case DISCUSSION

RA, OA and Gout

• Rheumatoid Arthritis is a chronic multisystem disease of unknown cause characterized by a symmetrical arthritis, with pain, swelling and stiffness

• Osteoarthritis is a degenerative joint disease, a type of arthritis that is caused by the breakdown and eventual loss of the cartilage, it represents failure of the diarthrodial (movable, synovial lined) joint.

• Gout is a disease that involves the build-up of uric acid in the body. Excess uric acid causes needle-shaped crystals to form in the synovial fluid.

Rheumatoid Arthritis:• autoimmune disease that causes chronic

inflammation of the joints • The symptoms can come and go, and each person

with RA is affected differently. • Other people have times when the symptoms get

worse (flares), and times when they get better (remissions).

• Others have a severe form of the disease that can last for many years or a lifetime. This form of the disease can cause serious joint damage.

• More often in women• Often starts during the 4th & 5th decades of life.

Pathogenesis

Rheumatoid Arthritis

• CHARACTERISTIC FEATURE: persistent inflammatory synovitis, involving the

peripheral joint in a symmetrical distribution• HALLMARK:

potential to cause cartilage damage, bone erosions and changes in joint integrity

ONSET OF RHEUMATOID ARTHRITIS:

1. Insidious - in approximately 2/3 of patients, systemic manifestations, including, fatigue, anorexia, musculoskeletal symptoms may precede overt symptoms of arthritis by months.

• In some patients, external events (major infections, surgical procedures, trauma, or childbirth) precede the clinical onset.

• insidious onset followed by progression to polyarticular involvement is the most common course.

2. Acute – occurs in approximately 10% of patients

• rapid development of polyarthritis accompanied by constitutional symptoms including fever, lymphadenopathy and splenomegaly

Rheumatoid arthritisSIGNS & SYMPTOMS:

• Stiffness- morning stiffness is one of the hallmark symptoms of rheumatoid arthritis

• Swelling – synovial fluid enters into the joint, hypertrophy of the synovium, thickening of the joint capsule

• Pain aggravated by movement – most common manifestation. Inflammation inside a joint makes it sensitive and tender.

SIGNS & SYMPTOMS:

• Skin nodules • Redness • Warmth - in large joints especially the knee

Rheumatoid Arthritis:

• This disease often occurs in more than one joint and can affect any joint in the body.

• Hands are most often affected • Swelling and tenderness are usually noted first at the

metacarpophalangeal and proximal interphalangeal joints Fusiform swelling at the proximal interphalangeal joints is typical.

• Distal interphalangeal joints - usually spared. • Grip strength - decreased because of pain and

mechanical derangement.

Rheumatoid Arthritis:

The hand and wrist are common sites of synovitis in rheumatoid arthritis. Marked swelling in the wrist and metacarpophalangeal joints is caused by

synovial proliferation. Modest ulnar deviation of the fingers is also

present.

Rheumatoid Nodules:

• Rheumatoid nodules commonly form near the extensor surface of the elbow. They can be fixed to the underlying periosteum or can be freely mobile.

Rheumatoid Nodules:• Rheumatoid nodules are the most common extra-articular

manifestation, occurring in about 15% of patients. • Subcutaneous • Found in areas exposed to pressure -- over the extensor

surfaces of the forearm, the olecranon bursa, the knuckles, the ischial regions, the Achilles tendon, and the bridge of the nose . Also occur in viscera.

• Firm and are either freely movable or attached to connective tissues

• Size - from a few millimeters to more than 2 cm in diameter and often occur in clusters.

• Have a rubbery or gritty feel and can be indistinguishable from gouty tophi on physical examination.

CAUSES:

• Unknown • Autoimmune• Things that may cause rheumatoid arthritis

are:1.Genes2.Environment 3.Hormones

DIAGNOSIS:

• physical exam• x rays• lab tests• Rheumatoid arthritis can be hard to diagnose

because: 1. There is no single test for the disease 2. The symptoms can be the same as other kinds of

joint disease 3. The full symptoms can take time to develop.

Treatment:

The goals of treatment are to: • Take away pain • Reduce swelling • Slow down or stop joint damage • Maintenance of function.• Control of systemic involvement.

• None of the therapeutic approach is curative, all are palliative.

• MEDICAL MANAGEMENT INVOLVES 5 GENERAL APPROACHES:

1. Use of aspirin, other NSAIDS & analgesics2. Use of low dose oral glucocorticoids3. Use of disease modifying or slow acting anti

rheumatoid drugs (DMARDS)4. Use of cytokine neutralizing agents5. Use of immunosuppressive & cytotoxic drugs

Lifestyle Changes• Here are some ways to take care of yourself:• Keep a good balance between rest and

exercise • Take care of your joints • Lower your stress • Eat a healthy diet.

