This relies on clinical features. Useful pointers are the presence of morning stiffness, symmetrical arthritis at multiple joints including the hands lasting 6 or more weeks and the presence of rheumatoid nodules. A positive rheumatoid factor and X-ray changes are also helpful. These American Rheumatism Association criteria are useful
for disease classification.
The X-ray changes of RA are shown. The characteristic lesion is an erosion that has the appearance of a mouse-bite on the surface of the affected bone. Eronsion are best seen in X-rays of the hands and feet. Other caanges include loss of joint space, which indicates things of the cartilage, porosis of the periarticular bone and cysts. In advanced disease, destruction of bone ends occurs.
Full blood count
A full blood count in RA shows anaemia (see above) and ESR and CRP are raised in proportion to the activity of the inflammatory process.
Test for rheumatoid factor are positive in about 80% of cases and for antinuclear antibodies in about 30%. Aspirated synovial fluid will show the changes outlined. Fluid from a suddenly painful rheumatoid joint should always be aspirated and cultured, as septic arthritis can occur in patients with RA.
The diagnosis of RA inevitably causes concern and patients require a lot of information, explanation and reassurance. Assessment is part of the diagnostic process and includes the activity of the inflammatory process, the severity of anatomical changes, the rate of progression and particular problems which have arisen, all factors which will determine the right approach to treatment. All aspects of a patient’s life-style should be reviewed including home, work and leisure activities with the emphasis on preserving as many activities as possible. RA is entirely consistent with a full, normal and busy life.
Physical activity does not increase the rate of deterioration of joints in RA and since patients are particularly at risk of developing progressive joint stiffness and deformity they should undertalce simple exercises to maintain joint mobility and muscle power. Restriction of movement is particularly likely to occur in the shoulders, while flexion deformities are more likely to occur in the knees. Both of these problems are easier to prevent than correct.
Plans must be made for the continuing care of a patient with RA. Most will require some supervision for many years, even if the disease is mild. ‘Shared care’ is recommended between the patient, GP and the hospital rheumatological services.
The second stage of treatment is devoted to the relief of symptoms. NSAIDs are the mainstay of such treatment and are more effective than simple analgesics.
INDIVIDUAL RESPONSE TO NSAIDS varies greatly. It is therefore desirable to try several different drugs for a particular patient in order to find the best. Each compound should be given for 1 week. Drugs with a low incidence of side-effects, a good safety record and a convenient dosage schedule should be tried first. Piroxicam 20 mg daily is a reasonable first choice, but many NSAIDs of equal efficacy are available. The major sideeffects of NSAIDs are gastrointestinal with haem orrhage being a major problem in the elderly. Other sideeffects include fluid retention, tubulo-interstitial nephritis and problems with drug interactions. The relief of night pain and morning stiffness is particularly important in RA and slow-release indomethacin (75 mg) talcen on retiring usually works well and can be given in addition to regular daytime therapy if necessary. If patients require additional relief, a simple analgesic can be talcen as required. Paracetamol can be used but many patients prefer a combination such as dextropropoxyphene and paracetamol.
CORTICOSTEROIDS are effective but are seldom used because of their side-effects. In explosive RA in the elderly, small doses of prednisolone (10 mg daily) are usually dramatically effective;the dose can be reduced over the years. In the younger patient, however, much larger doses of prednisolone, often for long periods, are necessary to control symptoms and because of sideeffects such treatment is best avoided.
REST IN HOSPITAL is often useful, either to produce a remission of the disease or to encourage a dispirited disabled patient. Localized rest for individual joints can be provided with splints, which are particularly useful for the wrist.
INTRA-ARTICULAR CORTICOSTEROID INJECTIONS are of value for particularly troublesome joints to avoid the risk of systemic steroids.
The third stage consists of long-term suppressive drug therapy with drugs such as penicillamine.
The indications for this type of treatment are:
• Progressive disease
• Troublesome extra-articular problems
• Failure of NSAIDs to control symptoms
• Excessive corticosteroid requirements
The current trend is to use these drugs very early in the treatment of RA with the aim of controlling the disease before structural damage appears in the joints. The characteristics of long-term suppressive therapy are:
A SLOW ACTION: these drugs start to work after 4-6 weeks and talce 6 months to produce their full effect. For this reason, NSAIDs should be continued for a few months at least.
IMPROVEMENT IN JOINT SYMPTOMS is accompanied by a fall in ESR and the titre of rheumatoid factor.
COMPLETE REMISSION or very effective suppression of disease can be achieved, delaying or preventing joint destruction.
The mode of action of these drugs is unknown and it is impossible to predict which patient will respond to a particular compound. It is often necessary to try several, as with NSAIDs.
The most effective drugs are penicillamine, azathioprine and methotrexate. Hydroxychloroquine, sulphasalazine and auranofin are a little less effective but safer. Intramuscular gold is as effective as penicillamine but because of the inconvenience of injections and the frequency of side-effects, which produces a low ultimate success rate, it is less used. Penicillamine is often the first choice of drug for younger patients, but because of failures due to lack of effect or side-effects one must be prepared to use all these drugs. Combinations are increasingly used for the difficult case. All of these drugs have side-effects and require careful monitoring with blood tests at appropriate intervals. Patients should be informed of the potential for side-effects and told to report new symptoms immediately. The antimalarial drug hydroxycWoroquine may affect the eyes and vision must be checked before therapy and immediately if any disturbance of vision is noted.
Regular supervision is required to assess the course of the disease and to treat complications.
ARTICULAR COMPLICATIONS. Joints may become stiff and painful and require intra-articular injections of corticosteroids and exercises to mobilize the joint and improve muscle power. Deformities can also sometimes be corrected by steroid injections and exercises. Rupture of the knee joint is treated with aspiration, injection of corticosteroid and rest. A Baker’s cyst behind
the knee does not itself require treatment since it merely reflects inflammatory changes in the knee joint. Steps should be taken to control the activity of the disease in the affected knee.
Painful feet may be treated with insoles; metatarsal bar insoles are particularly useful for subluxed metatarsal heads. More complex foot deformities may require special shoes such as space shoes.
At this stage in the disease replacement surgery plays an increasingly important role in the management of a patient with a wrecked joint. Not only can hips be replaced, but also knees, shoulders, elbows and the small joints of the hands.
Excision arthroplasty is of value in two situations. First, the painful subluxed metatarsal heads in the feet can be excised (Fowler’s operation) and the lateral deviation of the toes corrected at the same time. Second, the head of the ulna can be excised at the wrist, often relieving pain and allowing better movement. Osteotomy is occasionally used at the knee joint to relieve pain and correct deformity.
NON-ARTICULAR COMPLICATIONS. Many different symptoms require treatment. For example, the patient who develops carpal tunnel syndrome will require an injection of corticosteroid or surgical decompression of the median nerve.
SOCIAL AND DOMESTIC COMPLICATIONS. RA strains relationships and makes life difficult. Crises arise in these matters and patients often turn to a sympathetic physician for advice and help.
Despite all treatments, the disease may continue to progress and become disabling. Priorities in treatment then change. It is no longer relevant to control the disease and the aims of treatment become relief of symptoms and maintenance of a reasonable life-style. It may be useful to visit a patient’s home with a view to making life easier. A wheelchair may be required and many other aids and appliances can be used to reduce disability. Steps should be taken to preserve as much as possible of all aspects of the patient’s life. Successful management can make an enormous difference to the quality of life of rheumatoid patients.