Musculoskeletal Bones Rheumatoid Arthritis PharmaPedia PharmaGates

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*this material is free to be used in any educational procedure, downloaded , copied or shared once used without any content modification.*
Rheumatoid Arthritis ()
Definition:
Rheumatoid arthritis (RA)Is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks synovial joints. Rheumatoid arthritis (RA) is an autoimmune disease. autoimmune diseases are illnesses that occur when the body's tissues are mistakenly attacked by their own immune system.
While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms. However, rheumatoid arthritis is typically a progressive illness that has the potential to cause joint destruction and functional disability.
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. ==============================================================
Causes :
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.
The disease involves abnormal B cellT cell interaction, with presentation of antigens by B
cells to T cells .
B-cells & T-cells Inflammation is then driven either by B cell or T cell products stimulating release of TNF and
other cytokines. If TNF release is stimulated by B cell products in the form of RF or ACPA -containing immune complexes, through activation of immunoglobulin Fc receptors, then RA can be seen as a form of Type III hypersensitivity. tareget Antigen ACPA tumor necrosis factor TNF reumatoid factor RF type III hypersensitivity B-cells Ag Antigen
If TNF release is stimulated by T cell products such as interleukin-17 it might be considered

closer to type IV hypersensitivity ) type V)delayed hypersensitivity T-cells
The debate on the relative roles of immune complexes and T cell products in inflammation in
RA has continued for 30 years. There is little doubt that both B and T cells are essential to the disease. 30 T-cells B-cells B-cells & T-cells As with most autoimmune diseases, it is important to distinguish between the cause(s) that trigger the process, and those that may permit it to persist and progress.
1-Possible infectious triggers:

Some infectious organisms suspected of triggering rheumatoid arthritis include: Mycoplasma, Erysipelothrix, parvovirus B19 and rubella, but these associations have never been supported in epidemiological studies. Nor has convincing evidence been presented for other types of triggers such as food allergies. Epidemiological studies have confirmed a potential association between RA and two herpesvirus infections: Epstein-Barr virus (EBV) and Human Herpes Virus 6 (HHV6). : RA .)6 - HHV(6 ) EBV( Individuals with RA are more likely to exhibit an abnormal immune response to the EpsteinBarr virus.
Psychological factors physical and emotional effects or stress could be a trigger for the disease. Continued abnormal immune response. ==============================================================
Propapility:
About 1% of the world's population is affected 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. ===============================================================
Symptoms:
Stiffness( :)The joint does not move as well as it once did. Its range of motion (the extent to which the appendage of the joint, such as the arm, leg, or finger, can move in different directions) may be reduced. Typically, stiffness is most noticeable in the morning and improves later in the day. . . Inflammation: Redness, tenderness, and warmth are the hallmarks of inflammation. Swelling: The area around the affected joint is swollen and puffy. Nodules: These are hard bumps that appear on or near the joint. They often are found near the elbows. .. They are most noticeable on the part of the joint that juts out when the joint is flexed. Pain: Pain in rheumatoid arthritis has several sources. Pain can come from inflammation or swelling of the joint and surrounding tissues or from working the joint too hard. The intensity of the pain varies by the individual. These symptoms may keep you from being able to carry out your normal activities. General symptoms include the following: malaise (a "blah" feeling), fever, fatigue, loss of appetite,
weight loss,
myalgias (muscle aches), and weakness or loss of energy.
Additional symptoms of rheumatoid arthritis include:

Eye problems
Nodules under the skin
Pale skin
Redness and inflammation of the skin
Swollen glands
==========================================================
Diagnosis:
1- Imaging X-Ray of the hand & feet .
2-Blood tests * Rheumatoid Factor :

When RA is clinically suspected, immunological studies are required, such as testing for the presence of rheumatoid factor (RF, a non-specific antibody) BUT about 15% of patients. During the first year of illness, rheumatoid factor is more likely to be negative.
* Erythrocyte sedimentation rate (ESR) :

when increased confirms the presence of an inflammatory condition .
* C-reactive protein (CRP) :

