RHEUMATOID

ARTHRITIS
By:
Claudio Wangta
Oky Cahyanto
 What is Rheumatoid Arthritis ?
• Chronic autoimmune multisystemic inflammatory disease which affects many
organs but predominantly attacks the synovial tissues and joints producing
inflammatory synovitis

• The name is based on the term “rheumatic fever”, an illness which include joint
pain and is derived from Greek words “rheumatos” meaning flowing and the suffix “-
oid” means resembling thus giving it the translation as Joint Inflammation
resembling rheumatic fever
 Epidemiology

• RA has an overall prevalence of 0.5-1%. There is a female predominance, with the

disease being 2-3 times more common in women. Mostly found at 40 and 50 y.o
and no later than 80 y.o.
 Risk Factor

• Risk factors for systemic, extraarticular disease include age, presence of rheumatoid
factor (RF) or antinuclear antibodies, human leukocyte antigen (HLA)-DRB1
‘shared epitope’ alleles, early disability, and smoking.

• Patients with severe extraarticular RA often have high levels of RF at presentation

of systemic manifestations and are more likely to have circulating antibodies against
citrullinated proteins than are patients with RA but without extraarticular disease
 Patophysiology
• Aetiology is unknown, and probably multifactorial. It is generally considered that a genetic predisposition (HLA-DR B1
which is the most common allele of HLA-DR4 involved in RA) and an environmental trigger (Epstein-Barr virus

postulated as a possible antigen, but not proven) lead to an autoimmune response that is directed against synovial

structures and other organs.

• Activation and accumulation of T CD4 cells in the synovium starts a cascade of inflammatory responses which result in:

 Activation of the macrophages and synovial cells and production of cytokines such as IL4 and TNF, which in turn cause
proliferation of the synovial cells and increase production of destructive enzymes such as elastase and collagenase by

macrophages
 Patophysiology
 Activating B cell lymphocytes to produce various antibodies including rheumatoid factor (RF-IgM antibodies against Fc portion
of the IgG) which makes immune complexes that deposit in different tissues and contribute to further injury

 Directly activate endothelial cells via increased production of VCAM1, which increases the adhesion and accumulation of
inflammatory cells

 Producing RANKL which in turn activate osteoclasts causing subchondral bone destruction

• The inflammatory response leads to pannus formation. Pannus is an oedematous thickened hyperplastic synovium infiltrated by
lymphocytes T and B, plasmocytes, macrophages and osteoclasts. Pannus will gradually erode bare areas initially, followed by the
articular cartilage. It causes a fibrous ankylosis which eventually ossifies
 Rheumatoid Arthritis Sign and Symptoms
(Need to have 4 of 7)
• Morning Stiffness : ±1 hour before maximal improvement

• Arthritis of 3 or more joint area observed by the physician. 14 possible joint area involved are PIP, MCP, wrist,
elbow, knee, ankle, and MTP joint. Especially 2nd and 3rd PIP and MCP, DIP spared.

• Arthritis of hand joints are symmetrical

• Rheumatoid Nodule (found at olecranon-behind the elbow, calcaneal tuberosity-heel bone, MCP joint-hands)

• RF (+)

• Radiographic changes : erosion or bony decalcification

 Distribution of RA

• Affect small and medium

sied joint
• Typical symmetrical
inflammation in the wrist
and/or MCP joint
• SPARES DIP
 3 Kinds of deformities at RA
• Z Deformity  radial deviation at the wrist,
ulnar deviation of the digits, and often,
palmar subluxation of the proximal phalanx

• Swan neck Deformity  Hyperextension of

PIP, flexion of DIP

• Boutonniere Deformity  Flexion of PIP,

extension of DIP
Radiology Changes in Patient with RA
• The radiographic hallmarks of rheumatoid arthritis are:
1. Soft tissue swelling
2. Osteoporosis: initially juxta-articular
3. Joint space narrowing
4. Marginal Erosion: due to erosion by pannus of the “bare areas”
Radiology Changes in Juxta-Articular
Treatment of RA
 CORTICOSTEROID In RA
• Is an important adjuncts in management of RA
• Indication for systemic steroid are:
1. Treatment of rheumatoid flares
2. Treatment of extra-articular RA like vasculitis and ILD
3. As bridge therapy for 6-8 weeks before the action of DMARD begins
4. Maintenance dose of 10 mg or less of prednisolone daily in patient with active RA
5. In pregnancy, DMARD cannot be used