Presented by

Robina Shamim
(BSCN Student 2nd Semister 1st Year)
Faculty Younus Masih
Patho-Pharma

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 Is an autoimmune connective tissue disorder
that most commonly causes inflammation of
the joints and subsequent joint deformity.

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 Genetically
 Triggered by some unknown infectious

agents or endogenous antigens

 Role of Epstein-Barr virus
 Hormonal

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 Initiation phase
 Immune response phase or hyperplasia of

synovial
 Inflammatory phase
 Destruction phase

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Initiation Phase
 In the initiation phase there is some change in

the synovial lining.

Immune response phase
 In the immune response phase a large numbers

of infiltrating lymphocytes are present in the

synovial fluid.
Inflammatory Phase
 As a disease process continues during the

inflammation phase the resultant swelling

damages the tiny blood vessels in the synovial
membrane that contains the synovial fluid.

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 This phase occurs over time.
 If the inflammation process is not arrested a

thickened fibrous scar tissue called ‘pannus”

is formed. Pannus adheres to the articular
surface of the cartilage and eventually
invades the bone causing bony erosion which
can been seen in the X-ray

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  Altered B cell regulation

 Non specific immunologic G IgG

 Lymphocyte production

 Clients tissue as a foreign bodies

 Altered antibodies are called RA factors

 Immune complexes with IgG deposited in the

synovial membrane stimulates inflammation
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1. Morning stiffness lasting at least 1 hour
2. Swelling of the three or more joints
3. Symmetrical joint swelling
4. Rheumatoid nodules
5. Positive RF
6. Changes in X-ray indicating bony erosion
and decalcification

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 Muscle spasm and weakness
 Pain
 Hand deformity
 Nodules

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 Skin changes
 Generalized vasculitis may also occur.
 Pulmonary disease
 Pulmonary fibrosis
 Cardiac disease
 Pericarditis
 Ocular manifestation
 Blind
 Neurologic disease
 Peripheral Nerve involvement

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Pharmacologic measures
1. Anti-inflammatory
2. Non steroidal anti-inflammatory
drugs(NSAIDS)
3. DMARDs
Non-Pharmacological measures

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 Therapy with disease-modifying
antirheumatic drugs (DMARDs) should be
started as soon as the diagnosis of
rheumatoid arthritis (RA) is made.
 The early use of DMARDs has been

recommended in recent years to reduce

disease progression and long-term disability.
 The need for early use of DMARDs is

incorporated in new National Institute for

Health and Care Excellence (NICE) guidance.

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 Early use requires early referral in part
because DMARD initiation is the province of
specialists in secondary care. The optimum
use of these drugs requires specialist
experience and is complicated not only
because of their potential toxicity, but also by
the range and combination of drugs used.
There are a number of new DMARDs.

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 Gold:
 Given by intramuscular injection as sodium
aurothiomalate.
 Sodium aurothiomalate is licensed for the
treatment of active progressive RA.
 Can be an effective treatment but use is
restricted by severe adverse reactions (up to
5% of recipients).

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 Penicillamine:
 It is a chelating agent licensed for the
treatment of severe active RA, including
juvenile forms (and a range of other
conditions, including Wilson's disease).
 It has a similar method of action to gold
and more patients are able to tolerate it, but
side-effects occur frequently.
 The rate of onset of action is slow,
improvement may not be seen for three
months but, in patients who have shown no
benefit after a year of treatment, the drug
should be discontinued.

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Sulfasalazine:
 It is licensed for the treatment of RA which
has failed to respond to non-steroidal anti-
inflammatory drugs (NSAIDs).
 It has a similar action to gold.
 It has slightly more side-effects than
methotrexate.

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 Chloroquine and hydroxychloroquine:
 Hydroxychloroquine is an antimalarial
agent licensed for the treatment of RA,
juvenile idiopathic arthritis, discoid and
systemic lupus erythematosus (SLE), and
dermatological conditions caused, or
aggravated, by sunlight.[5]
 They are usually better tolerated than gold
or penicillamine.

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Methotrexate:
 May be used in the treatment of RA and
psoriatic arthritis.[6]
 It is a disease-modifying agent with both
anti-inflammatory and immunosuppressant
activity.
 It is also classified as an antimetabolite
cytotoxic agent, and is the most common first-
line agent for the early treatment of RA in the
UK.[5]

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Azathioprine:
 It is a cytotoxic drug and a prodrug of
mercaptopurine.
 It is used as an immunosuppressant for
many autoimmune conditions and to suppress
transplant rejection.
 It acts in a similar manner to methotrexate
but is usually reserved as second-line due to
its toxicity.

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Ciclosporin:
 It is a powerful immunosuppressant that
appears to act specifically on lymphocytes (mainly
helper T cells) resulting in depression of the cell-
mediated immune response.
 Unlike cytotoxic immunosuppressants (such as
cyclophosphamide) it has little effect on bone
marrow.[5]
 It is licensed for the treatment of severe active
RA when the usual second-line therapy is
inappropriate or ineffective.

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Leflunomide:
 Leflunomide has antiproliferative
properties.
 It is licensed for the treatment of adults
with active RA and also for active psoriatic
arthritis.
 It is used in the treatment of moderate-to-
severe active RA, often in combination with
methotrexate.

