1. LUGANSK STATE MEDICAL UNIVERSITY
DEPARTMENT OF INTERNAL MEDICINE
PROJECT WORK ON RHEUMATOID
ARTHRITIS
DR. IBEANU
CHARLES.S

2. OBJECTIVES:
• INTRODUCTION AND FACTS
• ETIOLOGY AND PATHOGENESIS
• CLINICAL MANIFESTATION
• DIAGNOSIS
• TREATMENT
• PROGNOSIS

3. INTRODUCTION
• Chronic autoimmune systemic connective tissue disease
• Multisystem affection. Primarily synovial joints causing progressing
lesion, erosion and destruction of affected joint.
• Affect 1-3% of global population
• Women (3x) > Men
• Peak age 35 – 65
• Therapeutic window is 12 weeks

4. FACTS
• There are about 63 million RA patients
• In Ukraine there are 340 RA patients per 100,000 patients
• Nearly 75% of them having erosions in the early stage of the disease
• 50% lose working ability in the first five years

5. ETIOLOGY &
PATHOGENESIS

6. ETIOLOGY AND PATHOGENESIS
• Unknown but likely multifactoral
• Genetic susceptibility
• Immunological reaction involving foreign antigen at synovial joint
• Inflammatory reaction on joint and tendon sheath
• Appearance of anti-IgG antibodies(rheumatoid factor) in blood and
synovium
• Possible role of infectious agents have been suggested to induce RA.
Among these are mycoplasma organism, Epstein-barr and rubella
virus and others
• Hormonal- sex hormone play role

7. PATHOGENESIS SCHEME
Immune deficiency of T-lymphocyte system which is triggered by some
internal and external factors
Leads to uncontrolled synthesis of antibodies (IgG) by B-lymphocytes
Plasmatic cells & lymphocytes of synovium percepts IgG as heterogenous
antigens & starts to produce rheumatoid factors against IgG
Immune complexes formation begins, this process stimulates different
reactions, activation of complement system which triggers immigration of
polymorphonuclear leukocytes to the synovial fluid
Macrophages (neutrophils) engulfs the immune complexes with further
release of lysosomal enzymes and other mediators of inflammation
This results to lesion of microcirculatory vessels and development of
inflammatory changes in synovium
Continuous inflammation stimulates synovial membrane proliferation with
formation of pannus, which is rambling on joint cartilage. The outer joint lesion
appear because of destruction of microcirculatory vessels of visceral organs by
immune complexes

8. CLINICS

9. CLINICAL MANIFESTATION
Signs and symptoms of rheumatoid arthritis may include:
• Tender, warm, swollen joints
• Morning stiffness > 1hr easing with physical activity
• Firm bumps of tissue under the skin on the arms (rheumatoid nodules)
• Fatigue, fever and weight loss
NB: Early rheumatoid arthritis tends to affects smaller joints first — particularly the
joints that attach fingers to the hands and toes to feet. As the disease
progresses, symptoms often spread to the knees, ankles, elbows, hips and shoulders.
In most cases, symptoms occur in the same joints on both sides of your body.

10. • Rheumatoid arthritis signs and symptoms may vary in severity and
may even come and go. Periods of increased disease activity, called
flares, alternate with periods of relative remission — when the
swelling and pain fade or disappear. Over time, rheumatoid arthritis
can cause joints to deform and shift out of place.

12. EXTRAARTICULAR INVOLVEMENT
• Constitutional symptoms (most common)
• Rheumatoid nodules (30%)
• Hematological- normocytic normochromic
anemia, leukocytosis/leucopenia, thrombocytosis
• Fellty’s syndrome- chronic nodular rheumatoid arthritis, splenomegaly, neutropenia
• Repiratory- pleural effusion, pneumonitis, pleuro-pulmonary nodules, ILD
• CVS- asymptomatic pericarditis, pericardial effusion, cardiomyopathy
• Rheumatoid vasculitis- mononeuritis multiplex, cutaneous ulceration, digital
gangrene, visceral infarction
• CNS- peripheral neuropathy, cord-compression from atlantoaxial/midcervical spine
subluxation, entrapment neuropathies
• EYE- keratoconjunctivitis sicca, episcleriitis, scleritis

14. DIAGNOSIS

15. CRITERIA FOR DIAGNOSIS
• Morning stiffness
• Arthritis of 3 or more joints
• Arthritis of hand joints
• Symmetric arthritis
• Rheumatoid nodules
• Serum rheumatoid factor
• Radiographic changes
NB: A person shall be said to have rheumatoid arthritis if he or she has
satisfied 4 of 7 criteria, with criteria 1-4 present for at least 6 weeks.