Increased when the disease is active but its not specific .
* Other tests :
Increased in : Alkaline phosphatase & Platelet count. Decreased in serum albumin . Normochromic,normocytic anaemia.
* The synovial fluid :

yellow, watery , turbid due to high white blood cell count & has low glucose content .
Treatment :
Lifestyle modification and analgesics are the mainstay of treatment. 1- Lifestyle modification : Exercise Physical therapy has been shown to significantly improve function, decrease pain, and delay need for surgical intervention in advanced cases. Exercise helps maintain joint and overall movement. Ask your health care provider to recommend an appropriate home exercise routine. Water exercises, such as swimming, are especially helpful. Exercise prescribed by a physical therapist has been shown to be more effective than medications in treating osteoarthritis of the knee.
Other lifestyle recommendations include:
*this material is free to be used in any educational procedure, downloaded , copied or shared once used without any content modification.* Applying heat and cold Eating a healthy, balanced diet Getting rest Losing weight if you are overweight Protecting the joints
2- Medication :
Analgesic Drugs : A- Paracetamol
Paracetamol is the first line treatment for OA. Mechanism of action: it exerts its analgesic action by raising the threshold of response to pain stimuli by interfering with their relay from the thalamus to the cortex, other forms of sensations however remain completely unaffected. Precautions: it should be given with care to patients with impaired kidney or liver & to patients with alcohol dependence. Dose: 1 tab. / 4-6 hours. N.B: 1) Can be safely used during pregnancy 2) Can be safely used with patients receiving anti-coagulants 3) Acetaminophen : is a metabolite of Paracetamol which has the same properties & action
N.B : Paracetamol ( Acetaminophen ) is not related to Non-Steroidal Anti-inflammatory Drugs but, its Analgesic Anti-pyretic Drug. Cetal Panadol Extra Paramol
* * *
Perfalgan
Abimol
Pyral
* * *
B- NSAIDs Mechanism of action: Most NSAIDs act as non-selective inhibitors of the enzyme cyclooxygenase (COX), inhibiting both the cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) isoenzymes. COX catalyzes the formation of prostaglandins and thromboxane from arachidonic acid. Prostaglandins act as messenger molecules in the process of inflammation. If paracetamol does not control your pain, non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can be used instead. Common side effects of NSAIDs include: 1-indigestion 2-stomach ulcer N.B : PPIs help to prevent stomach ulcers and internal bleeding by reducing the production of stomach acid. N.B : Selective COX-2 inhibitors are not suitable for pregnant women or those with a history of heart problems. 1-Ibuprofen Brufen Marcofen Megafen (ibuprfen + Paracetamol)
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* * *
2-Aceclofenac :
Amoflam
Bristaflam
Fenac
* *
3-Diclofenac :
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Rheumafen (diclofenac Na)
Dolfin (diclofenac Na & K)
Voltareen (diclofenac Na)
* *
Cataflam (dicolfenac K)
Catafast (diclofenac K)
Neurofenac (diclofenac Na + Vit.B complex)
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* * *
4-Indomethacin : Indomethacin
5-Ketoprofen :
Biprofenid
Ketofan
Ketolgin
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* *
6-Naproxen : Naprofen 500
7-Piroxicam : Felden
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8-Tolmetin :
Rumatol 200 , 400
Tolmet DS 400
9- Selective Cox II inhibitors : Arythrex (celecoxib) Celebrex (celecoxib) Mobic (meloxicam)
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* *
Mobitil (meloxicam)
Rheuxicam (lornoxicam)
Xefo (lornoxicam)
* * *
10-Other Anti-inflamatory drugs : Diacerein (diacerein) Nimalox (nimesulide) Sulide (nimesulide)
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* *
Ponstan fort (mefenamic acid)
Analfan (galfenine)
Nabutone (nabumetone)
* * *
Disease-modifyning antirheumatic drugs (DMARDs) :

They are used to reduce signs & symptoms & retard structural damage of the joint ( erosions & joint space narrowing ).
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1) Lefunamide Apetoid (leflunomide) Arthfree (leflunomide) Avara
N.B. : Leflunamide, has antiproliferative effect on B-cells
2) Sulphasalazine Salazopyrin 500
3)Methotrexate
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Methotrexate
4) Penicillamine
It decreases RF & interfering with DNA synthesis .
Artamine
Retadel
Rheumaton
4) Cyclosporin 5) Hydroxychloroquine
Plaquenil
Hydroquine
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6)Azathioprine Azathioprine Herceptin Immuless Imuran
9) Corticosteroids HydroCortisone Sigmacortin Solu-Cortef Hostacortin
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Prednisolone Hostacortil-H Predilone Predsol Xilone
Methyl Prednisolone Depomedrol MPA Urbasone
Betamethasone Betasone Betafos Diprofos
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Dexamethasone
Deltasone
Dexamethasone
Dexazone
Fortecortin
Epidron
Orazone
Oradexone
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Triamicnolone & other CS
Kenacort-A
Ultralan
Synacthen
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Dexamethasone & Chroropheniamine maleate Apidone Dexaphen Phenadone Vendexine
3- Complementary medicine : Many alternative medicines are purporting to decrease pain associated with arthritis.
Glucosamine & Chondroitin sulphate Combinations :

