RA-Clinical Features & Management
NATIONAL JOURNAL OF HOMOEOPATHY 1999 Mar / Apr VOL VIII NO 2.
Dr Gurmeet Mangat
Introduction
Rheumatoid arthritis (RA) is a chronic immuno-inflammatory disease characterized by arthritis of the small and large joints and at times, involvement of other organ systems. It tends to affect females more than males especially in the 3rd to 5th decades. This article highlights the clinical features and management strategies in RA.
Clinical Features
RA is characterised by articular features, extra-articular features and systemic features.
- Articular Features
Painful swelling accompanied by significant (more than 1hr in the morning) stiffness is the characteristic feature of all forms of inflammatory arthritides. RA is characterised by persistent (> 6-8 weeks) arthritis of the small joints of hands and feet. Due to this, walking becomes painful and activities of daily living like holding, gripping etc are difficult. In an established case, small and large joint arthritis is evident. Apart from small and large joints, atlanto-axial involvement, temporo-mandibular involvement and crico-aretynoid involvement can occur. Though almost all joints can be involved, dominant spine involvement (except for cervical spine) is uncommon.
It is important to realize that in early RA (RA < than 2-3 yrs), activity of the disease is severe but joint damage (erosions on X-rays) minimal. However with the passage of time and with inadequate treatment, damage eventually occurs and leads to deformities. Swan neck deformities, boutinierre deformities etc. are thus manifestations of underlying joint damage.
It has been suggested that EAF are uncommon in Indian patients. Though this could be true, often the method used to assess its prevalence determines the prevalence rate and these methods may not have been identical in the two groups. A comparison of EAFs between Indian RA patients and western RA patients is given in Table I.
Subcutaneous nodules are uncommon in Indian patients. Their usual site is on the extensor aspect of elbows. Occasionally they are present on the spine, sacrum, scalp and heels. Rarely, internal organs are involved.
Dry eyes as a part of "Sicca syndrome" (SS); occurs in 8-30 % of RA patients. It is more common in women and usually has an insidious onset. Episcleritis (prevalence-1.2-3.7%) and scleritis (prevalence-0.1-1.2 %) are both uncommon. Scleromalacia perforans is the consequence of untreated scleritis.
The various pulmonary manifestations of RA is given in Table II. Prevalence of interstitial lung disease (ILD) varies from 1-5% when assessed by X rays to 75 % when assessed by HRCT. Dry cough with dyspnoea is the usual symptom and basal end inspiratory crepts is the usual auscultatory finding.
Prevalence of pleural involvement varies between 5 -75 %. It commonly occurs in sero-positive males with definite nodules in the 5th decade. The fluid is an aseptic exudate, low in glucose and complements but high in LDH. Complications like pleural thickening, pneumothorax and empyema are rare.
Anaemia occurs in 20-60 % of patients with RA. Increased uptake but reduced release of iron and cytokine induced suppression of erythropoesis are two main contributory factors. However, 25-30% of patients have coexistent iron deficiency. Thrombocytosis occurs in active RA and neutropenia / pancytopenia in Felty's syndrome.
Vasculitis occurs in about 1% of patients. The usual presentations include digital infarcts, nail fold infarcts and digital gangrene. At times they present as sudden increases in nodules, scleritis, painful ulcers at atypical sites and mononeuritis multiplex. Organ involvement is rare.
Pericarditis is detected clinically in 1% of patients but its prevalence is around 20-30% on echo. It usually occurs in seropositive active disease. Constriction/tamponade are both rare. Endocardial involvement is rare with valvulitis leading to regurgitant lesions being more common than stenotic lesions. Aortic rather than mitral valve is more commonly involved. Myocarditis is rare but coronary vasculitis has been documented in about 20 % of patients at postmortem.
Neurological involvement can occur in the form of cervical spinal cord involvement due to AAD and subaxial involvement, mononeuritis multiplex in vasculitis or traction/pressure nerve impairment due to synovitis or deformities. Rheumatoid myositis is a rare entity.
Renal involvement is more often due to secondary causes like drugs, vasculitis, amyloid etc. An entity called "quot;rheumatoid nephropathy"quot; characterized by non-specific nephrosclerosis and mesangial hypercellularity has been described.
Osteoporosis is a known complication of rheumatoid arthritis. Pathogenetic factors include disease activity, immobility and drug (especially) induced bone loss. Further these patients are also predisposed to osteomalacia due to dietary calcium lack / Vit D deficiency and lack of sun exposure.