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 1= normal function
 2=adequate function for normal activities
 3= limited function for activates of daily

living
 4= inability to function independently

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 Rest
 Joint protection
 Pain management
Pharmacologic measures
1. Anti-inflammatory
2. Non steroidal anti-inflammatory
dru(NSAIDS)
3. DMARDs

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 Activity
 Emotional stability
 Quality of life

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Definition
Degenerative joint disease
A clinical syndrome of joint pain accompanied

by functional limitation and reduced QOL

◦ Hips
◦ Knees
◦ Small joints of hands

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OA onset at where joints occur, most commonly
affecting the hands and finger-ends, neck,
lower back, knees, and hips
 It is painful and can negatively influence

lifestyle, bringing on depression and a sense of

helplessness, and finances, as treatment
options can be expensive.
 It is also a very common cause for falls in the

elderly. It leads to weakened bone and muscle

strength, and this can severely worsen the
effects of a fall on an elderly person.

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 Two types of OA:
◦ Primary OA: attributed to age, heredity,
and activity-related deterioration on joint
cartilage, resulting in a total loss of
cartilage cushion between the bones of
joints (Figure 2 above).
◦ Secondary OA: caused by other
diseases/co-morbidities, such as obesity,
trauma, diabetes, etc.

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 Increasing age
 Women
 Obesity
 Joint injuries- sports/occupational repetitive

stress load

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 Features Rheumatoid Osteoarthritis
Arthritis
Age of onset Can happen at Usually later in life
any age
Speed of onset Rapid- weeks to Slow- over years
months
Distribution Symmetrical Initially asymmetrical monoarthritis
polyarthritis polyarthritis
Joints affected Small joints of Weight bearing joints- knees, hips
hands and feet
Duration of Stiffness worse in Stiffness <1hour and worse at the end of
morning the morning the day (after activity)
stiffness >1hour
Systemic Fatigue, fever, -
symptoms night sweats
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 Frequently, OA patients complain of:
◦ Stiffness in a joint after getting out of bed or sitting
for a long time
◦ Swelling and pain in one or more joints
◦ A Crunching feeling or the sound of bone rubbing
on bone
 **If your skin turns red or you feel hot, you
may not have OA;
 it could be of another cause, such as
rheumatoid arthritis

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Common Ways to Diagnose OA
Patient’s Clinical History and Physical Exam

X-rays or MRI images read by an

Orthopedist
 Imaging- 4 cardinal signs on Xray?
 Subchondrial sclerosis
 Osteophytes
 Narrowing of joint space
 Subchondrial cysts
Bloods
 CBC, U&Es, LFTs, ESR,
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 Goals of Treatment
◦ Control Pain
◦ Improve Joint Function
 Treatment Options
◦ Exercise
◦ Strengthening, Aerobic, Agility
◦ Weight Control
◦ Surgery

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 Complementary Methods
◦ Acupuncture
◦ Nutritional Supplements
◦ Restore Lifestyle
◦ Maintain Normal Weight
 Pain Medications
◦ Acetaminophen
◦ Corticosteroids
◦ Hyaluronic Acids

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Total joint replacement (TJR)
Prosthetic devices made from metal alloys,

high-density plastic, or ceramic material used

to replace severely affected joints. Can be
performed for degraded hips, knees,
shoulders, and ankles.

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 Viewing scope inserted into the joint,
allowing a surgeon to view and detect the site
of damage
 Sometimes this can be repaired through an

arthroscope.
 Often a successful procedure with recovery

time quicker than open joint surgery.

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 Pain r/t tissue injury secondary to
inflammation
 Activity intolerance r/t pain and joint stiffness
 Anxiety r/t chronic diseases
 High risk for injury (fall)

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 Assess activity level
 Administer pain killers as prescribed
 Encourage exercise with physiotherapist
 Encourage weight reduction
 Balance diet
 Avoid weight lifting
 Apply cold and hot therapy if joint not swollen
 Apply TENS with the advice of physiotherapist
or physician

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 Take Painkillers Before Surgery
 Inform your physician
 Studies in knee replacements have documented
reduced pain and other postoperative effects
 Request Inpatient Rehabilitation Soon after the
Operation
 Studies have shown that patients moved to
rehab as early as three days following surgery
have had successful recoveries and reduced
hospital costs.

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 Don’t Sit on OA; Approach It In the Long-
Term
 Don’t wait for symptoms to become

debilitating to act
 Studies show that surgeries performed at

later stages of joint deterioration due to OA

result in worse postoperative functional
status

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 Common Causes of Falls
◦ Degraded bone density and muscle strength in the
hip, knee, and ankle joints.
◦ Changes in Visual System
◦ Age-related changes in sight, such as hardening,
yellowing, and clouding of eye lens, decrease in
pupil diameter, clouding of intraocular fluids,
weakened eye muscles all contribute to decline in
sight
◦ Among hip fracture patients, vision impairment is
more frequent than in people without hip fractures

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 Changes in Perceptual and Auditory-
Vestibular Systems
◦ Declining ability to detect information combining
touch and kinesthetic data (haptic perception) hurts
ability to properly grasp and manipulate objects
◦ Vestibular system, located in the ear, is vital to
maintaining and coordinating balance. Age-related
changes to these systems hurts ability to adapt to
environmental changes or obstacles and greatly
increases the risk of falling

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