3rd stage Seminar! Huzaifa Hamid Ahmad

1. Muhammad Hussain
Goran Muhammad
Huzaifa Hamid

2. 
 INTRODUCTION
 EPIDEMOLOGY
 ETIOLOGY
 PATHOGENESIS
 RISK FACTORS
 DISTINCTIVE CLINICAL FEATURES
 COMPLICATIONS
 INVESTIGATIONS
 TREATMENT
Non –Pharmacological
pharmacological
• PREVENTION
 CONCLUSION
CONTENTS

3. 
Rheumatoid arthritis (RA) is an autoimmune disease that causes
chronic inflammation of the joints & can also cause
inflammation of the tissue around the joints, as well as in
other organs in the body.
An autoimmune disease is a disease where the immune
system attacks healthy parts of the body.
As it can affect multiple other organs of the body, RA is referred to
as a systemic illness and is sometimes called rheumatoid
disease.
Introduction

4. 
Diagram showing the
affected organ

5. 
Comparison of normal
joint and affected joint

6. 
 A joint (the place where two bones meet) is surrounded by a capsule
that protects and supports & it is lined with a type of tissue called
Synovium, which produces synovial fluid that lubricates and nourishes
joint tissues
It becomes inflamed, causing warmth, redness, swelling, and
pain & unable to move freely
As the disease progresses, the inflamed synovium
invades and damages the cartilage and bone of the joint. Surrounding
muscles, ligaments, and tendons become weakened
This process eventually leads to deformity and destruction of the joints
RA also can cause more generalized bone loss that may lead to
osteoporosis (fragile bones that are prone to fracture)
RA Contd…

7. 
The incidence of RA is in the region of 3 cases per 10,000
population per annum. Onset is uncommon under the age of 15
and from then on the incidence rises with age until the age of
80.
Some Native American groups have higher prevalence rates (5–
6%) and people from the Carribean region have lower
prevalence rates.
First-degree relatives prevalence rate is 2–3% and disease
genetic concordance in monozygotic twins is approximately
15–20%.
Epidemiology

8. 
 The cause of RA is unknown. It is assumed that a genetically
susceptible host is exposed to an unknown antigen & this
interaction gives rise to a persistent immunological response
 The activation of immune response is triggered by the following
factors.
They are:-
 GENETIC FACTORS:-RA is documented by presence of
immune cell reactivity and production of antibodies to
endogenous elements such as
immunoglobulins,collagen,andcellular components
Etiology

9. 
 PRESENCE OF HLA (human lymphocyte antigen):-The most
definite genetic association with RA is with HLA alleles.The
HLA-DR4 allele is associated with development & severity of
RA.
 Risk of an individual with HLA-DR4 to develop the disease is
between 2 & 6. In American Whites,60-70% of RA patients are
positive for HLA-DR4.
 Frequency of this allele among Dutch patients is greater than
90%.
Contd…

10. 
 There is a 30% concordance in monozygotic twins compared to
5% in fraternal twins and first degree relatives.
First degree relatives of patients develop RA at 4-6 times the
rate of standard population rate.
 INFECTIOUS FACTORS:- Presence of Epstein-Barr virus as
antigen. Of patients with RA ,80% have a circulating antibody
directed against antigens specific for this virus.
 Parvovirus particularly B19 & also Mycobacteria(as it
expresses HSP,heat sensitive protein)have been linked to RA.
Contd…

11. 
 ENDOCRINOLOGIC FACTORS:-. disease may improve
during pregnancy and flare after pregnancy. Breastfeeding may
also aggravate the disease
 Contraceptive use reduces the risk of developing RA. This
suggests possible deficiencies or changes in certain hormones,
may promote the development of RA
 ENVIRONMENTAL FACTORS:-Changes in barometric
pressures are associated with acute worsening of RA. Besides
climate,diet,trauma are also known to influence RA.
Contd…

