Arthritis

Arthritis is the number one cause of chronic disability (long-lasting). Affecting nearly 1 in 5 people in the UK, it refers to more than 100 diseases that cause pain, stiffness and swelling from the inflammation of a join or the area around joints.

Osteoarthritis

Osteoarthritis is the most common type of arthritis. It is a non-inflammatory (doesn’t cause swelling) degenerative joint disease characterised by the breakdown of the joint’s cartilage. Cartilage that cushions the bone of the hip starts to erode, eventually allowing the bones to grind together causing pain and stiffness. 

• Usually affects middle-aged and older people
• Affects about 3 million people in the UK
• Joint disease that gets worse over time

OA is subchondral bone and cartilage failure that increases with age. It compromises focal articular destruction that leads to deformity, bone cysts, oedema and loss of ROM. Risk factors include:

• Obesity
• Trauma
• Occupation
• High impact sports
• Avascular necrosis
• Joint congruity loss
• Familial tendancy

There are no specific blood tests for OA so radiology is primarily used. An X-ray would show joint space narrowing, osteophytes, subchondral sclerosis and cysts. MRI may show early cartilage changes but is not necessary.

Treatments include patient education, physical measures, medical intermittent options such as simple analgesics, NSAIDs and intra-articular steriod injection which has a short term benefit. Otherwise surgical intervention can be carried out with procedures such as arthroplasty (joint replacement), arthrodesis (fusion of adjacent bones) and realignment osteotomy (changing the length of the bone).

Rheumatoid Arthritis

Chronic, inflammatory type of arthritis. It is an autoimmune disease as certain immune cells malfunction and attack the body’s own tissues. It is the most common type of inflammatory arthritis. It typically begins in middle age (40-70) with 75% of people affected being women. 0.8% of the adult population is the UK have it and HLA-DR4 is present in 70% of RA patients. The male to female ratio is 1:3 and it is rarely seen in childhood, most commonly seen between 40 and 60 years old.The exact cause is still unknown, but the hand, feet and wrists are commonly affected. There is no cure, however early aggressive treatment can help to manage the disease. The synovium becomes inflamed, causing chemicals to be released that thicken the synovium and damage the cartilage and bone of the affected joint. This leads to inflammation of the synovium causing swelling and pain. As an autoimmune disease, the immune system fights infection and attacks the synovium, leading to damage of the joint, cartilage and nearby bone.

Rheumatic conditions are common, concerning up to 1 in 6 GP visits. They disturb connective tissue turnover, change immune function and result in inflammation. Whether or not the origin is due to genetics or the environment is unclear.

Mono-articular – affects one joint
Oligo-articular (or pauci-atricular) – affects a few joints
Poly-articular – affects many joints
Migratory – moves from joint to joint
Arthritis/Arthralgia – joint pain

When rheumatoid arthritis (RA) is suspected, immunological studies test for the presence of rheumatoid factor (RF). A negative RF does not rule out RA and instead names the arthritis seronegative – this is the case in about 15% of patients. During the first year of illness, the rheumatoid factor is more likely to be negative with some individuals converting to seropositive status over time. Note that RF is seen in other illnesses such as Hep C and even in approximately 10% of the healthy population leaving the test very unspecific. 

Interview History

• Age (including of onset)
• Male or female
• Pain/stiffness/swelling/deformity
• Site
• Onset
• Symmetry
• Mono, Oligo, Poly
• Character
• Frequency
• Aggs and eases
• PMH
• DH
• FH
• Disease Impact
• Extra-articular systemic features
• Pale, ulcerated skin
• Change in nails
• Rashes on scalp
• Dry, irritated eyes and mouth with possible discharge
• Shortness of breath or chest pain
• Changed bowel and bladder habits

Signs and Symptoms

• Joint pain, swelling, stiffness and warmth around the affected joint
• Morning stiffness that lasts 1 or more hours
• Same joint on both sides of the body is affected
• Small joints of the hands and feet are characteristically involved, although any joint can be affected
• Rheumatoid nodules (firm lumps under the skin) found on elbows and hands on about one fifth of patients with RA
• Fatigue and noticeable loss of energy
• Flu like symptoms with low grade fevers
• Loss of appetite, weight loss and anaemia. 
• Dry eyes and mouth
• Limited range of motion

No two RA cases are exactly the same, leading researches to suspect that RA is not one disease but rather several with commonalities.

