Rheumatoid Arthritis - Standard Treatment Guidelines

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks synovial joints. It can be a disabling and painful condition, which can lead to substantial loss of function and mobility if not adequately treated. The process produces an inflammatory response of the synovium (synovitis) secondary to hyperplasia of synovial cells, excess synovial fluid, and the development of pannus in the synovium. The pathology of the disease process often leads to the destruction of articular cartilage and ankylosis of the joints. Rheumatoid arthritis can also produce diffuse inflammation in the lungs, pericardium, pleura, and sclera, and also nodular lesions, most common in subcutaneous tissue. Although the cause of rheumatoid arthritis is unknown, autoimmunity plays a pivotal role in both its chronicity and progression, and RA is considered a systemic autoimmune disease. It's clinical diagnosis made on the basis of symptoms, physical exam, radiographs (X-rays)

These new classification criteria overruled the "old" ACR criteria of 1987 and are adapted for early RA diagnosis. The "new" classification criteria establish a point value between 0 and 10. Every patient with a point total of 6 or higher is unequivocally classified as an RA patient, provided he has synovitis in at least one joint and given that there is no other diagnosis better explaining the synovitis. The areas covered in the diagnosis:

1. joint involvement, designating the metacarpophalangeal joints, proximal interphalangeal joints, the interphalangeal joint of the thumb, second through third metatarsophalangeal joint and wrist as small joints, and elbows, hip joints and knees as large joints:

1. Involvement of 1 large joint gives 0 points


2. Involvement of 2-10 large joints gives 1 point


3. Involvement of 1-3 small joints (with or without involvement of large joints) gives 2 points


4. Involvement of4-10 small joints (with or without involvement of large joints) gives 3 points


5. Involvement of more than 10 joints (with involvement of at least 1 small joint) gives 5 points

2. serological parameters – including the rheumatoid factor as well as ACPA – "ACPA" stands for "anti-citrullinated protein antibody":

1. Negative RF and negative ACPA gives 0 points


2. Low-positive RF or low-positive ACPA gives 2 points


3. High-positive RF or high-positive ACPA gives 3 points


4. acute phase reactants: 1 point for elevated erythrocyte sedimentation rate, ESR, or elevated CRP value (c-reactive protein)


5. duration of arthritis: 1 point for symptoms lasting six weeks or longer

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Rheumatoid Arthritis. Following are the major recommendations :

Incidence of Condition In Our Country

About 1% of the world's population is afflicted by rheumatoid arthritis, women three times more often than men. Onset is most frequent between the ages of 40 and 50, but people of any age can be affected. The incidence of RA is in the region of 3 cases per 10,000 population per annum. It is up to three times more common in smokers than non-smokers, particularly in men, heavy smokers, and those who are rheumatoid factor positive. First-degree relatives prevalence rate is 2–3% and disease genetic concordance in monozygotic twins is approximately 15–20%.

Differential Diagnosis

Differential diagnosis of Rheumatoid Arthritis include

1. Crystal induced arthritis


2. Osteoarthritis


3. SLE


4. Psoriatic Arthritis


5. Lyme Disease


6. Reactive Arthritis

Prevention And Counselling

As no direct cause for the disease has been identified the preventive measures could not be established.

Patient needs to be counselled regarding the chronic nature of the disease and need for regular treatment, possible complications and possible treatment options and chances of improvement.

Optimal Diagnostic Criteria, Investigations, Treatment & Referral Criteria

SITUATION 1: At Secondary Hospital / Non Metro situation : Optimal standards of Treatment in situations where technology and resources are limited

Clinical diagnosis:

Rheumatoid arthritis typically manifests with signs of inflammation, with the affected joints being swollen, warm, painful and stiff, particularly early in the morning on waking or following prolonged inactivity. Increased stiffness early in the morning is often a prominent feature of the disease and typically lasts for more than an hour.

For diagnosis and management of other body system involvement by RA Physician needs to be consulted.

Clinical diagnosis can be made as per the guidelines given by ACR & EULAR.

Investigations:

1. X Ray

2. Complete Blood Picture

3. ESR

4. CRP

5. Liver function test

6. Renal function test

7. Rheumatoid Factor (RA)

8. Anti-citrullinated protein antibodies (ACPAs) or anti-CCP

Treatment:

not applicable

Standard Operating Procedure

In Patient :

Surgery

• Arthroscopy Synovectomy in early stage


• Joint Replacement in late stages

Out Patient : supplementation and bracing

1. Disease modifying anti-rheumatic drugs (DMARDs)

a. First Line DMARDs:

1. Methotrexate


2. Hydroxychloroquine


3. Sulfasalazine


4. Leflunomide

b. Second Line

1. Azathioprine


2. cyclosporin (cyclosporine A)


3. D-penicillamine


4. gold salts (Oral & Parenteral)


5. minocycline

2. Anti-inflammatory agents and analgesics

a. Anti-inflammatory agents include:

1. glucocorticoids


2. Non-steroidal anti-inflammatory drug (NSAIDs, most also act as analgesics)

b. Analgesics include:

1. Paracetamol


2. Opiates


3. Diproqualone


4. Lidocaine topical

3. Bed rest during acute flare ups

4. Physiotherapy

Day Care

1. Injectable medications

2. Intra articular Steroid injection

Referral criteria:

For further evaluation and management of cases not responding to conventional therapy.