• Rheumatoid Arthritis is a chronic multisystem disease of unknown cause characterized by a symmetrical arthritis, with pain, swelling and stiffness

• Osteoarthritis is a degenerative joint disease, a type of arthritis that is caused by the breakdown and eventual loss of the cartilage, it represents failure of the diarthrodial (movable, synovial lined) joint.

• Gout is a disease that involves the build-up of uric acid in the body. Excess uric acid causes needle-shaped crystals to form in the synovial fluid.

OSTEOARTHRITIS

• Degenerative Arthritis • Most common• caused by the breakdown and eventual loss of

the cartilage of one or more joints• Before age 45, osteoarthritis occurs more

frequently in males. • After age 55 years, it occurs more frequently

in females

• Hip Osteoarthritis – common in men• Interphalangeal jont & thumb base

Osteoarthritis – common in women• hands, feet, spine, and large weight-bearing

joints, such as the hips and knees

CLASSIFICATION OF OSTEOARTHRITIS:

• Primary osteoarthritis/ IDIOPATHIC- most commona. Localized Osteoarthritis

1. hands2. feet3. knee4. hip5. spine6. other single sites (glenohumeral,

sternoclavicular)

• Secondary osteoarthritisa. Traumab. Congenital or developmentalc. Metabolicd. Endocrinee. Calcium deposition diseasesf. Other bone & joint diseasesg. Neuropathich. Endemic

RISK FACTORS:

1. AGE – most powerful risk factor2. Female sex3. Race4. Genetics5. Major joint trauma6. Repetitive stress7. Obesity8. Congenital / developmental disease9. Prior joint disorders10. Metabolic / endocrine disorders

CAUSES:• AGING

- water content of the cartilage increases and the protein makeup of cartilage degenerates- Repetitive use of the joints irritates and inflames the cartilage joint pain and swelling. Eventually, cartilage begins to degenerate by flaking or forming tiny crevasses. - In advanced cases, there is a total loss of the cartilage cushion between the bones of the joints. - Loss of cartilage cushion friction between the bones pain and limitation of joint mobility - When the cartilage deteriorates, the bone next to it becomes inflamed and can be stimulated to produce new bone in the form of a local bony protrusion, called a "spur."

SIGNS AND SYMPTOMS:• NOT a systemic disease1. pain in the affected joint(s) after repetitive use

- most common symptom of osteoarthritis. Joint pain is usually worse later in the day.

2. Swelling3. Warmth4. Bony crepitus - characteristic5. Stiffness of the joints can also occur after long

periods of inactivity

I. Heberden’s nodes–Bony enlargement of the distal interphalangeal joint (DIP)–Most common form of idiopathic osteoarthritis

II. Bouchard’s nodes–Bony enlargement of the proximal interphalangeal joint (PIP)

DIAGNOSIS:

• CLINICAL• RADIOGRAPHIC EVIDENCE1. loss of joint cartilage2. narrowing of the joint space between

adjacent bones 3. bone spur formation

TREATMENT:

• Goal of treatment in osteoarthritis:1. Reduce joint pain 2. Reduce inflammation 3. Maintaining joint function4. Minimizing disability

• no specific treatment to halt cartilage degeneration or to repair damaged cartilage in osteoarthritis

TREATMENT:

• NONPHARMACOLOGIC MEASURES:1. Weight reduction 2. Avoiding activities that exert excessive stress on the

joint cartilage3. Rest4. Physical and occupational therapy5. Thermal modalities6. Exercise – walking, cycling

• Some patients with osteoarthritis have minimal or no pain, and may not need treatment.

• Rheumatoid Arthritis is a chronic multisystem disease of unknown cause characterized by a symmetrical arthritis, with pain, swelling and stiffness

• Osteoarthritis is a degenerative joint disease, a type of arthritis that is caused by the breakdown and eventual loss of the cartilage, it represents failure of the diarthrodial (movable, synovial lined) joint.

• Gout is a disease that involves the build-up of uric acid in the body. Excess uric acid causes needle-shaped crystals to form in the synovial fluid.

GOUT

•Overload of uric acid in the body, and recurring attacks of joint inflammation

•Half of the time, gout affects the metatarsophalangeal (MTP) joint. This is the joint at the base of the big toe.

GOUT• In gout, excess uric acid causes needle-shaped crystals to

form in the synovial fluid. As your immune system tries to get rid of the crystals, it causes the inflammation and pain of arthritis.

• The first attack of gouty arthritis usually happens in just one joint, usually in the metatarsophalangeal (MTP) joint.

• Other joints that are commonly affected include:1. mid-foot2. ankle3. heel4. knee joints5. fingers6. wrists7. elbows

GOUT:

• Over time, patients with gout can develop tophi, or lumps that grow around crystal deposits in joints or near pressure points.

• Tophi most often occur in the fingers, wrists, ears, knees, elbows, forearms, and heels. Tophi can also grow in the kidneys, heart, and eyes.

