•           RA is a chronic multisystem disease of unknown etiology characterised by its pattern of diathrodial joint involvement.

•           Its primary site of pathology is synovium in joints.

•           It usually involves peripheral joints in symmetric distribution

•           Joint changes probably represent autoimmune reaction

Pattern of onset

•           Insidious onset:- 60-70% cases, over weeks to months with symmetrical joint involvement

•           Acute onset :- 8-15 % cases. Less symmetrical, extremely painful joints, diffuse pain in surrounding tissues.

•           Intermediate onset:- 15-20% cases develop symptoms over days to weeks.

Investigations: lnflammtory Markers

•               ESR: Is raised during acute phase and levels fall slowly-after 1 week fall is about 50%.

•               CRP: Acute phase reactant. Level falls down quickly. It distinguishes between inflammtory and non inflammtory arthritis.

Antibodies

RA Factor: positive in 70% at the onset.

·       It is a lgM subclass.

·       With higher RA Factor titre patients develop more severe and eroding arthritis than RA Factor -ye patients

Anti CCP Antibody: It has high sensitivity and specificity.

•           It is a predictor of erosive disease and joint damage

•           New markers of diagnosis of RA is MMP-3

•           Matrix metaloprotinase (MMP-3) play an important role in remodelling of extracellular matrix.

•           MMP-3    is     produced    by    articular    synovial                 cells,                    fibroblasts         and chondroblasts.

•           Stromelysins (MMP-30 PRODUCTION IS INCREASED IN RA)

Hematological Parameters: Normocytic normochromic anemia

Plain radiography; describes bone erosions, joint space, bone alignment, soft tissue swelling, etc

Before proceeding towards treatment of RA, following points should be kept in mind

•           Nothing is 100%

•           Good history and physical examination along with knowledge of musculoskeletal system is important when evaluating a patient of RA

•           Do not order lab tests unless you know why to order and what to do if it comes back abnormal.

•           Patients with chronic inflammatory monoarticular arthritis of >8 weeks duration whose evaluation has failed to define an etiology needs synovial biopsy

•           All patients with +ve RA Factor do not have RA.

•           If associated with high grade fever, rule out infection.

Criteria

In 2010 the 2010 ACR / EULAR Rheumatoid Arthritis Classification Criteria were introduced. These new classification criteria overruled the "old" ACR criteria of 1987 and are adapted for early RA diagnosis. The "new" classification criteria, jointly published by the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) establish a point value between 0 and 10. Every patient with a point total of 6 or higher is unequivocally-classified as an RA patient, provided he has synovitis in at least one joint and is no other diagnosis better explaining the synovitis.

Four areas are covered in the diagnosis

•           Joint involvement, designating the metacarpophalangeal joints, proximal interphalangeal joints, the interphalangeal joint of the thumb, second through third metatarsophalangeal joint and wrist as small joints, and elbows, hip joints and knees as large joints:

•           Involvement of 1 large joint gives 0 points

•           Involvement of 2-1 0 large joints gives 1 point

•           Involvement of 1-3 small joints (with or without involvement of large joints) gives 2 points

•           Involvement of 4-10 small joints (with or without involvement of large joints) gives 3 points

•           Involvement of more than 10 joints (with involvement of at least 1 small joint) gives 5 points

Serological parameters -including the rheumatoid factor as well as ACPA - 'ACPA" stands for 'anti-citrullinated protein antibody":

•           Negative RF and negative ACPA gives 0 points

•           Low-positive RF or low-positive ACPA gives 2 points

•           High-positive RF or high-positive ACPA gives 3 points

Acute phase reactants: 1 point for elevated erythrocyte sedimentation rate, ESR, or elevated RP value (c - reactive protein)

Duration of arthritis: 1 point for symptoms lasting six weeks or longer

Treatment:

Aims

•           Relief of inflammation and pain

•           Correction and control of systemic manifestations

•           Prevention of deformity

•           Correction of existing deformity

•           Improvement of functional capacity

Supportive measures

•           Patient education

•           Behavioural modifications

•           Rest

•           Splints- orthotic devices

•           Physical therapy

Pharmacological treatment

•           Analgesics

•           NSAIDs: Naproxen and etoricoxib can be used for a longer period

•           Naproxen500mgBID

•           Piroxicam20mgQlD

•           Aceclofenac 100 mg BD

•           Diclofenac sodium 50 mg TDS

•           Etoricoxib 60-120 mg OD or BD

•           Glucocorticoids: -are given for short time to-suppress the inflammatory process.

•           DMARD's

DMARD - disease modifying antirheumatic drugs

D-penicillamine

125-250 mg OD then increase to 250 mg BD. Hydroxychloroquine

6.5 mg/kg/day or 2 00 - 400 mg per day.

Leflunomide

Start with 100 mg /day as a loading dose for 3 days then 20mg per day

Methotrexate (Mtx)

15-25 mg weekly along with folic acid 1 mg/day to reduce the toxicifies.

Sulfasalazine (SSZ)

40mg/kg/day

In addition, less used DMARDS are Azafhioprine, Cyclosporine and gold

salts.

These drugs can be used for a long time depending upon the response.

However, time tested and reliable drug is methotrexate which should be given to every patient. For side effects CBC, creatinine, LFTs should be done every 2-3 months.

First line treatment

1.                Any NSAIDs to subside the symptoms.

2.                Methotrexate should be started along with to modify the disease process. In addition, if the symptoms are severe, any other DMARD can be added to the therapy because combination therapy has shown excellent safety and efficacy over methotrexate alone.

3.                Steroid are not a preferred drug but in full flare up of the joint it should be used for a short period to suppress the inflammation and to avoid joint damage.

Combination DMARD therapy MTX + SSZ + OH-Chloroquine MTX + Leflunomide

Biologic Therapies, or Biologics

These are newer drugs that reduce inflammation in a more highly targeted manner than DMARDs. These are used when there is inadequate response with the DMARDS. These new drugs are very expensive and not easily available and full efficacy is still to be evaluated.

Surgical Treatment

Reserved for patientswith severely damaged joints It includes

·                 Arth roplasty/ Total joint replacement

·                 Open/Arthroscopic synovectomy

·                 Reconstructive hand surgery