12. 
 RA is characterised by the infilteration of various inflammatory
cells into the joint
 The synovial membrane becomes highly vascularised &
synovial fibroblasts proliferate & inflammatory cells release
numerous CYTOKINES & GROWTH FACTORS into the
joint
 These agents cause synovial cells to release proteolytic enzymes
&Proliferating inflammatory tissue (PANNUS-tissue serving as
origin of joint erosions) subsequently leads to the destruction of
intra articular & peri articular structures leading to the joint
deformities and dysfunction
Pathogenesis

13. 
 Gender
 Age
 Family history
 Smoking
 Overweight
 HLA gene
Risk factors

14. 
 Tender, warm, swollen joints
 Symmetrical pattern of affected joints
 Joint inflammation often affecting the wrist and finger joints
closest to the hand
 Joint inflammation sometimes affecting other joints, including
the neck, shoulders, elbows, hips, knees, ankles, and feet
 Fatigue, occasional fevers, a general sense of not feeling well
 Pain and stiffness lasting for more than 30 minutes in the
morning or after a long rest
 Variability of symptoms among people with the disease
Distinctive clinical
features of RA

15. 
Symmetrical pattern of
affected joints

16. 
 Since RA is a systemic disease, its inflammation can affect
organs and areas of the body other than the joints like
eyes,skin,lungs,heart & blood vessels
 Examples of other areas that may be affected include:-
 SJOGREN’S SYNDROME:-inflammation of the glands of the
eyes and mouth and causes dryness of these areas
 PLEURITIS causes chest pain with deep breathing or coughing
 Tissue inflammation surrounding the heart, PERICARDITIS
Complications

17. 
 Rheumatoid disease can reduce the number of red blood cells
ANEMIA and white blood cells.
 Decreased white cells can be associated with an enlarged spleen
i.e FELTY'S SYNDROME and can increase the risk of
infections.
 RHEUMATOID NODULES can occur around the elbows and
fingers where there is frequent pressure.
 VASCULITIS rare and serious complication is blood-vessel
inflammation which can impair blood supply to tissues and
lead to tissue death. This is most often initially visible as tiny
black areas around the nail beds or as leg ulcers.

18. 
EROSIVE CHANGES GIVE RISE TO JOINT
INSTABILITY
&SUBLUXATION.CHARACTERISTIC
DEFORMITIES INCLUDE ULNAR
DEVIATION,SWAN NECK,BOUTONNIERE
SYNDROME.

19. 
 Are made after a full medical and family history and physical
and diagnostic testing are evaluated by a qualified health care
professional.
 Medical testing may include a wide variety of tests like:-
 ESR (Erythrocyte Sedimentation Rate
 CRP (C – Reactive prot ) INFLAMMATORY
 RF (Rheumatoid factor)blood tests MARKERS
 ANA (Anti nuclear antibodies)
 JOINT X-RAYS
 MRI (Magnetic resonance imaging) & US (ultra sound)
Investigations

20. 
 ESR…It is a test that measures how fast red blood cells
(erythrocytes) drop to the bottom of a collection tube.
 CRP…C-reactive protein, another common test for
inflammation is useful both in making a diagnosis and
monitoring disease activity and response to anti-inflammatory
therapy.
 RA FACTOR… is an autoantibody that is present in the blood
of most people with RA & directed against host
immunoglobulin & present in 75-80% in patients with RA.

21. 
• ANA ….These are investigated to rule out possibility of other
connective tissue disorders like SLE. ANA’s are raised in 80%
of patients with SLE & 20% of patients with RA.
• X-RAYS….Erosions can be seen at the joint margins & loss of
joint space due to erosion of cartilage & bone may be identified.
• MRI & US SCAN…used to detect inflammatory activity. so
these are increasingly used to detect early changes in RA
patients.

22. 
Laboratory tests include an
• elevated alkaline phosphatase,
 elevated platelet count,
 decreased serum albumin level
 Anti-CCP antibodies: This blood test detects antibodies to
cyclic citrullinated peptide (anti-CCP). This test is positive in
most people with RA
and can even be positive years before rheumatoid arthritis
symptoms develop.

