se of low dose oral glucocorticoids
3. se of disease modifying or slow acting anti
rheumatoid drugs (

)
4. se of cytokine neutralizing agents
5. se of immunosuppressive  cytotoxic drugs
0ifestyle ¦hanges
p Here are some ways to take care of yourself:
p Keep a good balance between rest and
exercise
p Take care of your joints
p 0ower your stress
p Eat a healthy diet.
p 

  is a chronic multisystem disease of
unknown cause characterized by a symmetrical
arthritis, with pain, swelling and stiffness
p w
  is a degenerative joint disease, a type of
arthritis that is caused by the breakdown and
eventual loss of the cartilage, it represents failure of
the diarthrodial (movable, synovial lined) joint.
p  is a disease that involves the build-up of uric acid
in the body. Excess uric acid causes needle-shaped
crystals to form in the synovial fluid.
 OSTEOARTHRITIS
p egenerative
rthritis
p Most common
p caused by the breakdown and eventual loss of
the cartilage of one or more joints
p Before age 45, osteoarthritis occurs more
frequently in males.
p After age 55 years, it occurs more frequently
in females
p Hip Osteoarthritis ʹ common in men
p Interphalangeal jont & thumb base
Osteoarthritis ʹ common in women
p hands, feet, spine, and large weight-bearing
joints, such as the hips and knees
 ¦0ASSIFI¦ATION OF OSTEOARTHRITIS:

p 
   


 
- most common
a. 0ocalized Osteoarthritis
1. hands
2. feet
3. knee
4. hip
5. spine
6. other single sites (glenohumeral, sternoclavicular’
p ë    



a. rauma
b. ¦ongenital or developmental
c.
etabolic
d. ndocrine
e. ¦alcium deposition diseases
f. ther bone  joint diseases
g. europathic
h. ndemic
 RISK FA¦TORS:
1. AGE ʹ most powerful risk factor
2. Female sex
3. Race
4. Genetics
5. Major joint trauma
6. Repetitive stress
7. Obesity
8. ¦ongenital / developmental disease
9. rior joint disorders
10. Metabolic / endocrine disorders
 ¦AUSES:
p AGING
- water content of the cartilage increases and the protein
makeup of cartilage degenerates
- Repetitive use of the joints Î irritates and inflames the
cartilageÎ joint pain and swelling. Eventually, cartilage begins
to degenerate by flaking or forming tiny crevasses.
- In advanced cases, there is a total loss of the cartilage
cushion between the bones of the joints.
- 0oss of cartilage cushion Î friction between the bones Î



 
 




À When the cartilage deteriorates, the bone next to it
becomes inflamed and can be stimulated to produce new
bone in the form of a local bony protrusion, called a   
 SIGNS AND SYMTOMS:
p NOT a systemic disease
. pain in the affected joint(s) after repetitive
use À most common symptom of
osteoarthritis. Joint pain is usually worse
later in the day.
2. Swelling
3. Warmth
4. Bony crepitus - characteristic
5. Stiffness of the joints can also occur after
long periods of inactivity
I. Heberden͛s nodes
XBony enlargement of the
distal interphalangeal joint
(DI’
XMost common form of
idiopathic osteoarthritis
II. Bouchard͛s nodes
XBony enlargement of
the proximal
interphalangeal joint
(I’
 DIAGNOSIS:
p ¦0INI¦A0
p RADIOGRAHI¦ EVIDEN¦E
1. loss of joint cartilage
2. narrowing of the joint space between
adjacent bones
3. bone spur formation
 TREATMENT:
p Goal of treatment in osteoarthritis:
1. Reduce joint pain
2. Reduce inflammation
3. Maintaining joint function
4. Minimizing disability

p no specific treatment to halt cartilage

degeneration or to repair damaged cartilage in
osteoarthritis
 TREATMENT:
p NONHARMA¦O0OGI¦ MEASURES:
1. Weight reduction
2. Avoiding activities that exert excessive stress on the joint
cartilage
3. Rest
4. hysical and occupational therapy
5. Thermal modalities
6. Exercise ʹ walking, cycling

p Some patients with osteoarthritis have minimal or no

pain, and may not need treatment.
p 

  is a chronic multisystem
disease of unknown cause characterized by a
symmetrical arthritis, with pain, swelling and
stiffness
p w
  is a degenerative joint disease, a
type of arthritis that is caused by the breakdown and
eventual loss of the cartilage, it represents failure of
the diarthrodial (movable, synovial lined) joint.
p  is a disease that involves the build-up of uric
acid in the body. Excess uric acid causes needle-
shaped crystals to form in the synovial fluid.
 GOUT
pOverload of uric acid in the body,
and recurring attacks of joint
inflammation

pHalf of the time, gout affects the

metatarsophalangeal (
) joint.
This is the joint at the base of the
big toe.
 GOUT
p In gout, excess 
 
 causes needle-shaped crystals to
form in the synovial fluid. As your immune system tries to get
rid of the crystals, it causes the inflammation and pain of
arthritis.
p The first attack of gouty arthritis usually happens in just one
joint, usually in the metatarsophalangeal (MT’ joint.
p Other joints that are commonly affected include:
1. mid-foot
2. ankle
3. heel
4. knee joints
5. fingers
6. wrists
7. elbows
 GOUT:
p Over time, patients with gout can develop

