Guidelines

Sock's Rheumatoid Arthritis Page 1:

RA affects 1% of the adult population. This low prevalence means that the average family physician often develops little experience with its diagnosis or management.

It is typical of patients with RA that their symptoms wax and wane after diagnosis and treatment decisions.

A typical presentations include intermittent joint inflammation that can be confused with bursitis,tendinitis,gout or pseudogout,proximal muscle pain and tenderness mimicking polymyalgia rheumatica or diffuse musculoskeletal pain seen in fibromyalgia.

Symmetric joint swelling,although not invariable,is characteristic of RA . Careful palpation of the joints can help to distinguish the swelling of joint inflammation from the bony enlargement seen in osteoarthritis.

Fusiform swelling of the PIP joints of the hands is a common early finding. MCP,wrists,elbows,knees,ankles and MTP are other joints commonly affected where swelling is easily detected.

In contrast to gout or septic arthritis,redness of affected joints is not a prominent feature of RA. Pain on passive motion is the most sensitive test for joint inflammation. Occassionally inflamed joints will feel warm to the touch.

Inflammation,structural deformity,or both may limit the range of motion of the joint.

The inflamed joint lining,the synovium,can invade and damage bone and cartilage. Inflammatory cells release many enzymes that may digest bone and cartilage. The involved joint(s) can lose its alignment and shape,resulting in pain and loss of movement.

Symptoms include inflammation of joints,swelling,difficulty moving and pain. Other symptoms may include loss of appetite,fever,loss of energy and anemia.

The body's natural immune system does not operate as it should resulting in the immune system attacking healthy joint tissue, causing inflammation, and subsequent joint damage.

Studies show that patients with active,polyarticular,RF positive RA , have a >70% probability of developing joint damage or erosions within 2 years of the onset of disease.

Other studies suggests that early aggressive treatment may alter the course,and most rheumatoligists who care for patients with RA favor aggressive treatment early in the course of the disease.

Formal diagnosis of RA requires the case meet at least four of the seven ACR criteria;

1) Morning stiffness lasting one hour. In fact,even stiffness for more than 30 minutes strongly suggests inflammatory diseases. Alleviation of morning stiffness with activity is a hallmark of inflammatory arthritis later in the day, continued actual activity will aggravate the problem and exacerbate the pain.

2) Swelling in three or more joints simultaneously.

3) Swelling in the hand joints (PIP,MCP, or wrist).

4) Symmetric arthritis-initially,joints on one side of the body may be involved,but the arthritis tend to spread to the other side of the body.

5) Erosions or decalcifications on x-ray of the hand.

6) Subcutaneous rheumatoid nodules.

7) A positive serum rheumatoid factor assay.

These are ACR guidelines,established under laboratory conditions, and some mild RA patients might not have all of the suggested criteria.

A slightly positive RF is a strong indication of RA but some people without RA have a slight RF in their blood stream. Same with ANA tests. ANA tests suggests the presence of inflammatory disease.

Not all rheumatoid arthritis patients will meet this criteria which was set up for laboratory testing purposes only. The seronegative rheumatoid factor patient may be often found in this category.

The HLA genes are involved with the human immune system. The presence of specific types of the HLA-DR4 gene may be important in predicting the type, the severity,and future course of the disease but not all severe-moderate RA patients will have the marker (guideline if present).

Most doctors use a variety of approaches to treat RA. These are used in different combinations and at different time-frame during the course of the disease,and are chosen according to the patient's individual situation.

Not all patients react equally to the same medication. It may take time to find the right combination for the individual patient.

Treatment is another key area for communication between patient and doctor. Both rest and exercise help in important ways. People with RA,need a good balance between the two with more rest when the disease is more active, and more exercise when it is not. Rest help to reduce active joint inflammation, pain and to fight fatigue.

One of the components associated with RA. Too much rest or inactivity is equally deterrent . Inactivity will result in stiffer joints. The length of time needed for rest will vary from person to person,but in general,a shorter rest break every now and then is more helpful then a long time spent in bed.