In RA it is generally thought that an environmental agent triggers an inflammatory reaction in the synovial membrane which becomes self perpetuating either due to the persistence of the inciting agent in the synovial membrane or because of the development of autoimmunity to joint specific antigens e.g. cartilage components.

RA has systemic effects including vasculitis (either as digital vasculitis or leg ulcers), carpral tunnel syndrome, lung disease (including pulmonary rheumatoid nodules and pulmonary fibrosis) and eye involvement (scleritis and episcleritis).

RA tends to run in families with environmental factors such as psychological stress, air pollution and other medial illness having an impact. Chronic synovitis is juvenile chronic arthritis from bony erosions, hyperplastic thickened synovium and damaged cartilage.

Investigations

• Haematology – Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein
• Biochemistry – Liver, Bone, Thyroid, Uric Acid
• Immunology – Auto-antibodies for example RF, Anti-Nuclear Antibodies (ANA), Anti-double stranded DNA (Anti-dsDNA)
• Radiology – Xray/MRI
• Joint Aspiration

Medication

Painkillers

Reduce pain rather than inflammation 

Used to control symptoms

Most common = paracetamol

Codeine sometimes prescribed as a combined medicine with paracetamol

Known as cocodamol

Non-steroidal anti-inflammatory drugs (NSAIDs)

Relieve pain, stiffness and swelling in joints

GP prescribed

Do not slow down progression of RA

Possibly not suitable for those with asthma, peptic ulcer, angina, heart attack/stroke victims or those who are taking low-dose aspirin

Two types

Traditional NSAIDs

Ibuprofen, naproxen or diclofenac

COX-2 inhibitors (coxibs)

Celecoxib or etoricoxib

Can increase risk of stomach problems such as internal bleeding

Breaks down lining that protects against damage from acids

Unlikely – 1 in 2-3000

COX-2 has lower risk of serious stomach problems, but carries the risk of heart attacks and strokes

If taking a NSAID, you will almost certainly have to take another medicine such as a PPI (proton pump inhibitor) to reduce the amount of acid in your stomach and therefore greatly reduce the chances of serious damage to the lining.

Corticosteroids

Reduce pain, stiffness and swelling

Tablet (eg prednisolone) or injection into the muscle (help lots of joints)

Usually used when NSAIDs fail to provide relief

Rapid relief and the effect can last from a few weeks to several months

Usually short term, as long term use can have serious side effects

Weight gain

Osteoporosis

Easy bruising

Muscle weakness

Thinning of the skin

Worsening of diabetes and glaucoma (eye disease)

Disease-modifying anti-rheumatic drugs (DMARDs)

Ease symptoms and slow progression of RA

Eg methotrexate, leflunomide, hydroxychloroquine and sulfasalazine

Can take 4-6 months to notice DMARDS working

When antibodies attack the tissue in the joint, they produce chemicals that can cause further damage to the bones, tendons, ligaments and cartilage. DMARDs work by blocking the effects of these chemicals

Earlier you start taking it, the more effective it will be

May have to try 2 or 3 types before you find the one that is best suited to you

Methotrexate is often the first drug given for RA

You may take it with another DMARD

Side effects include sickness, diarrhoea, mouth ulcers, hair loss and rashes on the skin, effect on blood count and liver (results in regular blood tests to monitor)

Less commonly it affects the lungs, so you will usually have a chest X-ray and possibly breathing tests when starting taking it

Around half who start taking methrotrexate will still be taking it 5 years later

Biological treatments

TNF-alpha inhibitors eg etanercept, infliximan, adalimumab and certolizumab

Rituximab

Tocilizumab

Taken in combination with methotrexate or another DMARD

Stop particular chemicals in the blood from activating your immune system to attack synovium

Side effects include skin reactions at site of injection, infections, nausea, fever and headaches. There is a slight risk that biological treatments can reactivate TB, septicaemia and hep B and, in rare cases, trigger new autoimmune problems.

