Rheumatoid arthritis

Rheumatoid arthritis is an autoimmune rheumatic disease of unknown etiology, characterized by chronic erosive arthritis ( synovitis ) and   systemic inflammatory lesion of internal organs. For arthritis is characterized by a variety of options and start ­ currents

Classification and stages of rheumatoid arthritis

The main diagnosis:

1. arthritis seropositive. *
2. arthritis is seronegative. *
3. Specific clinical forms of arthritis :
   • Felty ‘s syndrome ;
   • Still’s disease develop in adults.
4. Likely arthritis .

Clinical stage

1. Very early – disease duration less than 6 months.
2. Early – disease duration of 6-12 months.
3. Deployed – the duration of the disease is more than 1 year with typical symptoms.
4. Late – disease duration of 2 years or more, severe destruction of small and large joints (III-IV X-ray stage), the presence of complications.

The presence of extra-articular (systemic) manifestations

1. Rheumatoid nodules
2. Dermal vasculitis (necrotizing vasculitis , nail bed infarctions, digital arteritis, live angiitis )
3. Vasculitis with damage to other organs
4. Neuropathy (mononeuritis, polyneuropathy )
5. Pleurisy (dry, effusion), pericarditis (dry, effusion)
6. Sjögren syndrome
7. Eye damage (scleritis, episcleritis , retinal vasculitis

The presence of erosion filed by X-ray, MRI / ultrasound

1. Erosive
2. Non-erosive

X-ray stage

I – Small periarticular osteoporosis. Single cystic enlightenment of bone tissue. Slight narrowing of the articular crevices in individual joints.

II – Moderate (pronounced) periarticular osteoporosis. Constriction of the articular fissures. Single erosion of articular surfaces . Small bone deformities.

III – Same that II, but multiple erosion of the articular surfaces (5 or more), multiple pronounced deformities of bones, subluxations and dislocations of joints.

IV – Same as III, plus single (multiple) bone ankylosis, subchondral osteosclerosis, osteophytes at the edges of the articular surfaces.

Functional class

I – Fully preserved self-service, non-professional and professional activities.

II – Self-service, professional activity, unprofessional activity are kept.

III-Saved self-service, limited to non-professional and professional activities.

IV – Limited self-care, non-professional and professional activities.

Presence of complications

1. Secondary systemic amyloidosis;
2. Secondary osteoarthritis ;
3. Systemic osteoporosis
4. Osteonecrosis ;
5. Tunnel syndromes ( carpal canal syndrome, compression of the ulnar, tibial nerves);
6. Instability of the cervical spine, subluxation in the atlanto-axial joint, including myelopathy ;
7. Atherosclerosis.

First symptoms

Prodromal period (not always): general symptoms (fatigue, weight loss, arthralgia, including when changing atmospheric pressure, sweating, low-grade fever, deterioration of appetite), increased ESR, moderate anemia.

Variants of onset and early signs of rheumatoid arthritis

1. Symmetric polyarthritis with a gradual increase in pain and stiffness, mainly in the small joints of the hands (the most common option);
2. Acute polyarthritis with a predominant lesion of the joints of the hands and feet, severe morning stiffness.
3. Mono- or oligoarthritis of the knee or shoulder joints, followed by the rapid involvement of the small joints of the hands and feet;
4. Acute monoarthritis of one of the large joints (resembles septic arthritis or microcrystalline arthritis);
5. Acute polyarthritis oligo- or with severe systemic manifestations (febrile fever, lymphadenopathy, hepatosplenomegaly) resembling Still’s disease in adults. This option often develops in young patients;
6. ” Palindromic rheumatism” – characterized by the development of multiple recurrent attacks of acute symmetric polyarthritis with damage to the joints of the hands, less often – the knee and elbow joints, lasting from several hours to several days and ending with full recovery;
7. Recurrent bursitis, tendosynovitis , especially often in the area of ​​the wrist joints;
8. Acute polyarthritis in the elderly with multiple lesions of small and large joints, severe pain, limited mobility and the appearance of diffuse edema (RS3PE syndrome, Remitting seronegative symmetric synovitis with pitting edema – remitting seronegative symmetric synovitis with pillow edema);
9. Generalized myalgia with the development of the following symptoms: stiffness, depression, bilateral carpal tunnel syndrome, weight loss. The characteristic symptoms of RA develop later.

In some patients, RA can debut with undifferentiated arthritis – HA ( oligoarthritis of large joints / asymmetrical arthritis of the hands joints / seronegative oligoarthritis of the joints of the hands / migratory unstable polyarthritis). At the same time, during the first year of observation, 30-50% of patients with RA develop reliable RA, 40-55% experience spontaneous remission, the remaining patients have RA or another disease is detected.

Extra-articular manifestations of arthritis

General symptoms: general weakness, weight loss, low-grade fever.

Rheumatoid nodules: tight, painless, not welded to underlying tissues. The skin over them is not changed. Localized in the outer surface of the olecranon, tendons of the hand, Achilles tendons, sacrum, scalp. Usually appear 3-5 years after the onset of arthritis .

Vasculitis :

1. Digital arteritis;
2. Cutaneous vasculitis (including gangrenous pyoderma);
3. Peripheral neuropathy ;
4. Vasculitis with damage to the internal organs (heart, lungs, intestines, kidneys);
5. Palpable purpura;
6. Microinfarcts of the nail bed;
7. Mesh livedo .