16. 2010 ACR/EULAR Classification Criteria
 a score of ≥6/10 is needed for classification of a patient as having definite RA
 A. Joint involvement SCORE
 1 large joint 0
 2−10 large joints 1
1−3 small joints (with or without involvement of large joints) 2
 4−10 small joints (with or without involvement of large joints) 3
 >10 joints (at least 1 small joint)†† 5
 B. Serology (at least 1 test result is needed for classification)
 Negative RF and negative ACPA 0
 Low-positive RF or low-positive ACPA 2
 High-positive RF or high-positive ACP 3
 C. Acute-phase reactants (at least 1 test result is needed for classification)
 Normal CRP and normal ESR 0
 Abnormal CRP or normal ESR 1
 D. Duration of symptoms
 <6 weeks 0
 ≥6 weeks 1

17. LABORATORY INVESTIGATIONS
• CBC-TLC, DLC, Hb, ESR & CRP
• Acute phase reactants
• Rheumatoid Factor (RF)
• Anti- CCP antibodies

18. RHEUMATOID FACTOR
• Antibodies that recognize Fc portion (fragment crystallizable) of IgG
• Can be IgM , IgG , IgA
• 85% of patients with RA over the first 2 years become RF+
• A negative RF may be repeated 4-6 monthly for the first two year of disease, since some
patients may take 18-24 months to become seropositive.
• PROGNISTIC VALUE- Patients with high titres of RF, in general, tend to have POOR
PROGNOSIS, MORE EXTRAARTICULAR MANIFESTATION.
• Causes: Rheumatoid arthritis, Sjogrens syndrome, Vasculitis such as polyarteritis
nodosa, Sarcoidosis, Systemic lupus erythematosus, Cryoglobulinemia, Chronic
liver disease, Infections- tuberculosis , bacterial endocarditis, infectious
mononucleosis, leprosy, syphilis, leishmaniasis, Malignancies, Old age(5% women
aged above 60)

19. ACUTE PHASE REACTANTS
Positve ACR Negative ACR
MILD ELEVATIONS:
- Ceruloplasmin
- Complement C3 & C4
MODERATE ELEVATIONS:
- Heptoglobulin
- Fibrinogen (ESR)
- Alpha-1. acid glycoprotein
- Alpha-1- proteinase inhibitor
MARKED ELEVATIONS:
- C- reactive protein (CRP)
- Serum amyloid A protein
- Albumin
- Transferrin

20. ANTI- CCP
• IgG against synovial membrane peptides damaged via inflammation
• Sensitivity (65%) & Specificity (95%)
• Both diagnostic & prognostic value
• Predictive of Erosive Disease
• Disease severity
• Radiologic progression
• Poor functional outcomes
• OTHER LAB ABNORMALITIES
• Elevated APRs( ESR, CRP )
• Thrombocytosis
• Leukocytosis
• ANA
• 30-40%
• Inflammatory synovial fluid
• Hypoalbuminemia

21. RADIOLOGICAL &
HISTOLOGICAL
FEATURES

22. RADIOLOGICAL FEATURES
• Peri-articular osteopenia
• Uniform symmetric joint space narrowing
• Marginal subchondral erosions
• Joint Subluxations
• Joint destruction
• Collapse
• Ultrasound detects early soft tissue lesions.
• MRI has greatest sensitivity to detect synovitis and marrow changes.

