Rheumatoid arthritis, Prognostic Features, Management and Complications

NICE has stated that clinical diagnosis is more important than criteria such as those defined by the American College of Rheumatology. 2010 American College of Rheumatology criteria Target population. Patients who

  • Have at least 1 joint with definite clinical synovitis
  • With the synovitis not better explained by another disease

Classification criteria for rheumatoid arthritis (add the score of categories A-D; a score of 6/10 is needed definite rheumatoid arthritis)

Key RF = rheumatoid factor

  • ACPA = anti-cyclic citrullinated peptide antibody

Factor                                                                                               Scoring

A. Joint involvement
   1 large joint                                                                                           0
2 - 10 large joints                                                                                     1
1 - 3 small joints (with or without the involvement of large joints)        2
4 - 10 small joints (with or without the involvement of large joints)      3
10 joints (at least 1 small joint)                                                               5

B. Serology (at least 1 test result is needed for classification)

Negative RF and negative ACPA                                                            0
Low-positive RF or low-positive ACPA                                                 2
High-positive RF or high-positive ACPA                                               3


C. Acute-phase reactants (at least 1 test result is needed for classification)

Normal CRP and normal ESR                                                               0
Abnormal CRP or abnormal ESR                                                          1

Rheumatoid arthritis Prognostic Features

A number of features have been shown to predict a poor prognosis in patients with rheumatoid arthritis, as listed below Poor prognostic features
  • Rheumatoid factor positive
  • Poor functional status at presentation
  • Hla dr4
  • X-ray: early erosions (e.g. After < 2 years)
  • Extra-articular features e.g. Nodules
  • Insidious onset
  • Anti-ccp antibodies
In terms of gender, there seems to be a split in what the established sources state is associated with a poor prognosis. However, both the American College of Rheumatology and the recent NICE guidelines (which looked at a huge number of prognosis studies) seem to conclude that female gender is associated with a poor prognosis.

Rheumatoid arthritis management

The management of rheumatoid arthritis (RA) has been revolutionized by the introduction of disease-modifying therapies in the past decade. NICE has issued a number of technology appraisals on the newer agents and released general guidelines in 2009. Patients with evidence of joint inflammation should start a combination of disease-modifying drugs (DMARD) as soon as possible. Other important treatment options include analgesia, physiotherapy, and surgery.

Initial therapy
  • In the 2009 NICE guidelines, it is recommended that patients with newly diagnosed active RA start a combination of DMARDs (including methotrexate and at least one other DMARD, plus short-term glucocorticoids)
DMARDs
  • Methotrexate is the most widely used DMARD. Monitoring of FBC & lfts is essential due to the risk of myelosuppression and liver cirrhosis. Other important side-effects include pneumonitis
  • Sulfasalazine
  • Leflunomide
  • Hydroxychloroquine

TNF-inhibitors
  • The current indication for a TNF-inhibitor is an inadequate response to at least two DMARDs including methotrexate
  • Etanercept: recombinant human protein, acts as a decoy receptor for TNF-α, subcutaneous administration, can cause demyelination, risks include reactivation of tuberculosis
  • Infliximab: monoclonal antibody, binds to TNF-α and prevents it from binding with TNF receptors, intravenous administration, risks include reactivation of tuberculosis
  • Adalimumab: monoclonal antibody, subcutaneous administration
Rituximab
  • An anti-cd20 monoclonal antibody results in B-cell depletion
  • Two 1g intravenous infusions are given two weeks apart
  • Infusion reactions are common
Abatacept
  • Fusion protein that modulates a key signal required for activation of T lymphocytes
  • Leads to decreased T-cell proliferation and cytokine production
  • Given as an infusion
  • Not currently recommend by NICE

Rheumatoid Arthritis complications

A wide variety of extra-articular complications occur in patients with rheumatoid arthritis (RA):
  • Respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy
  • Ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, chloroquine retinopathy
  • Osteoporosis
  • Ischaemic heart disease: ra carries a similar risk to type 2 diabetes mellitus
  • Increased risk of infections
  • Depression
Less common
  • Felty's syndrome (RA + splenomegaly + low white cell count)
  • Amyloidosis


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