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Rheumatoid arthritis

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Part 1 Aetiology and epidemiology
In the UK, about 400,000 adults are affected by rheumatoid arthritis (RA), with about 20,000 new cases presenting each year.1 This potentially crippling, chronic, systemic inflammatory disease, which commonly starts between the ages of 35-50, may also develop for the first time in the elderly and is more common in women. The cause of RA is unknown, but it is recognised as an auto‑ immune disease and it is thought that genetic, hormonal and environmental factors - such as bacterial or viral infections in those who, for genetic reasons, may be more susceptible to the disease - play a part.2

Although episodes of remission occasionally occur, the progress of RA is generally downhill, with increasing disability, morbidity and mortality. A poor prognosis is likely in those with persistent synovitis, early erosive disease, extra-articular signs, a positive rheumatoid factor, family history of RA, and in men. About one third of patients are no longer able to work within two years of onset, and life expectancy may be reduced by five-10 years.2

Radiological progression marks increasing functional impairment in RA, due to the thickening of the synovium that produces collagenase and stromelysin - which contribute to cartilage destruction - and the production of the inflammatory cytokines IL-1 and TNF-, which stimulate cartilage destruction and bone absorption.3 This can be modified, or even halted, if treatment is instituted early, preferably within three months of onset of symptoms.1

Aetiology and epidemiology

Rheumatoid arthritis (RA) affects 400,000 people in the UK.

RA is an autoimmune disease in which genetic, hormonal and environmental factors play a part.

RA is a chronic, systemic inflammatory disease.

RA causes increasing disability, morbidity and mortality over the years.

Part 2 Presentation
In the early stages, RA usually presents with pain, swelling and stiffness in a number of joints, most commonly the small joints of the hands and/or feet; larger joints, such as the knees, hips, elbows or shoulders, may sometimes be involved. The distribution of the joint problems tends to be symmetrical, and stiffness is more of a problem in the early mornings or after a period of rest. The swelling results from synovitis associated with inflammation of the synovial membrane that lines joints, tendon sheaths and bursae.

The patient may also complain of feeling tired, run a slight fever and lose weight.

With disease progression, joint deformities occur, particularly in the hands and feet, but other joints may be affected. Hand problems include swan neck deformity, ulnar deviation or Boutonniere's deformity of the fingers, in which there is fixed flexion at the proximal interphalangeal joint (PIP) and extension of the terminal phalanx. Other extra-articular complications include: firm subcutaneous nodules, which occur mainly over pressure points such as the elbow; vasculitis, with the appearance of small nail infarcts or ulcerated areas; neuropathies, such as carpal tunnel syndrome, which result from trapped nerves; and severe problems of spinal cord compression, should subluxation of joints in the neck occur. Involvement of tissues may affect the lung, leading to shortness of breath, cough and chest pains. Renal disease and cardio-vascular problems may also develop, as well as side-effects of medication, e.g. NSAIDs may cause problems such as gastrointestinal ulcers and bleeding.

Referral for specialist opinion

Urgent referral to a specialist should be considered, even if rheumatoid factor is negative, in the following cases:

Persistent unexplained synovitis.

Symptoms affecting the small joints of the hands and/or feet.

More than one joint is affected.

Ideally, referral should be within three months of onset of symptoms.

Part 3 Management
If the prospects for the patient are to be improved, an early diagnosis must be made and other conditions, such as polymyalgia rheumatica, Lyme disease, osteoarthritis, fibromyalgia, psoriatic arthritis, systemic lupus erythematosus or gout, ruled out.4

If a patient is found to have synovitis on clinical examination and the diagnosis of RA is in question, some initial tests are required to confirm the possibility of this disease: rheumatoid factor (RF); anticyclic citrullinated peptide (CCP) antibodies should be taken if the RF is negative or if there is a need to inform decision-making about starting treatment; and X-ray of the hands and feet should be performed when there is persistent synovitis in the small joints of these regions.

NICE recommends that patients be referred early for a specialist full assessment, within three months of the onset of symptoms, so that the implications of the disease can be explained, the various options for management and treatment discussed, and patients made aware of other services that may be of help. It is stressed that patients should have ongoing access to a multi- disciplinary team for advice, support and counselling.1 The current recommendation for treatment of newly diagnosed patients is as follows.

First, a combination of disease-modifying anti-rheumatic drugs (DMARDs), such as methotrexate, together with another drug such as penicillamine, gold, chloroquin, hydrochloroquine or sulfasalazine, should be implemented. A short-term course of glucocorticoid, either by mouth, intramuscularly or into an affected joint, is also recommended, to get the condition under control.

If combination DMARD therapy is not suitable for a newly diagnosed case, a single DMARD should be offered, and the dose increased rapidly to achieve the desired effect. Once control of the condition is gained, it should be possible to reduce the dosage to maintenance levels, while specialist monitoring continues.

Symptom control with analgesics such as paracetamol, codeine or compound analgesic can be offered. A NSAID/cyclo-oxygenase-2 inhibitor, together with a proton pump inhibitor, may be necessary if pain control is insufficient, at the lowest effective dose for the shortest possible time.

Management

First-choice treatment: combination DMARDs.

Short-term course of glucocorticoid recommended.

Symptom control with analgesics (plus PPI).

Long-term monitoring and supervision, with access to multidisciplinary team.

Surgery for irreversible deformity, poor joint function, nerve compression and persistent synovitis.


Part 4 Follow-up and prevention
Unfortunately, there is no known way of preventing the onset of RA, but early intervention with the appropriate treatment should improve the patient's future quality of life. Between 10 and 20 per cent of patients with an acute episode of adequately treated RA may then enjoy some years of remission, but it is likely that the majority will continue to have exacerbations, or persistent and progressive problems.

Although overall supervision should be undertaken by the specialist, professionals in practice will have the opportunity to recognise when things go wrong and be able to discuss the condition with the patient. They will also need to make appropriate referrals back to specialists, physiotherapists, podiatrists and occupational therapists who should all be involved in any given case.

Control of RA may be monitored by regular checks on C-reactive protein (CRP), a marker of inflammation. This should initially be done monthly, until there is satisfactory control, and will indicate the need to raise or lower the level of medication.

Surgery may be considered in case of progressive irreversible deformity, poor joint function, persistent localised synovitis or nerve compression - as in carpal tunnel syndrome.1

Some patients may wish to pursue the course of complementary therapies (fish and plant oils, herbs, vitamins and dietary supplements, or acupuncture) in addition to their treatment. However, although they may obtain temporary relief of symptoms, there is no evidence to suggest that such therapies are of long-term benefit.

Follow-up

Overall supervision should be undertaken by a specialist.

Professionals in practice have the opportunity to recognise when things go wrong and discuss this with the patient.

Professionals in practice also need to make appropriate referrals back to specialists, physiotherapists, podiatrists and occupational therapists.

Resources
National Rheumatoid Arthritis Society: www.nras.org.uk/help_for_you/helpline/default.aspx

Arthritis Research UK: www.arthritisresearchuk.org

Arthritis Foundation - Rheumatoid arthritis: www.arthritis.org/rheumatoid-arthritis.php

Patient UK - Rheumatoid arthritis: www.patient.co.uk/health/Rheumatoid-Arthritis.htm

References
1. National Institute for Health and Clinical Excellence. Rheumatoid arthritis - NICE clinical guideline 79. NICE:London;2009.

2. Smith H. Rheumatoid arthritis - emedicine. Rheumatology. 2010.

3. Altman R. Rheumatoid Arthritis (RA) - Maeck Manual Professional. 2008.

4. Draper R. Rheumatoid arthritis - Patient UK. 2010.

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