Proper exercise is important for maintaining,healthy and strong muscles, preserving joint mobility,and maintaining flexibility. It can help patients sleep better,reduce pain,maintain a positive attitude, reduce stress,and reduce excessive weight.

Programs should be planned and carried out to take in account the person's physical abilities, limitations, and changing needs.

People with RA faces emotional challenges as well as physical. The emotions they feel because of the disease-fear, anger, frustration-combined with pain and physical limitations can increase the stress level and resulting increase in pain. Although there is no scientific evidence that stress causes RA,it is thought it may. It is up to the patient to avoid unnecessary stress.

Most patients take medications. Some medications are used for pain relief, others are used to reduce inflammation. Still others employ DMARDs,to try to slow down the progression of the disease.

The person's general condition, the current and predicted severity of the disease,the length of time the patient will take the drug,and the drug's effectiveness and potential side effects,are important considerations in prescribing drugs,for an individual RA patient--it may take time--be patient

Special diets,vitamin supplements,and other alternative approaches have been suggested for the treatment of RA. Although many of the approaches may not be harmful--some are--controlled scientific studies have not been conducted or have found no definite benefit to these therapys.

Some alternate or complementary approaches may help the patient cope or reduce some of the stress associated with living with a chronic illness. As with any therapy,patients should discuss the benefits and drawbacks with their doctors before beginning an alternative or new type of therapy.

If the doctor feels the approach has value and will not be harmful,it can be incorporated in the treatment regimen. However,it is important,not to neglect conventional therapy.

As far as nutrition goes, a well balanced,nutritional diet is the normal requirement for patients. Unfortunately doctors are trained,little in medical school, in nutrition. Dentists are trained more in nutrition. A dietician should be sought for advice if needed--check creditability--any one can call themselves a dietician.

Some patients will require some form of supplements according to one's condition, which your physician should be aware of.

Drugs used to treat RA may cause death,disability,and diseases, especially if the treatment continues in the setting of undetected toxicity. Prevention of toxicity may be enchanced by pretreatment asssessment of individual risk factors for toxicity and by careful patient and physician education about safe use of the drug.

Patients and their physicians must be alert to the signs and symptoms of toxicity that should promp discontinuation of the drug and physician reassessment. Some drug toxicity may be discovered by appropiate monitoring before serious problems become clinically apparent.

The 3 major drug categories for the treatment of RA are the NSAIDs, DMARDs, and glucocorticoids. Most NSAIDs have common GI and renal toxicity that may be averted by careful patient selection and administeration of the drug. The individual DMARDs have specific toxicities for which monitoring protocols have been developed.

The serious side effects of systemic glucocorticoids are largely related to dose and duration of treatment. There should be basic monitoring in patients with uncomplicated RA.

Additional monitoring may be appropiate for patients with comorbid disease,concurrent medication,or other risk factors

While the utimate goal of treating RA is to induce a complete remission,this occurs only in rare cases.

Complete remission is defined as the absence of :

1)symptoms of active inflammatory joint pain (in contrast to mechanical joint pain).

2) morning stiffness.

4) synovitis on joint examination.

5) elevated erythrocyt sedimentation rate (ESR) or C-reactive protein (CRP) level.

If complete remission is not achieved,the management goals are to control disease activity, alleviate pain,maintain function for essential activities of daily living and work,maximize quality of life,and slow the rate of joint damage.

Patients and their families should understand that the disease is often cyclic in nature,and they should expect "good" and "bad" days. Further,they should understand that their actions on any given day can cause a exacerbation or "flare"of the disease (i.e., a "bad" day). While a patient may never be able to completely stop a bad day,frequently a patient can manage his or her life to reduce a number of bad days.

Central to controlling bad days is planning activities and rest periods. Patients and their families must understand the need for planning virtually every activity of their lives. This is necessary because a patient with this disease can cause a flare by over-working or by increasing physical or emotional stress. Rest and adequate,right,exercise is important for the patient with RA and cannot be overemphasized.