CAUSES:

1. HYPERURICEMIA- It means that you have high levels of uric acid in

your blood- This can happen for two reasons: - (1) your body creates too much uric acid, or - (2) your kidneys don't excrete the uric acid

effectively. - Whether or not you will develop gout is

related to how bad your hyperuricemia is over time.

CAUSES:

• For people who create too much uric acid, the cause is usually genetic.

• Other medical conditions, such as obesity, hypertension, and diabetes, can also make some people more likely to develop gout.

• Alcohol both raises uric acid levels in the body and impairs the kidneys' ability to excrete the buildup.

CAUSES:

2. ACUTE CAUSES- Attacks of gouty arthritis seem to be caused

by sudden increases or decreases in the amount of urate in your synovial fluid.

- This rapid change can be caused by injury to the joint, alcohol use, or use of certain drugs.

CAUSES:

3. OTHER FACTORS- Heredity- Obesity - Kidney problems- High hemoglobin levels- High triglyceride levels- Hypertension

SIGNS AND SYMPTOMS:1. Very painful joint 2. Swelling 3. Warm 4. Red - The signs and symptoms happen within eight to

twelve hours. - Most of the time the attacks happen at night- Walking and standing are almost impossible if the

legs or feet are affected.- Many patients have flu-like symptoms, including fever

and chills.

SIGNS AND SYMPTOMS• The pain may go away on its own in a few hours, or it

may take a few weeks.• Gouty arthritis attacks come and go.• Over time the attacks happen more often, last longer,

and involve more joints.• Eventually the pain doesn't ever completely go

away joints stay swollen and tender even between flare-ups, and the flare-ups start to happen every few weeks some patients develop tophi on joints or pressure points and kidney stones.

Gout -hand

Gout – big toe

DIAGNOSIS

history of repeated attacks of painful arthritis at the base of the toes

Physical Exam Blood tests - to determine uric acid levels.• Joint aspiration - examined to look for uric acid

crystals. • X-rays - to examine both the bones and joints to

rule out abnormal changes associated with gout.

TREATMENT: • Gout cannot be cured, but it can be very successfully

treated. • PHARMACOLOGIC MEASURES:1. colchicine 2. nonsteroidal anti-inflammatory drugs (NSAIDs)3. corticosteroids to decrease swelling and relieve pain. • All of these drugs work quickly and are very effective. • These drugs may be given by mouth, through an intravenous

line into your bloodstream, or injected directly into the joint.

LIFESSTYLE CHANGES:1. Change your diet. Avoid foods that are high

in purines like anchovies, red meats, shellfish, beer, red wine and salt

2. Quit taking drugs such as diuretics. 3. Lose weight. 4. Quit drinking alcohol. 5. Avoid activities that stress your joints. 6. Drink plenty of fluids to help your kidneys

work more efficiently.

RHEUMATOID ARTHRITIS

OSTEOARTHRITIS GOUT

CAUSES Unknown ;Autoimmune

Aging; Cartilage destruction

Hyperuricemia

SIGNS & SYMPTOMS

Morning stiffness lasting >45 min. Swelling ; Pain aggravated by movement; Skin nodules; Redness Warmth

Joint pain; Morning stiffness lasting less than 30 minutesJoint instability; Heberden's and Bouchard's nodes

Rapid onset of pain usually in the MTP joint followed by warmth, swelling, reddish discoloration, and marked tenderness

DIAGNOSIS medical historyphysical examx rayslab tests

ClinicalRadiographic evidence

History of repeated attacks of painful arthritis at the base of the toes; Physical Exam; Blood testsJoint aspiration

TREATMENT Non pharmacologic: weight reduction and avoiding activities that exert excessive stress on the joint cartilage Pharmacologic: Aspirin, NSAIDS, cox2 inhibitors

Non pharmacologic: adequate fluid intake, weight reduction, dietary changes, reduction in alcohol consumption, Pharmacologic measures: medications to reduce hyperuricemia

Rheumatoid arthritis

Osteoarthritis Gout

TREATMENT Non pharmacologic: weight reduction and avoiding activities that exert excessive stress on the joint cartilage, healthy diet Pharmacologic: Aspirin, NSAIDS, DMARDS,Cox2 inhibitors

Non pharmacologic: weight reduction and avoiding activities that exert excessive stress on the joint cartilage Pharmacologic: Aspirin, NSAIDS, cox2 inhibitors

Non pharmacologic: adequate fluid intake, weight reduction, dietary changes, reduction in alcohol consumption, Pharmacologic measures: medications to reduce hyperuricemia

Bibliogrphy:

• Kasper et al; Harrison’s Principle of Internal Medicine 17th ed.

• http://www.niams.nih.gov • http://www.medicinenet.com/

rheumatoidarthritis• http:www.medscape.com• www.aafp.org/afp/20050915/1037.htm