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Rheumatoid arthritis

Dr Rajesh Varma

CKS Rheumatoid Arthritis

Patient website Versus Arthritis

Abbreviations

Conventional disease modifying anti-rheumatic drug (cDMARD)

Definition

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease, typically affecting the small joints of the hands and the feet
(usually both sides equally and symmetrically) although any synovial joint can be involved.

Prevalence

RA affects 1% of the UK population.
The incidence of the condition is low: 1.5 per 10,000 per year (Men) and 3.6 per 10,000 per year (Women)

The incidence increases with age, with a peak onset at 30–50 years.
RA is 2–4 times more common in women than in men.

Complications

  • CNS: Neuropathy, Cervical myelopathy, Depression.

  • RS: Interstitial lung disease, pleural effusion, fibrosing alveolitis.

  • CVS: Cardiovascular disease, Pericarditis

  • Dermatology: Vasculitis, vasculitic ulcers, rheumatoid nodules.

  • Eye: Dry eye syndrome (keratoconjunctivitis sicca), peripheral ulcerative keratitis.

  • MSK: Carpal tunnel syndrome, Increased joint replacement surgery, Tendon rupture, avascular necrosis (pain without synovitis)

  • Metabolic/endocrine: Amyloidosis, Anaemia.Felty's syndrome (enlarged spleen and low white blood cell count)

  • Malignancy: Lymphomas — the risk is double in people with RA, independent of immunosuppressant use.

  • General systemic: Fatigue.Weight loss.

  • Serious infections.

  • Increased mortality.

Complications associated with drug treatment

  • Gastrointestinal problems — NSAIDs

  • Infection — glucocorticoids and immunosuppressants

  • Liver toxicity — methotrexate-related.

  • Malignancy — particularly TNF-alpha inhibitor-related (increased risk of skin cancer).

  • Osteoporosis — glucocorticoid related and inherent to RA condition independently of glucocorticoid use.

Diagnosis

  1. Persistent synovitis, where no other underlying cause is obvious (for example, psoriatic arthritis).

  2. Symmetrical synovitis of the small joints of the hands and feet, although any synovial joint may be affected.

  3. Pain, swelling, heat and stiffness (early morning) in affected joints;

  4. There is a positive metacarpophalangeal squeeze test +/- inability to make a fist or flex fingers

  5. Additional features: Rheumatoid nodules (extensor surfaces), vasculitis, other body systems (for example, eye, lungs, and heart), fatigue, fever, weight loss, sweats

Primary care investigations pending specialist assessment

  1. blood test for rheumatoid factor, anti-cyclic citrullinated peptide (anti-CCP) antibodies

  2. X-ray of the hands and feet — these help with diagnosis and determination of disease severity.

  3. Full blood count, renal and liver function tests

  4. C-reactive protein or erythrocyte sedimentation rate

Differential Diagnosis

  • Connective tissue disorders — systemic lupus erythematosus (SLE): non-deforming polyarthritis in the small joints of the hands and feet, rash, mouth ulcers, alopecia, Raynaud's syndrome or Sicca syndrome.

  • Fibromyalgia — numerous myofascial trigger points and somatic symptoms are present.

  • Osteoarthritis

  • Polyarticular gout

  • Polymyalgia rheumatica — shoulder pain and stiffness

  • Psoriatic arthritis — small joints of the hands and feet, but is less often symmetrical, involves distal interphalangeal joints, Psoriasis is present,

  • Reactive arthritis — to recent had a viral or bacterial infection.

  • Sarcoidosis

  • Septic arthritis — suspect this if a single joint is hot and swollen, especially if there are signs of sepsis (such as fever).

  • Seronegative spondyloarthritis — suspect this if there is a history of psoriasis, back pain, or bowel problems.

Referral

  1. Refer people with persistent synovitis with an unknown cause to a rheumatologist for an appointment (within 3 weeks of referral) for specialist assessment.

  2. Refer URGENTLY, within 3 working days of presentation if any of the following are present:

    Small joints of the hands or feet are affected.

    More than one joint is affected.

    There has been a delay of ≥ 3 months between the onset of symptoms and the person seeking medical advice.

Initial management of suspected RA

Offer NSAID, at the lowest effective dose for the shortest possible along with a proton pump inhibitor (PPI) until a rheumatology appointment is available.
Do not prescribe a glucocorticoid in primary care before a specialist assessment is carried out

Drug treatment of RA (initiated by Rheumatologists)

The dose is increased, depending on tolerance, in order to achieve the treatment target (remission or low disease activity)


1st line Monotherapy Conventional disease modifying anti-rheumatic drug (cDMARD) as monotherapy PLUS Short-term bridging treatment with glucocorticoids

methotrexate

leflunomide

sulfasalazine.

Hydroxychloroquine (palindromic disease).

Short-term (2-3 months) bridging treatment with glucocorticoids (oral, intramuscular or intra-articular) may be used when starting a new cDMARD to improve symptoms while waiting for the new DMARD to take effect.

2nd line Additional cDMARDs in combination

3rd line Biological DMARDs
Used in combination with methotrexate, or alone (depending on the product licence) for people who cannot take methotrexate

Management of RA flare in primary care

  1. Excluding septic arthritis (suspect this if a single joint is hot and swollen, especially if there are signs of sepsis). 

  2. Seeking specialist advice.

  3. Offering short-term treatment with glucoccorticoids (preferably intra-articular, otherwise intramuscular, or an oral).

Other aspects of primary care management

  • Ensure that all adults with RA have:

  • Rapid access to specialist care for flares.

  • Ongoing drug monitoring — regular blood monitoring required for individual DMARDs if this is not carried out in secondary care) and NSAIDs - prescribing issues.

  • Check for the development of comorbidities, such as hypertension, ischaemic heart disease, osteoporosis and depression.

  • Assess symptoms that suggest complications, such as vasculitis and disease of the cervical spine, lung or eyes.

  • Offer pneumococcal and yearly influenza vaccinations

Referral to a specialist for a surgical opinion

  • Persistent pain due to joint damage or other identifiable soft tissue cause.

  • Worsening joint function.

  • Progressive deformity.

  • Persistent localized synovitis.

  • Imminent or actual tendon rupture.

  • Nerve compression.

  • A stress fracture.