Damage to the cardiovascular system:

1. Pericarditis;
2. Myocarditis;
3. Endocarditis;
4. Extremely rare – coronary arteritis, granulomatous aortitis;
5. Early and rapid development of atherosclerotic lesions and their complications (myocardial infarction, stroke).

Primary lesions of the respiratory system:

1. Diseases of the pleura: pleurisy, pleural fibrosis;
2. Diseases of the respiratory tract: crick-arytenoid arthritis, the formation of bronchiectasis , bronchiolitis (follicular, obliterating), diffuse panbronchiolitis ;
3. Interstitial lung diseases: interstitial pneumonia, acute eosinophilic pneumonia, diffuse alveoli, amyloidosis, rheumatoid nodes;
4. Vascular lung disease: vasculitis, capillary – Rita, pulmonary hypertension.

Secondary lesions of the respiratory system:

1. Opportunistic infections: pulmonary tuberculosis, aspergillosis, cytomegalovirus pneumonitis , atypical mycobacterial infection;
2. Toxic damage due to medication: methotrexate , sulfasalazin .

Kidney damage: most often associated with the development of amyloidosis (characteristic of nephrotic syndrome – proteinuria 1-3 g / l, cylindruria , peripheral edema). Sometimes develops membranous or membranous- proliferative glomerulonephritis with trace proteinuria and microhematuria.

Amyloidosis: kidney damage (proteinuria, renal failure), intestine (diarrhea, intestinal perforation), spleen ( splenomegaly ), heart (heart failure) are observed .

Blood system:

1. Anemia
2. Thrombocytosis
3. Neutropenia
4. Lymphopenia

Arthritis Variants

1. Prolonged spontaneous clinical remission;
2. Intermittent course with a change of periods of complete or partial remission and exacerbations involving previously unaffected joints;
3. A progressive course with increasing destruction of the joints, the involvement of new joints, the development of systemic manifestations;
4. Quickly progressive course with constantly high disease activity, severe extra-articular manifestations.

Non-drug treatment of rheumatoid arthritis

1. To give up smoking;
2. Maintaining an ideal body weight;
3. A balanced diet high in polyunsaturated fatty acids;
4. Change stereotype of motor activity;
5. Exercise therapy and physiotherapy;
6. Orthopedic aid.

Articular lesions in arthritis :

1. Morning stiffness in the joints, lasting not less than an hour (duration depends on the severity of synovitis );
2. Pain on movement and palpation, swelling of the affected joints;
3. Reducing the force of compression of the hand, muscle atrophy of the hand;

Brush Lesions:

1. Ulnar deviation of the metacarpophalangeal joints;
2. Damage to the fingers of the hands according to the “boutonniere” type (flexion of 8 proximal interphalangeal joints) or “swan neck” (over- flexion in proximal interphalangeal joints)
3. Deformation of the brush type “Lorgnette”

Knee lesions:

1. Flexion and valgus deformities;
2. Baker’s cysts (popliteal fossa cysts).

Foot Damage:

1. Deformation with the lowering of the front arch
2. Subluxations heads plyusnefalango – O joints
3. Deformation of the first finger ( hallux valgus )

Cervical spinal lesions: subluxations of the atlanto-axial joint, which may be complicated by compression of the arteries.

Lesions of the ligament apparatus, synovial bags:

1. Tendosynovitis in the wrist, joints of the hand;
2. Bursitis (usually in the elbow joint);
3. Synovial cysts of the knee joint.

The main groups of drugs for the treatment of rheumatoid arthritis

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Non-selective and selective. NSAIDs have a good analgesic effect, but do not affect the progression of joint destruction and the general prognosis of the disease. Patients receiving NSAIDs require follow-up with an assessment of UAC, liver function tests, creatinine levels , as well as EFGDS in the presence of additional risk factors for gastroenterological side effects.

Along with NSAIDs, it is recommended to use paracetamol, weak opioids , tricyclic antidepressants, and neuromodulators for the relief of joint pain .

Glucocorticosteroids (GK)

The use of glucocorticoids in combination with basic anti-inflammatory drugs is recommended .

In some situations (for example, in the presence of severe systemic manifestations of arthritis ), pulse glucocorticoid therapy for rapid, but short-term suppression of the inflammatory activity of vanity is permissible. Also, glucocorticoids can be used locally (intraarticular injection).

Before treatment, it is necessary to assess the presence of comorbid conditions and the risk of side effects.

In the program of dynamic monitoring of these patients, monitoring of blood pressure, lipid profile, glucose level, and densitometry monitoring are recommended.

Basic anti-inflammatory drugs (DMARDs)

Drugs with anti-inflammatory and immunosupress spring activity. Basic therapy should be given to all patients, and treatment should begin as soon as possible. Anti-inflammatory drugs can be administered both as monotherapy and as part of combination therapy with other anti-inflammatory or genetically engineered biological drugs. Patient management also requires dynamic observation with an assessment of general condition and clinical indicators.

Genetically engineered biologicals

Preparations based on monoclonal antibodies that bind to cytokines involved in the pathogenesis of RA, their receptors, etc. The use of a genetically engineered biological drug requires mandatory exclusion of tuberculosis before starting treatment and during further observation. It is also necessary to conduct the treatment of concomitant somatic pathology – anemia, osteoporosis, etc.

In some situations, surgical treatment may be required – joint prosthetics, synovectomy , arthrodesis.

Timely and correctly selected therapy allows patients with A rthritis to achieve good results in maintaining working ability, and in some patients, to bring life expectancy to a population level.