Rheumatoid arthritis

• Int. ภัททนพ เงาดุลย

วัต
Pathophysiology
- Genetic susceptibility (HLA-DR4)
- Immunologic reaction from foreign
antigen
- Inflammatory reaction of joint and
tendon sheath (IL1-,IL6-,TNF)
- Appearance of rheumatoid factors in
blood and synovium (anti-IgG
autoantibody และ anti-CCP )
- Maintain of the inflammatory process
- Chronic synovitis and articular cartilage
destruction
 Risk factor
• Genetic factors and family history
• Previous infection with certain bacteria and viruses
• Smoking or exposure to secondhand smoke
• Exposure to air pollution and certain chemicals and minerals
• Sex, as 70% of those with RA are women
• Age, as it mostly develops between 40 and 60 years
 Poor Prognostic factor
• Persistently moderate or high disease activity
despite conventional synthetic DMARD (csDMARD) the
rapy according to composite measures including joint c
ounts
• High acute phase reactant levels
• High swollen joint count
• Presence of RF and/or ACPA, especially at high levels
• Presence of early erosions
• Failure of two or more csDMARDs
 Diagnosis
• Clinical manifestation
• Lab investigation
Rheumatoid factor
Anti CCP
ESR, CRP
ANA ; exclude SLE
synovial analysis:gout
Film hand and feet
Clinical manifestation
 Clinical manifestation

Osteoarthritis
Rheumatoid arthritis
 Clinical manifestation
• OA VS RA
 Lab investigation
Rheumatoid factor
Anti CCP
ESR, CRP
ANA ; exclude SLE
synovial analysis:gout
Film hand and feet
• Rheumatoid factor
Sensitivities: 77% , Specificity 73%
• Anti-CCP
Sensitivities: 80%, Specificity 87 %
• RF + Anti-CCP
Sensitivities 100%, Specificity 87%
• Film hand and feet
 Differential diagnosis
• Rheumatoid arthritis
• OA
• Gout
• Connective tissue disease
>> SLE, scleroderma, polymyositis(proximal muscle w
eakness)
>> Vasculitis
• Psoriatic arthritis(DIP joint predominately, frequentl
y asymmetric)
 Treatment
• Goal : Disease remission or low disease activit
y
Disease activity level
CsDMARDs boDMARDs tsDMARDs
Methotrexate(MTX) TNF inhibitors JAK inhibitors
Hydroxychloroquine(HCQ) • Etanercept • Tofacitinib
Sulfasalazine(SSZ) • Adalimumab • Baricitinib
Leflunomide(LEF) • Certolizumab

• Golimumab

• Infliximab
Abatacept : Co-stimulation inh
Rituximab : Anti-B cell (CD20)
IL-6 receptor inhibitors

• Tocilizumab

• Sarilumab
 Treatment
• MTX (2.5)
• Start 3 tab/wk
• Asian max dose = 15 mg/wk
• Side effect: Bone marrow suppression, Hepato
toxic, Renal toxicity, GI disorder
 Treatment
• SSZ(500)
• >> wk 1 : 500 mg orally once a day in the even
ing
>> wk 2 : 500 mg orally twice a day (morning a
nd evening)
• MAX dose: 3 gm/day
• Side effect: N/V , decrease appetite, rash
 Treatment
• Leflunomide(20)
• Loading dose: 100 mg orally once a day for 3 d
ay
• Maintenance: 20 mg once a day
• (If not well tolerated, the dose may be decreas
e to 10 mg orally once a day)
• Side effect: Cytopenia, Hepatotoxic, Diarrhea,
N/V
EULAR
recommendations for
the management of
rheumatoid arthritis
with synthetic and
biological disease-
modifying
antirheumatic drugs:
2019 update
+ Folic Note: HCQ only in mild symptom
Relative contraindications for methotrexate use

• Renal dysfunction (dosage adjustments needed)

• Significant abnormal results on LFT
• Hepatitis
• Cirrhosis
• Significant pulmonary disease
• Blood dyscrasias(Severe anemia,leukopenia,thrombocytopeni
a)
• Excessive alcohol consumption
• Active infectious disease ( tuberculosis, pyelonephritis)
• HIV or AIDS
 Poor Prognostic factor
• Persistently moderate or high disease activity
despite conventional synthetic DMARD (csDMARD) the
rapy according to composite measures including joint c
ounts
• High acute phase reactant levels
• High swollen joint count
• Presence of RF and/or ACPA, especially at high levels
• Presence of early erosions
• Failure of two or more csDMARDs
CsDMARDs boDMARDs tsDMARDs
Methotrexate(MTX) TNF inhibitors JAK inhibitors
Hydroxychloroquine(HCQ) • Etanercept • Tofacitinib
Sulfasalazine(SSZ) • Adalimumab • Baricitinib
Leflunomide(LEF) • Certolizumab

• Golimumab

• Infliximab
Abatacept : Co-stimulation inh
Rituximab : Anti-B cell (CD20)
IL-6 receptor inhibitors

• Tocilizumab

• Sarilumab
 Glucocorticoid
• When to use: Start DMARD/change DMARD
• Low dose : ≤ 7.5 mg/day
• Short course 3 mo.
• Failure of withdraw GC >> Failure of therapeu
tic phase
>> add Biologic or JAK
 การติดตามการรักษา
• DAS score (DAS28) เป็ นเกณฑ์ทน ี่ ่าเชอ ื่ ถือและ
้
ประเมินโดยใชจำนวนข ้อน ้อยทีส
่ ด ุ
• Larsen score หรือ Sharp/van de Heijde score
้
มักใชในทางวิ จัยมากกว่าทางปฏิบต ั เิ นือ่ งจากมี
รายละเอียดในการอ่านผลภาพรังสม ี าก
• CBC, ESR
 Monitoring
• CBC: WBC < 4,000 : increase frequency of monitor
WBC < 3,500 : withhold
Platelet < 150,000 : withhold
• Liver : ALT 2-3 fold: Reduce the dose and repeat in 1-2 wks
ALT > 3 fold : withhold
• Renal: pre-renal or acute renal failure: withhold
• Rash, Abnormal bruise: withhold
 Disease Remission
• Disease remission 6-12 mo
• Do not Discontinue all treatment
• Tapering RA treatment
Glucocorticoid >> Biologic agent >> DMARD* : continue
 Reference
• EULAR recommendations for the management
of rheumatoid arthritis with synthetic and
biological disease-modifying antirheumatic dr
ugs: 2019 update
• 2010 ACR/EULAR Classification Criteria for
Rheumatoid Arthritis
• Uptodate