, or lumps that grow around crystal
deposits in joints or near pressure points.
p Tophi most often occur in the fingers, wrists,
ears, knees, elbows, forearms, and heels.
Tophi can also grow in the kidneys, heart, and
eyes.
 ¦AUSES:
1. HYERURI¦EMIA
- It means that you have high levels of uric acid
in your blood
- This can happen for two reasons:
- (1’ your body creates too much uric acid, or
- (2’ your kidneys don't excrete the uric acid
effectively.
- Whether or not you will develop gout is
related to how bad your hyperuricemia is
over time.
 ¦AUSES:
p For people who create too much uric acid, the
cause is usually 6  
.
p Other medical conditions, such as obesity,
hypertension, and diabetes, can also make
some people more likely to develop gout.
p 6both raises uric acid levels in the
body and impairs the kidneys' ability to
excrete the buildup.
 ¦AUSES:
2. A¦UTE ¦AUSES
- Attacks of gouty arthritis seem to be caused
by sudden increases or decreases in the
amount of urate in your synovial fluid.
- This rapid change can be caused by injury to
the

     

 6 
 ¦AUSES:
3. OTHER FA¦TORS
- Heredity
- Obesity
- Kidney problems
- High hemoglobin levels
- High triglyceride levels
- ypertension
 SIGNS AND SYMTOMS:
1. Very painful joint
2. Swelling
3. Warm
4. Red
- The signs and symptoms happen within eight to
twelve hours.
- Most of the time the attacks happen at night
- Walking and standing are almost impossible if the
legs or feet are affected.
- Many patients have flu-like symptoms, including
fever and chills.
 SIGNS AND SYMTOMS
p The pain may go away on its own in a few hours, or it
may take a few weeks.
p Gouty arthritis attacks come and go.
p Over time the attacks happen more often, last
longer, and involve more joints.
p Eventually the pain doesn't ever completely go
awayÎ joints stay swollen and tender even between
flare-ups, and the flare-ups start to happen every few
weeks Î some patients develop tophi on joints or
pressure points and kidney stones.
Gout -hand
Gout ʹ big toe
 DIAGNOSIS
† history of repeated attacks of painful arthritis
at the base of the toes
† hysical Exam
† Blood tests - to determine uric acid levels.
p Joint aspiration - examined to look for uric
acid crystals.
p X-rays - to examine both the bones and joints
to rule out abnormal changes associated with
gout.
 TREATMENT:
p Gout cannot be cured, but it can be very successfully
treated.
p 


¦ ¦


. colchicine
2. nonsteroidal antiÀinflammatory drugs (NSAIDs’
3. corticosteroids to decrease swelling and relieve pain.
p All of these drugs work quickly and are very effective.
p These drugs may be given by mouth, through an intravenous
line into your bloodstream, or injected directly into the joint.
 0IFESSTY0E ¦HANGES:
1. ¦hange your diet. Avoid foods that are high
in purines like anchovies, red meats,
shellfish, beer, red wine and salt
2. Quit taking drugs such as diuretics.
3. 0ose weight.
4. Quit drinking alcohol.
5. Avoid activities that stress your joints.
6. Drink plenty of fluids to help your kidneys
work more efficiently.
 RHEUMATOID OSTEOARTHRITIS GOUT
ARTHRITIS
CAUSES Unknown ; Aging; Cartilage Hyperuricemia
Autoimmune destruction

SIGNS & Morning stiffness Joint pain; Morning Rapid onset of pain usually in the
SYMPTOMS lasting >45 min. stiffness lasting less than MTP joint followed by warmth,
Swelling ; Pain 30 minutes swelling, reddish discoloration,
aggravated by Joint instability; and marked tenderness
movement; Skin Heberden's and
nodules; Redness Bouchard's nodes
Warmth
DIAGNOSIS medical history Clinical History of repeated attacks of
physical exam Radiographic evidence painful arthritis at the base of the
x rays toes; Physical Exam; Blood tests
lab tests Joint aspiration

TREATMENT Non pharmacologic: Non pharmacologic: adequate

weight reduction and
avoiding activities that
exert excessive stress on
the joint cartilage
Pharmacologic: Aspirin,
NSAIDS, cox2 inhibitors
fluid intake, weight reduction,
dietary changes, reduction in
alcohol consumption,
Pharmacologic measures:
medications to reduce
hyperuricemia
 Rheumatoid Osteoarthritis Gout
arthritis
TREATMENT Non pharmacologic: Non pharmacologic: Non pharmacologic:
weight reduction and weight reduction and adequate fluid intake,
avoiding activities avoiding activities weight reduction,
that exert excessive that exert excessive dietary changes,
stress on the joint stress on the joint reduction in alcohol
cartilage, healthy diet cartilage consumption,
Pharmacologic: Pharmacologic: Pharmacologic
Aspirin, NSAIDS, Aspirin, NSAIDS, measures:
DMARDS,Cox2 cox2 inhibitors medications to
inhibitors reduce
hyperuricemia
 Bibliogrphy:
p Kasper et al; Harrison͛s rinciple of Internal
Medicine 17th ed.
p http://www.niams.nih.gov
p http://www.medicinenet.com/rheumatoidart
hritis
p http:www.medscape.com
p www.aafp.org/afp/20050915/1037.htm