Kembara Xtra - Medicine - Rheumatoid Arthritis

Kembara Xtra - Medicine - Rheumatoid Arthritis 
​Rheumatoid arthritis (RA) is a chronic inflammatory disease that predominantly causes synovial inflammation and bone and cartilage loss.

 Classification: according to the length of the illness (1)
Early: 6 months; Established: 6 months; Depending on the severity of the disease: low, moderate, high, or in remission

EPIDEMIOLOGY Incidence
The United States has an annual incidence of about 40 per 100,000 people.
Prevalence
Female:male, 2:1; prevalence: 0.5–1% of the world's population

PATHOPHYSIOLOGY AND ETIOLOGY
Unknown; frequently brought on by stress or insult (such as infection, smoking, or trauma).
Genetics
HLA-DRB1

RISK ELEMENTS
younger females (5th to 6th decade), first- and second-degree relatives, Native Americans, regions of North America, smoking, obesity, and infections associated with poorer socioeconomic status
DIAGNOSIS HISTORY
The onset of arthritis is sneaky, symmetrically affecting small joints, with morning stiffness lasting for about an hour, a low-grade temperature, and weight loss.

Physical examination findings include radial deviation at the wrist, ulnar deviation, boutonnière deformity, proximal interphalangeal joint subluxation, proximal interphalangeal joint swelling and tenderness, proximal interphalangeal joint swelling and tenderness, subcutaneous nodules, pericardial friction rubs, splinter hemorrhage, palpable purpura, skin ulceration, and nail fold infarcts, and sensory and/

DISTINCTIVE DIAGNOSIS
Lyme arthritis, polymyalgia rheumatica (PMR), postinfectious reactive arthritis, tophaceous gout, viral hepatitis, osteoarthritis, calcium pyrophosphate dihydrate deposition (CPPD), arthropathy, and systemic lupus erythematosus

DETECTION & INTERPRETATION OF DIAGNOSIS
Increased CRP and ESR
Rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies are detected by serology.
X-rays are used to track the development of disease and spot its destruction. Erosions, pannus, and synovitis on an MRI of the hands and wrists. Synovial thickening/erosions can be evaluated using ultrasound.
American College of Rheumatology diagnostic standards (1)
 Clinical synovitis in at least one joint that cannot be attributed to another illness
A score of 6 indicates cooperative involvement in RA.
1 large joint receives no points, 2 to 10 large joints receive one point, 1 to 3 small joints receive two points, 4 to 10 small joints receive three points, and >10 joints receive five points.
In serology
 Low-positive anti-CCP antibodies or negative RF (0 pts)
Low RF or low anti-CCP antibody positivity (2 points)
Antibodies against the CCP or RF that are highly positive (3 points)
Reactants in the acute phase
0 points for a normal CRP or ESR
 Unusual ESR or CRP (1 point)
 The length of the symptoms
6 weeks (zero points)
Six weeks (one point)

Tests in the Future & Special Considerations

Lab testing for DMARDs includes CBC, liver transaminases, and serum creatinine.

Other/Diagnostic Procedures
Joint aspiration to rule out septic arthritis and crystal arthropathy Synovial fluid study in RA shows yellowish-white, turbid, elevated white blood cell (3,500 to 50,000 cells/mm), protein: 4.2 g/dL (42 g/L), and serum-synovial glucose difference >30 mg/dL

Interpretation of Tests
Anti-CCP antibodies are 90–98% specific for RA and are present in 60–70% of RA patients. They frequently exist before clinical arthritis does. It is related to erosive illness.
50% of patients had rheumatoid factor positivity at the time of diagnosis, and another 20-35% develop it within six months.
X-ray imaging is used to track the development of the disease and spot its destruction. MRI of the hands and wrists can detect synovitis, erosions, and pannus; ultrasonography can detect these conditions.

GENERAL MEASURES/TREATY
Quitting smoking, eating a balanced diet, getting regular exercise, and maintaining good dental hygiene

MEDICATION DMARDs include azathioprine, cyclosporine, glucocorticoids, gold (oral and intramuscular), hydroxychloroquine, leflunomide, methotrexate (MTX), minocycline, penicillamine, and sulfasalazine.

Abatacept, adalimumab, anakinra, certolizumab, etanercept, golimumab, infliximab, rituximab, tocilizumab, and tofacitinib are examples of biologic agents.

Recommended strongly
Use DMARD monotherapy (MTX recommended) rather than double or triple medication if disease activity is modest. Use combination standard DMARDs, TNF inhibitors, or non-TNF biologics instead of continuing traditional DMARD monotherapy if the disease activity is still moderate to high despite DMARD monotherapy. Do not stop all RA treatments if the patient's condition is in remission.
– If a patient on conventional DMARD, TNF inhibitor, or non-TNF biologic therapy experiences a disease flare, add a short-term glucocorticoid at the lowest dose and for the shortest amount of time. Taper off the medicine if the patient is in remission.

Before beginning treatment, screening for hepatitis B and C infection is recommended. Prior to getting a biologic, patients on hydroxychloroquine should have a baseline ophthalmologic examination.

QUESTIONS FOR REFERRAL
Orthopedic surgery issues

SURGICAL AND OTHER PROCEDURE
Arthrodesis, synovectomy, and tendon realignment

ALTERNATIVE & COMPLEMENTARY MEDICINE
Physical, occupational, and psychosocial interventions

CONSIDERATIONS FOR ADMISSION, THE INPATIENT, AND NURSING
gastrointestinal perforation, diverticulitis, and severe infection

CONTINUAL CARE/DIET
Eat lots of fruits and veggies while avoiding greasy foods.

PROGNOSIS
Autoantibody, chronic disease, HLA, and erosive disease all have poor prognoses.


COMPLICATIONS
Leukemia, lymphoproliferative illness, anemia, depression, carpal tunnel syndrome, focal glomerulonephritis