23. 
 Goals of Treatment
 Relieve pain
 Reduce inflammation
 Slow down or stop joint damage
 Improve a person's sense of well-being and ability to
function.
 Current Treatment Approaches
 Lifestyle
 Medications
 Surgery
 Routine monitoring and ongoing care.
Treatment

24. 
 Physiotherapy is a vital part of treating RA
 Heat,cold and electrotherapy helps to reduce pain and swelling
 program of exercise strengthens joints & minimize deformity
and increase the range of movement and functions
 Natural treatments include using massage with herbs,magneto
therapy etc
 Occupational therapy educates patients to protect joints with the
use of appliances and splints.
 Surgical techniques can be effective in relieving pain and
restoring function.
Non-Pharmacological

25. 
• ANALGESICS –used only for pain relief
Eg:-Paracetamol-325 to 650mg every 4-6hrs or 1gm 3-4
times/day
Topical Analgesic(Capsaicin)-apply 3-4 times/day
• NSAID’s-used as an adjunct along with DMARD’s to reduce
the inflammation
Eg:-Ibuprofen-1.2-3.2 gms/day in 4 divided doses TID
Aspirin-325-650mg for every 4hrs for pain
3,600mg for inflammation 4 times daily
NSAID’S mainly act by inhibiting COX -1 &2 enzymes blocking
COX enzyme site & thus reduces inflamation
Pharmacological

26. 
 CORTICOSTEROIDS-used because of their anti inflammatory
& immunosuppressive property
Eg:-Prednisone & methyl prednisolone given orally or IV,IM-
7.5mg daily as single dose/infusion
-Act by suppressing the cytokines
• DMARD,s(disease modifying anti-rheumatic drugs)-used to
slow down the progression of disease
• These include METHOTREXATE-5 to 25 mg once
weekly;Oral or IM
• SULFASALAZINE-initially 500mg OD,increasing in weekly
steps 0f 500mg to 1gm BD

27. 
 The primary purpose is to reduce pain, improve the affected
joint’s function, and improve the patient’s ability to perform
daily activities
 Joint replacement:involves removing all or part of a damaged
joint and replacing it with synthetic components.
 Most commonly replaced joints are the hips and knees.
Current Surgery Approaches

28. 
 Arthrodesis (fusion): is a surgical procedure that involves
removing the joint and fusing the bones into one immobile unit,
often using bonegrafts from the person’s own pelvis
 useful for increasing stability and relieving pain in affected
joints
 Tendon reconstruction: RA can damage and even rupture
tendons, the tissues that attach muscle to bone
 reconstructs the damaged tendon by attaching an intact tendon
to it

29. 
 Routine monitoring and ongoing care: Regular medical care is
important to monitor the course of the disease, determine the
effectiveness and any negative effects of medications, and
change therapies as needed
 Healthful diet:- overall nutritious diet with enough—but not an
excess of—calories, protein, and calcium is important
 Those taking methotrexate need to avoid alcohol as most
serious long-term side effects is liver damage
General Approaches

30. 
 Stress reduction:- Stress also may affect the amount of pain a
person feels
 Regular rest periods can help, as can relaxation, distraction, or
visualization exercises
 Joint care:- using a splint for a short time around a painful joint
reduces pain and swelling by supporting the joint and letting it
rest
 Rest and exercise:- good balance between rest and exercise is
required
They reduce active joint inflammation and pain and to fight
fatigue,maintaining healthy and strong muscles, preserving joint
mobility, and maintaining flexibility

31. 
There is no known way to prevent RA because the exact cause of
the disease is not known
Preventive measures can be taken only after diagnosis of
the disease.
But making some modifications in :-
Diet(consume nutritious food )
Relaxed Life style
Avoiding smoking & alcohol consumption
Maintaining ideal body weight
Exercises like swimming,cycling ,yoga can prevent the increased
risk of RA.
Prevention

32. 
 RA is the most common inflammatory disease affecting 1% of
population & can affect virtually every area of a person’s life
from work life to family life
One study showed that more than a quarter of women
stopped working within 4 years after being diagnosed with
rheumatoid arthritis &also interferes with the joys and
responsibilities of family life
Fortunately, current treatment strategies, including pain-
relieving drugs and medications that slow joint damage, a
balance between rest and exercise, and patient education and
support programs, allow most people with the disease to lead
active and productive lives
Conclusion

33. 
Thank You