Planning by the patient with RA should be done on a yearly,monthly,and daily basis. E.G., if the patient is considering a vacation,the dates should be marked on a calendar well in advance so there is ample time to pack and adequately prepare the trip. Patients who prepare immediately before the trip may be too fatigued and sore to enjoy the trip,and may initiate a flare.

Similarily,weeks should be planned so that there are rest days interspread with work days. And even the hours of the day could be planned so that after a period of physical activity,a period of rest follows.

Planning should incorporate changes in body position. Patients should be encouraged to change their position frequently during the course of the day. Ideally,position changes should occur every few hours. the patient with RA who sits most of the dy should periodically get up and walk around.

The patient who stands most of the day,should find some way to periodically sit and rest. It should be acknowledged by all involved that at some point changes in life style may need to be made and individualized to patient ability and needs.

There is much evidence that emotional highs and lows play a part in the RA exacerbation. Clearly,we cannot plan for every stressful or emotional situation, but there are some instances when we can. E.G.,if the patient with RA gets overly emotionally involved in a event,avoid it. If driving at night or in bad weather is stressful to the patient,plan to avoid during those times.

One problem with good days,especially in the newly diagnosed patient,is that there may be a tendency to be patient to believe they have been "cured" or that the physician may have incorrectly diagnosed the problem. This is why educating the patient and family is important. Everyone has a opinion on treating or the explanation of "arthritis" (inflammation)----avoid this common pitfall,especially " proven cures".

Changes in therapy of RA during the period 1979 to 1996-- Objective to evaluate the use of DMARDs,cytotoxic agents,and corticosteriods therapy in patients diagnosed with RA in two periods-1979 to 1987 and 1988 to 1996. Review of the records of 788 patients with RA diagnosed at the Department of Rheumatology,

The University Hospital-Scandinavia. Researchers found a significant increase in the proportion of patients who started with auranofin, sulfasalazine, methotrexate and corticosteriod in 1988-96 compared to 1979-87.

The initiation use of gold salts,antimalarials,and D-penicillamine declined significantly from the first to second period.

Patients diagnosed with RA between 1988-96 were treated more actively then patients designed in the period 1979-87.

During 1988-96 auranofin,sulphasalazine,methotrexate and corticosteriod replaced gold salts,antimalarials and D-penicillamine.

RA warning signs can represent a worsening or complications of the disease, side effects of medication,or a new illness that is complicating the conditions of patients with RA. Patients with RA should be aware of these signs so they can contact their physician.

Lack of improvement of joint symptoms-if it is showing no improvement or worsening,advise your doctor. After starting a new treatment program it sometimes take time for the medication,physical therapy etc. to control the inflammation.

Fever- A mildly elevated temperature is not unusual in person with active inflammation from RA. A true fever (temperature above 100.4 F. or 38 degrees C.) is not normal and can suggest infection. RA patients are prone to increased risk because of the disease itself and because of their medications.

Many of our medications suppress the immune system of the body,that is responsible for defending against infectious microbes. These medications can increase the risk of a more serious infection when a bacteria or virus strikes.

Tender,warm.swollen joints.

Symmetrical pattern.e.g., if one knee is affected,the other one is also.

Joint inflammation often affecting the wrist and finger joints closest to the hand,other affected joints can include those of the neck, shoulders, elbows, hips, knees, ankles, and feet-(toes-sole).

Fatigue,occasional fever,a general sense of not feeling well (malise)

Pain and stiffness lasting for more than 30 minutes in the morning or after a long rest.

Symptoms can last for many years.

Symptoms in other parts of the body besides the joints.

Variability of symptoms among people with the disease.

Laboratory Tests:

The usefulness of laboratory tests in assessing Rheumatoid Arthritis:

O= not useful in making diagnosis.

1= positive or negative is rarely helpful in investigating the condition.