SITUATION 2: At Super Specialty facility in Metro Location where higher end technology is available

Clinical diagnosis:

Rheumatoid arthritis typically manifests with signs of inflammation, with the affected joints being swollen, warm, painful and stiff, particularly early in the morning on waking or following prolonged inactivity. Increased stiffness early in the morning is often a prominent feature of the disease and typically lasts for more than an hour.

For diagnosis and management of other body system involvement by RA Physician needs to be consulted.

Clinical diagnosis can be made as per the guidelines given by ACR & EULAR.

Investigations:

1. X Ray

2. Complete Blood Picture

3. ESR

4. CRP

5. Liver function test

6. Renal function test

7. Rheumatoid Factor (RA)

8. Anti-citrullinated protein antibodies (ACPAs) or anti-CCP

9. Anti-MCV assay (antibodies against mutated citrullinated Vimentin).

10. point-of-care test (POCT) for the early detection of RA has been developed. This assay combines the detection of rheumatoid factor and anti-MCV for diagnosis of rheumatoid arthritis and shows a sensitivity of 72% and specificity of 99.7%

Treatment:

not applicable

Standard Operating Procedure

In Patient :

Surgery

• Arthroscopy Synovectomy in early stage


• Joint Replacement in late stages

Out Patient : supplementation and bracing

1. Disease modifying anti-rheumatic drugs (DMARDs)

a. First Line DMARDs:

1. Methotrexate


2. Hydroxychloroquine


3. Sulfasalazine


4. Leflunomide

b. Second Line

1. Azathioprine


2. cyclosporin (cyclosporine A)


3. D-penicillamine


4. gold salts (Oral & Parenteral)


5. minocycline

2. Anti-inflammatory agents and analgesics

a. Anti-inflammatory agents include:

1. glucocorticoids


2. Non-steroidal anti-inflammatory drug (NSAIDs, most also act as analgesics)

b. Analgesics include:

1. Paracetamol


2. Opiates


3. Diproqualone


4. Lidocaine topical

3. Bed rest during acute flare ups

4. Physiotherapy

5. Biological agents (biologics) include:

1. tumor necrosis factor alpha (TNFα) blockers – etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), certolizumab pegol (Cimzia), golimumab (Simponi)


2. Interleukin 1 (IL-1) blockers – anakinra (Kineret)


3. monoclonal antibodies against B cells – rituximab (Rituxan)


4. T cell costimulation blocker – abatacept (Orencia)


5. Interleukin 6 (IL-6) blockers – tocilizumab (an antiIL-6 receptor antibody) (RoActemra, Actemra)

Day Care

1. Injectable medications

2. Intra articular Steroid injection

Referral criteria:

Window of opportunity DMARDs exists within 4 to 6 months of the onset of disease. Early diagnosis & institution of right therapy is thus crucial.

WHO DOES WHAT? AND TIMELINES

Doctor

Early diagnosis and appropriate treatment. Counsel the patient for prevention and dietary advice.

Nurse

counseling the patient. Injectable treatment

Technician

Appropriate bracing manufacturing and application of braces Physiotherapy

Resources Required For One Patient / Procedure (Patient Weight 60 Kgs)

(Units to be specified for human resources, investigations, drugs and consumables and equipment. Quantity to also be specified)

Situation	Human Resources	Investigations	Drugs & Consumables	Equipment
1.	Doctor Nurse Technician	1. X Ray 2. Complete Blood Picture 3. ESR 4. CRP 5. Liver function test 6. Renal function test 7. Rheumatoid Factor (RA) 8. Anticitrullinated protein antibodies (ACPAs) or antiCCP.	a.DMARDs b. NSAIDs aa. Steroid bb. Consumables for surgery	Lab equipment Imaging equipment Exercise e quipments Equipments for Operating Room
2 (In Addition to Situation 1)		1. Anti-MCV assay 2. point-of-care test (POCT)	Biologic Agents

Guidelines by The Ministry of Health and Family Welfare :

Dr. P.K. DAVE, Rockland Hospital, New Delhi, Dr. P.S. Maini, Fortis Jessa Ram Hospital, New Delhi

Reviewed By

Dr. V.K. SHARMA Professor Central Instiute of Orthopaedics Safdarjung Hospital New Delhi