Systemic Features
Fever, loss of weight, loss of appetite are the common systemic features in patients with RA.
Treatment of RA
Will not not be dealt with here except to give some indications for the uncommon use of intercurrent remedy.
Surgery for RA
A multi-disciplinary approach is currently practiced in most rheumatology units while managing RA. Excision of the proliferative tenosynovitis and bony prominences near tendons helps to prevent tendon ruptures. Tendon transfers and release of the median nerve and other entrapped nerves are also done in the early stages. Early excision of persistent synovitis also helps prevent joint damage.
Expertise has increased amongst orthopaedic surgeons' performing joint replacements. Hip and knee replacements have improved the quality of life in RA patients.
Approach to a Patient with RA - The Practical Aspects
Assessment of a patient with RA begins with clinical assessment of disease activity, extent of joint damage and functional disability. A careful note of the medications taken by the patient prior to the visit, their beneficial and side-effects help in formulating a treatment plan. Concomitant diseases should also be taken into consideration prior to starting treatment.
Investigations are done to assess activity (CBC/ESR), damage (radiographs of the hands/feet and other involved joints) and to decide which drugs can be started in a particular patient (SGPT/creatinine/albumin/ eye check prior to chloroquine therapy).
Patient education is of paramount importance. There is a need to stress that the disease is chronic and patient compliance essential. There are many existing wrong concepts and fads as regards the disease in the patient's mind and care should be taken to educate them appropriately.
Active disease needs active treatment from the first day. Active and passive splints and appropriate physiotherapy are of value in increasing the strength and stability of the joints and preventing progression of deformity. Active exercises should however be avoided during periods of acute flare.
The damage in the joint is assessed radiologically and note is made of the functional disability due to the damage. Sometimes it may worthwhile re-assessing the disability a few months after initiating treatment, as the initial disability may be due to a combination of damage and active disease. Damage leading to significant functional disability often needs orthopaedic intervention. Replacements of the knee, hip replacements and shoulder lead to substantial functional improvement in properly selected cases.
Treatment of the EAFs
Dry eyes and dry mouth need patient education regarding eye protection and oral hygiene. Further artificial tears are available and should be used liberally.
ILD needs to be assessed. Radiographs usually reveal basal reticulonodular shadows. PFT often suggests a restrictive disease with an element of small airway obstruction with or without abnormal diffusion. HRCT is useful in assessing the activity of the ILD. Ground glass appearance denotes active alveolitis, which is amenable to therapy, while fibrotic scars indicate chronic disease. Bronchoscopy, bronchoalveolar lavage and transbronchial biopsy may all be needed to confirm the diagnosis and to also help assess the activity of the ILD. Active alveolitis needs acute medicines. Chronic lesions need conservative treatment.
Aspiration is needed for pleural effusion only if there is diagnostic dilemma or massive effusion. Slow resolution is the usual rule with effective control of rheumatoid process.
The approach in patients with anaemia would be to rule out GI loss or drug induced anaemia. Once these have been ruled out, treatment of the RA often leads to an improvement in the haemoglobin. ANA, C3, C4, urine routine and creatinine are all useful in assessing a patient with vasculitis. While digital infarcts and nail fold infarct do not need aggressive therapy, vasculitic ulcers, mononeuritis multiplex etc. need active therapy.
Pericarditis usually responds to the treatment of RA. ? If treatment of RA does not lead to a resolution or if the pericarditis is significant, a small dose of steroid may be initiated and often leads to a favourable outcome.
Table I: Prevalence of extra-articular features in rheumatoid arthritis
| Indian | Western | |
| Sec Sjog. | 2-30% | 20% |
| Vasculitis | 1-9% | > 1% |
| Nodules | 5- 8.5% | 30% |
| Lymphnodes | 4% | 50% |
| ILD | 1-8% | 41% |
| Renal | 1-5% | 3-17% |
| CNS | 0.75% | rare |
| Cardiac | 0.5-0.7% | uncommon |
| Felty's | 1% | 5% |
Table II: Lung Involvement in RA
Interstitial lung disease (ILD)
Pleurisy / pleural effusion.
Bronchiolitis obliterans with or without
obstructive pneumonia.
Rheumatoid nodule in the lung.
Caplan's syndrome
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