Glucosamine involved in the manufacture of glycosaminoglycan, which forms cartilage tissue in the body; also present in tendons & ligaments. Dose: one cap. 3 times daily. Dorofen Elasticin Genuphil
* *
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Glucosamine
Glucosamine-Comp
Move Free
* *
Methyl Sulphonyl Methane (MSM) :

Natural source of sulphur needed by joints & muscle to gaurd against pain & cramps. It may relieve pain similar to nonsteroidal anti-inflammatory drugs Joifit 500 MSM 1000 Nitora
* * *
Omega-3 fatty acid :
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Essential fatty acids are molecules that cannot be synthesized by the human body but are vital for normal metabolism. One of the two families of these essential fatty acids is the omega-3 fatty acids. Omega 3
Anti-oxidants Vitamins ( Vit. A, C, E ) Acupuncture Mud Pack Therapy :

Mud pack therapy has been suggested to temporarily relieve pain in patients with osteoarthritis of the knees .According to researchers, treatment with mineral-rich mud compresses, can be used to augment conventional medical therapy in these patients. 4-Surgery : If the above management is ineffective, joint replacement surgery or resurfacing may be required in advanced cases. Severe cases of OA might need surgery to replace or repair damaged joints. Surgical options include:

Arthroscopic surgery to trim torn and damaged cartilage. Changing the alignment of a bone to relieve stress on the bone or joint. Surgical fusion of bones, usually in the spine ( arthrodesis ) Total or partial replacement of the damaged joint with an artificial joint ( knee replacement, hip replacement, shoulder replacement, ankle replacement, elbow replacement)
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5-Braces & Splints : Splints and braces can sometimes support weakened joints . Some prevent the joint from moving; others allow some movement. You should use a brace only when your doctor recommends one. Using a brace the wrong way can cause joint damage, stiffness, and pain.
Complications :

Adverse reactions to drugs used for treatment

Anemia Bleeding gastric ulcers Chronic pain Immobility and disability Instability of neck bones Joint deformity and destruction Rheumatoid vasculitis, a type of inflammation of the blood vessels, which can lead to atherosclerosis, stroke, heart attack, and other cardiac conditions. Skin ulcerations and infections
Decreased ability to perform everyday activities, such as personal hygiene, or cooking Decreased ability to walk Surgical complications
Advices for patient :

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*.*this material is free to be used in any educational procedure, downloaded , copied or shared once used without any content modification
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:Refrences
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1

If TNF release is stimulated by T cell products such as interleukin-17 it might be considered

1-Possible infectious triggers:

myalgias (muscle aches), and weakness or loss of energy.

Additional symptoms of rheumatoid arthritis include:

Nodules under the skin

Redness and inflammation of the skin

2-Blood tests * Rheumatoid Factor :

* Erythrocyte sedimentation rate (ESR) :

* C-reactive protein (CRP) :

* The synovial fluid :

Other lifestyle recommendations include:

Analgesic Drugs : A- Paracetamol

Rheumafen (diclofenac Na)

Dolfin (diclofenac Na & K)

Voltareen (diclofenac Na)

Neurofenac (diclofenac Na + Vit.B complex)

6-Naproxen : Naprofen 500

Rumatol 200 , 400

9- Selective Cox II inhibitors : Arythrex (celecoxib) Celebrex (celecoxib) Mobic (meloxicam)

10-Other Anti-inflamatory drugs : Diacerein (diacerein) Nimalox (nimesulide) Sulide (nimesulide)

Ponstan fort (mefenamic acid)

Disease-modifyning antirheumatic drugs (DMARDs) :

1) Lefunamide Apetoid (leflunomide) Arthfree (leflunomide) Avara

N.B. : Leflunamide, has antiproliferative effect on B-cells

2) Sulphasalazine Salazopyrin 500

6)Azathioprine Azathioprine Herceptin Immuless Imuran

9) Corticosteroids HydroCortisone Sigmacortin Solu-Cortef Hostacortin

Prednisolone Hostacortil-H Predilone Predsol Xilone

Methyl Prednisolone Depomedrol MPA Urbasone

Betamethasone Betasone Betafos Diprofos

Triamicnolone & other CS

Dexamethasone & Chroropheniamine maleate Apidone Dexaphen Phenadone Vendexine

Glucosamine & Chondroitin sulphate Combinations :

Methyl Sulphonyl Methane (MSM) :

Omega-3 fatty acid :

Anti-oxidants Vitamins ( Vit. A, C, E ) Acupuncture Mud Pack Therapy :

Adverse reactions to drugs used for treatment

Advices for patient :

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