RHEUMATOID ARTHRITIS – Symptoms, Diagnosis and Treatment

Rheumatoid Arthritis is a chronic systemic autoimmune disorder. It involves mainly synovium ( soft tissue lining the joint, tendon and bursae) of various joints in our body. Rheumatoid Arthritis affects 1% population of the world. Females are more commonly affected than males (3: 1 female-male ratio). This is a systemic disorder as it involved multi-system other than joints. Rheumatoid Arthritis differs from osteoarthritis as osteoarthritis is a degenerative disease. 

SIGNS AND SYMPTOMS

Symptoms vary from patients to patients. sometimes there is a ‘flare’ of the disease-causing severe joint pain and disability, Sometimes there is ‘remission’ where the patient is totally free from pain. Symmetric swelling of multiple joints with tenderness is common. The primarily single joint is affected initially. Then gradually progress to multiple joints. Early morning stiffness for more than half an hour is a pathognomonic symptom of Rheumatoid Arthritis. Stiffness of joint may increase during inactivity or overactivity commonly involved joints are PIP ( Proximal Interphalangeal Joint), MCP ( Metacarpophalangeal Joint ), MTP ( Metatarsophalangeal joints), wrist, ankle, knees, etc.

RHEUMATOID NODULE

Rheumatoid Nodule is a subcutaneous nodule found over bony prominences especially near the elbow joint. It can be found over bursae or tendon sheath or even lung.

EYE SYMPTOM

The eye is also involved in Rheumatoid Arthritis. Dry eyes, episcleritis, scleritis, ulcerative keratitis, scleromalacia are common ocular symptoms. Sometimes dry mouth like features is also seen.

OTHER SYMPTOMS

Other extraarticular symptoms are interstitial lung disease, pericarditis, pleural disease, and palmar erythema. These symptoms occur rarely. Sometimes Rheumatoid Arthritis is associated with neutropenia and splenomegaly. This is called Felty’s Syndrome.

INVESTIGATIONS

SEROLOGICAL – Rheumatoid Arthritis factor or rheumatoid factor estimation from serum is the most commonly used serological test. It is not a gold sensitive test. Rheumatoid factor can be found in other autoimmune diseases or chronic syphilis, chronic tuberculosis also. Anti-CCP antibody is the most specific test for Rheumatoid Arthritis. It is almost 95% specific and can be detected in early Rheumatoid Arthritis.

RADIOLOGICAL

Along with serological test radiological tests are also specific for Rheumatoid Arthritis. At the early stages of the disease radiological changes are mild or normal. The earliest radiological changes are found in hands or feet includes soft tissue swelling. In advanced stages, joint space occurs. Soft tissue swelling can be easily detected by MRI (Magnetic Resonance Imaging) or USG (Ultra Sonography). Joint erosion or deformity may be seen in x-ray also.

TREATMENT

The primary goal of Rheumatoid Arthritis treatment is to reduce joint pain and inflammation and prevent joint deformity. Early diagnosis and treatment is the main key to prevent joint deformity. Drugs are given for symptomatic relief and prevention of joint erosion. NSAIDs give only symptomatic relief but it lacks preventing joint damage.

  • CORTICOSTEROIDS – Corticosteroid not only reduces inflammation but also decreases joint erosion. Corticosteroids should be given at low doses like oral prednisolone 5-10 mg daily. Higher doses of corticosteroids are given for extra-articular manifestations. Corticosteroid should not be stopped abruptly, it must be tapered off. Intraarticular corticosteroid ( specially triamcinolone) is given where joint pain is severe.
  • DMARDs – DMARDs ( Disease Modifying Anti Rheumatoid Drugs ) are the most specific and most useful drugs for Rheumatoid Arthritis patients. Early treatment with DMARDs prevents joint erosion and disease progression. Commonly used DMARDs are methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, and tofacitinib.
  1. Methotrexate – It is the most effective drug and acts by suppressing the body’s immunity. It is usually given 7.5mg per week orally. Common side effects of methotrexate are gastritis and stomatitis. Methotrexate also causes bone marrow suppression. Folinic acid supplementation is essential during methotrexate therapy.

2. Sulfasalazine – This DMARDs group drug is also used to treat Rheumatoid Arthritis. It causes hemolysis in G-6PD deficiency patients and reduces serum folic acid. Hence, serum G-6PD levels must be measured before starting sulfasalazine. Folic supplementation is also given to restore serum folic acid. Sulfasalazine also causes neutropenia and thrombocytopenia. CBC ( Complete Blood Count ) should be done at regular intervals during sulfasalazine therapy.

3. Hydroxychloroquine – Though hydroxychloroquine is an antimalarial drug it is also used to treat Rheumatoid Arthritis. The most important side effect of hydroxychloroquine is pigmentary retinitis. For this reason, eye check up is necessary every year.

4. Leflunomide – Leflunomide is another DMARDs found to be useful in Rheumatoid Arthritis. It is given usually 20mg orally single dose. This drug causes liver damage, diarrhea and hair loss.

5. Tofacitinib – Tofacitinib is useful for methotrexate-resistant Rheumatoid Arthritis. It acts by inhibiting the janus kinase 3 enzyme.

  • TNF – Alpha Blockers – There are three TNF – Alpha Blockers that are commonly used to treat severe Rheumatoid Arthritis or drug-resistant Rheumatoid Arthritis. These drugs are infliximab, adalimumab, etanercept. Infliximab is available in intravenous injection or infusion form. Adalimumab is given in a subcutaneous route every alternate week (40mg). Etanercept is also given as 50 mg subcutaneous injection weekly. Latent tuberculosis should be investigated before starting TNF alpha-blockers.

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