2= positive or negative is sometimes useful helpful.

3= a positive or negative test is often helpful.

4= a positive or negative test is always helpful in investigating the condition.

5= ANA=antinuclear antibodies

6= HLA-B27--CBC=complete blood count. ESR= erythrocyte sedimentation rate. CRP = C-reactive protein. RF = rheumatoid factor, SFA = synovial fluid level.HLA =human leukocyte antigen.--4/8/00--CMAJ Table of Contents, Rheumatology:

Usefulness of laboratory tests in assessing disease after physical examination and history.

CBC=3,ESR=3,CRP=1,RF=3, ANA=2, SFA=3,HLA-B27=0 --(The presence of different types of the HLA-DR4-gene, may be useful to help in predicting the type,the severity.and future course of RA--Test not done reguarily in clinical practise,same for CRP,which measures inflammation--Rheumatology./2000 issue.

HLA-DR4 gene while found in some moderate-severe patients it is not present in all patients in the group.) The presence of HLA-DR4 antibody in 70% of patients with RA lends support to the genetic predisposition to the disease. Rheumatoid Factor (s) (RF) are antibodies to IgG,and are present in 60-80 % of adults with the disease.

High titers of RF are usually associated with more severe and active joint disease,greater systemic involvement,and a poorer prognosis of remission. RA,as well as other autoimmune diseases,includes widespread immunologic and inflammatory alterations of connective tissue. Because the autoimmune diseases share many clinical findings,making a differential diagnosis may be often difficult.

Although the autoimmune disorders are considered acquired diseases,their causes usually cannot be determined. The etiology of RA remains unknown. Metabolic and nutritional factors,the endocrine system, geographic, phychologic, and occupational data have been extensively studied with no conclusive findings.

Some researchers say a unknown antigen initiates the autoimmune response resulting in RA,but it is not a definite established fact.

There also has been continuous suspicion of an infectious origin of the disease process,which has included various bacteria and viruses,but without evidence of precipitating events or scientific evidence.

Pregnancy and JRA: The course of RA during pregnancy is usually benign. In about three fourths of pregnancies, the symptoms of the disease lessen. In these cases, most women experience relief in the first trimester that continues throughout the pregnancy. RA does not adversely affect pregnancy outcome. With occasional exception, RA returns after the third to fourth month postpartum.

Juvenile chronic arthritis by definition starts before the age of 16. It not only affects the joints but can also have extra-articular manifestations. Patients suffering from this disease may have difficulties in pregnancy. Growth inhibition of the pelvis or hip may interfere with a vaginal delivery.

The temporomandibular joint and larynx can be involved in young patients and should be considered in case of difficulty with intubation, if needed. However, in the only reported case series, by Nelson and Ostensen, patients with juvenile-onset RA seem to experience improvement during pregnancy. There was no increased risk of poor pregnancy outcomes.

The diagnosis is made on the basis of clinical evaluation and with the supporting laboratory data, namely the presence of rheumatoid factor. This should be positive within 1 year of onset of the disease. Generally, titers of 1:160 or greater confirm the diagnosis.

Unfortunately, other etiologies can result in positive titers, such as other rheumatic diseases, chronic inflammatory processes (such as tuberculosis), and subacute bacterial endocarditis.

Treatment of RA in pregnancy mostly entails drug therapy. Clinicians must determine which agent is safe and effective for a given patient. Acetaminophen should be the first line, and, if not adequate, other nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin should be considered depending on the gestational age of the fetus (NSAIDs used in the third trimester can result in premature closure of the fetal ductus arteriosus).

If these agents do not provide relief, corticosteroids are the next line of treatment. Sulfasalazine and penicillamine treatment also seem to be safe for use during pregnancy. Antimalarial drugs such as chloroquine should be avoided, as they may cause chorioretinitis in the fetus. Gold causes blood dyscrasias, drug rashes, and nephropathy and is therefore of theoretical risk to the fetus.