Genetic?
Some evidence that RA can run in families. Genes may be one factor in the cause of the condition, however having a family member with RA doesn’t necessarily mean that you will inherit the condition. An identical twin has a one in five chance of developing it, so genes do not explain much of the risk.

Hormones?
RA is three times more common in women than men – due to oestrogen? No conclusively proven but may be involved in the development and progression of the condition.

Old Treatments

The concept of gradually escalating intensity treatment, which has been in use for many years is now considered out dated. This is because it is known that erosions begin to occur within the first 18 months, so active treatment from the onset with early use of DMARDs is more sensible.

Diagnosis

RA is difficult to diagnose because there are many conditions that cause hoint stiffness and inflammation.

• GP physical examination
• Referral to rheumatologist
• Blood test
• Can’t definitely diagnose

Erythrocyte Sedimentation Rate (ESR)

Red blood cells placed into a test tube of liquid

Timed to see how fast they fall to the bottom of the tube (mm/h)

If sinking faster than usual, may have an inflammatory condition such as RA

C-reactive protein (CRP)

Checks how much CRP is in blood

Produced by liver, and if there is more than usual there is an inflammation somewhere in your body

Full Blood Count

Measure red blood cells to rule out anaemia

Eight out of 10 people with RA have anaemia

Having anaemia does not prove that you have RA

Rheumatoid Factor

Checks to see if the antibody RF is present in your blood.

Present in 8 out of 10 people who have RA

Cannot always be detected in early stages

Present in 1 in 20 who do not have RA

• Joint Imaging
• X-rays of joints
• Differentiate between types of arthritis
• Ultrasound
• Confirm presence, distribution and severity of inflammation and joint damage
• MRI
• Show what damage has been done to a joint

Stages of RA

Clinical RA

Inflammation of both hands

Ganglion

Joint deformity progressed with severity of disease

Advanced RA

Soft tissue swelling of wrist and MCP and PIP joints

Endstage RA

Ulnar deviation/drift of fingers

Soft tissue swelling of MCP (metacarpophalangeal) joints

Subluxation (dislocation) of MCP joints

Wasting of the small muscles of the hands

Soft tissue swelling and reduced range of movement of the wrists

• Swan Neck Deformity – typical RA deformity. Power grip is impossible, patient can only manage a pinch grip between the thumb and middle finger.

Carpal Tunnel Syndrome

• Commonly seen in RA
• Entrapment of medial nerve in the carpal tunnel as a result of synovial inflammation
• Leads to numbness, tingling and pain in the distribution of the median nerve in the hand
• Thumb to 4^th finger – not medial side of hand
• Treated with injection of corticosteroid into the carpal tunnel

Avascular Necrosis

Supply of blood to the femoral head is cut off and the bone begins to wither. As a result, the surrounding cartilage begins to deteriorate, producing pain and other symptoms.

Fibromyalgia

Affects 750,000 people in the UK.

70-90% of the people who develop this disease are women aged 20 to 50.

Lifestyle changes

• Medication – make use of them. Aspiring free pain relievers, anti-inflammatory drugs, corticosteroids, disease modifiers and sleep medications.
• Exercise – regular exercise keeps the body moving and flexible. It may lessen pain, increased movement and reduce fatigue.
• Heat or Cold – many provide short term relief from pain and stiffness when applied to joints
• Pacing Activities – protects joints by alternating periods of activity with periods of rest to prevent tiring of the joints from the stress of repeated tasks.
• Joint protection – learning to use joints in a way that avoids excess stress. Avoid using sore and weak joints. Walking with assistive devices such as a cane. Weight control helps ease pain by reducing stress.
• Attending arthritis support group.