25. STAGES
• I. Periarticular osteoporosis
• II. Osteoporosis + narrowing of joint space (there can be the solitary
erosion)
• III. Same as stage (II) + pleural erosion
• IV. Same as stage (III) + osteal ankylosis

27. HISTOLOGY

28. MANAGEMENT

29. GENERAL CONCEPTS
• Treat early to avoid damage, disability
• Sequential monotherapy is outdated
• If inadequate response to first DMARD, add a second DMARD (―step
up‖)
• Occasionally, combination therapy as intial therapy is indicated

30. CURRENT TREATMENTS FOR RA
• Non-biologic DMARDs
-Methotrexate
-Sulfasalazine
-Leflunomide
• New jak kinase inhibitor
-Tofacitinib
• Biologic DMARDs
-Cytokine inhibitors
> Anti-TNF
> Anti-IL-1
> Anti-IL-6
-Cellular depletion/inhibitor
> B cell depleting
> T cell costimulatory inhibitor

31. RA: INTIAL DMARD TREATMENT
• Hydroxychloroquine
- Only occasionally; for mild disease
• Methotrexate
- Starting dose: 15 mg/wk
- Pre-treatment eval: Hep B/C, baseline H % F xrays, ESR/CRP (plus CBC,
CMP)
- Post- treatment lab monitoring: q 3-4 mos with MD visits
• Exceptions:
- Liver disease: SSZ or TNF inhibitor
- Pre-pregnancy: TNF inhibitor

32. INADEQUATE RESPONSE TO MTX
• By +/- 4 months (at 20-25 mg/wk)
• ADD DMARDs
- If mild activity remaining, HCQ
- If moderate activity remaining:
> SSZ +/- HCQ (―triplr therapy‖) OR
> Leflunomide (Arava) OR
> Biologic: TNF inhibitor

33. BIOLOGIC DMARDS: CYTOKINE INHIBITORS
• Anti- TNF
- Etanercept, adalimumab, infliximab, certolizumab, golimumab
- Efficacy similar; possibly more infectious risk with infliximab
- Infliximab should be used with MTX; others can be used as monotherapy
• Anti-IL-6 receptor – Tocilizumab
- Effective as monotherapy or with MTX
- Elevates lipids more than other biologics; relatively contraindicated in
patients with diverticulosis/itis
• Anti-IL-1
- Anakinra, rilonocept, canakinumab
- Much less effective than other DMARDs except for Still’s disease

34. BIOLOGIC DMARDS: CELL BASED
INHIBITORS
• B cell depleting agent: Rituximab
- Very effective but (very) small risk of progressive multifocal
leukoencephalopathy
• T cell co-stimulatory inhibitor: Abatacept
- Slower onset of action but safer from infectious viewpoint

35. NEW DMARD: TOFACITINIB
# Janus kinase (JAK-3) inhibitor
- Key kinase in signaling of cytokine receptor
> IL-2, IL-4, IL-7, IL-9, IL-15, IL-21
# Oral drug (Xeljanz); dose 5 mg bid; quick onset of action
# Can be used as monotherapy or in combination with other non-
biologic DMARDs
# Potential side effects: cytopenias, lipid
elevations, infections, malignancy

36. THERAPEUTIC CHALLENGE IN RA
• So many effective therapies
• Need for a rational approach based on
• - Comparative effectiveness of agents
• - Pathway differences (e.g , IL-1, TNF, IL-6)
• Biomarkers to pre-identify those who are likely to respond to one
agent but no another

37. PROGNOSIS
The course of the disease varies greatly. Some people have mild short-term
symptoms, but in most the disease is progressive for life. Around 20%–30% will have
subcutaneous nodules (known as rheumatoid nodules); this is associated with a poor
prognosis.
RA is known to reduce the lifespan of patients by anywhere from 3-12 years. A new
line of research does, however, show that the use of new biologic drug therapies
extend the lifespan of patients with RA and reduce the risk and progression of
atherosclerosis.
"Young age at onset, long disease duration, the concurrent presence of other health
problems (called co-morbidity), and characteristics of severe RA—such as poor
functional ability or overall health status, a lot of joint damage on x-rays, the need for
hospitalisation or involvement of organs other than the joints—have been shown to
associate with higher mortality―
Positive responses to treatment may indicate a better prognosis. Research shows that
RA sufferers suffer a doubled risk of heart disease, independent of other risk factors