Rheumatoid Arthritis

(RA)
CPG of RA 2019
Dr. wan ahmad khairulsani
 Contents
 Definition 
 Diagnosis 
o Investigation
 Classification ACR/EULA
 Prognostic criteria
 Treatment 
o Pharmacological 
 Definition
• Rheumatoid arthritis (RA) is a chronic and progressive autoimmune
disease which primarily affects the joints.
• It is characterised by :
uncontrolled proliferation of synovial tissue
 and a wide array of multisystem co-morbidities
(extra-articular)
(CPG Management of RA 2019)
Diagnosis
• The key presenting symptoms of joint inflammation are:
 joint pain and swelling
early morning stiffness lasting ≥60 minutes
 present for at least 6/52.
• The typical articular pattern of RA is symmetrical polyarthritis affecting:
a) metacarpophalangeal (MCP) joints
b) proximal interphalangeal (PIP) joints
c) interphalangeal joint of thumbs
d) wrists
e) elbows
f) metatarsophalangeal (MTP) joints
Ddx 
Rheumatic Psoariatic Gout Osteoarthritis
Arthritis (RA) Arthritis (PsA) (OA)
Age onset variable  (average ≥ 30 years old adulthood ≥ 45 years old
30-50years old)
Joint distribution symmetric Asymmetric Asymmetric Asymmetric
No. of affected Polyarticular Oligoarticular Mono or Mono or
joints oligoarticular oligoarticular
Sites of hand Proximal (MCP & Distal (DIP) Distal Distal
involved PIP)
Morning stiffness +++ +/- - -
Investigation
• Specific Blood ix:
1. Inflammatory markers:
i. ESR and/or
ii. C-reactive protein (CRP)
2. Rheumatoid factor (RF) and/or
3. Anti-citrullinated peptide antibody (ACPA)*
 *ACPA is interchangeable with anti-cyclic citrullinated peptide (anti-CCP)

• Presence of both RF and ACPA indicate a more severe disease.

• ACPA should be considered in clinically suspected RA where RF is
negative.
 Imaging
Hand x-ray
 May normal in initial 6/12 presentation
• soft-tissue swelling,
• juxta-articular demineralization
• joint space narrowing
• bone erosions.
 These changes are symmetrical and spare the distal IP joints.
Imaging
Musculoskeletal ultrasound
 Detect bone erosion or synovitis (subclinical)
 to aid early diagnosis and management
 Ultrasound is more accurate than clinical assessment in early RA
  combining ultrasound detected synovitis joint counts with 2010 ACR/EULAR
classification criteria increased diagnostic sensitivity from 55.2% → 72.4% and specificity
from 78.5%  →  87.7%

Magnetic Resonance Imaging

 Good modality but it use limited due to cost and availability
CLASSIFICATION
CRITERIA
(ACR/EULAR) 2010
 A score of ≥6 is classified as having
definite RA
 A score of <6 may fulfil the criteria over
time
 Prognostic criteria
a. Older age
b. Female
c. Obesity
d. Smoking
e. Positive marker ( RF/anti-ccp/ACPA)
f. High level ESR/CRP
g. Anemia
h. High erosion score at baseline
Treatment 
Algorithm treatment CPG of RA 2019
 EULAR RA(2019)
management
recommendations
 Therapy with DMARDs should be started as
soon as the diagnosis of RA is made
 DMARDs delay disease progression, preserve
joint integrity and minimise systemic
complications
 Corticosteroids serve as a bridging therapy
while awaiting the initiation and/or effect of
DMARDs
 NSAIDs are generally used for symptomatic
treatment on a short-term and/or as needed
basis
 Treatment should be aimed at reaching a target
of sustained REMISSION or LDA
 Outcome
measure 
 28 joints assessed are :
 PIP joints (10 joints)
 MCP joints (10)
 wrists (2)
 elbows (2)
 Shoulders (2)
 knees (2)

• TJC : Tender joint count

• SJC : Swollen joint count
• PGA: Patient Global disease Activity
• EGA: Evaluator Global disease Activity
Pharmacological treatment

N-SAID :
o Adjunct therapy to relieve pain and reduce inflammation in RA
o Topical or oral form
o SE : GI disturbance, renal and CV systems

Corticosteroid :
o primarily be used as bridging therapy until csDMARDs exhibit their efficacy (up to 8 weeks).
o Use for short term therapy (<3/12) as add-on therapy to csDMARDs
o Supplemented with calcium and vit-D to prevent osteoporosis
Conventional synthetic DMARD DMARDs
Targeted synthetic DMARD
(tsDMARD)
(csDMARD)
methotrexate MTX • Tofacitinib
Sulfasalazine SSZ • Baricitinib
Hydroxychloroquine HCQ
leflunomide

Biologic (bDMARD)
DMARDs
Biosimilar DMARD
• Anti-TNF :infliximab (IFX), etanercept (bsDAMRD)
(ETN), adalimumab (ADA) and • Infliximab
golimumab (GOL) • Adalimumab
•  IL-6 receptor blocker: tocilizumab
(TCZ)
• Anti-B cell agent: RTX
csDMARDs
tsDMARD/bDMARD/bsDMARD
Pharmacological Treatment
csDMARD
tsDMARDs & bDMARDs