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Table of Contents
INVITED REVIEW
Year : 2022  |  Volume : 15  |  Issue : 1  |  Page : 1-4

Rheumatoid arthritis: A challenging inflammatory disease


Rheumatology Unit, Clinic Hera, Vienna, Austria

Date of Submission17-Feb-2022
Date of Acceptance20-Feb-2022
Date of Web Publication25-Mar-2022

Correspondence Address:
Johannes Grisar
Rheumatology Unit, Sanatorium Hera, Löblichgasse 14, 1090 Vienna
Austria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hmj.hmj_22_22

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  Abstract 


Introduction: Rheumatoid arthritis (RA) represents the most common inflammatory joint disease of the western world. The main clinical manifestations of this disease are swelling and tenderness of the joints, mainly in the fingers accompanied by morning stiffness. Several laboratory parameters, like surrogates of inflammation but also rheumatoid factor (RF) and antibodies against citrullinated peptide (anti-ccP) are helpful for diagnosis as well as imaging tools, mainy X-rays, ultrasound and magnetic resonance imaging (MRI). Methods: This review will focus on the clinical manifestations and the pathophysiology of RA and highlight the therapeutic options. Results: With regards to efficacious therapies methotrexate (MTX) still represents the anchor drug for initial treatment combined with short term glucocorticoids. If this therapy fails however, several therapeutic options like bDMARDs and Janus Kinase (JAK) inhibitors have emerged during the last decades.Following the well established treat to target principle, the goal of a successful therapy is either remission or, if this can not be reached, low disease activity according to composite scores. The disease activity should be controlled in regular intervals. Conclusions: RA is a frequent inflammatory joint disease. The goal of a sufficient therapy is to reach clinical remission and we nowadays have a broad armamentarium available to treat this disease sufficiently in a large population of patients.

Keywords: Biologic disease-modifying drugs, methotrexate, radiographic progression, rheumatoid arthritis, treat to target


How to cite this article:
Grisar J. Rheumatoid arthritis: A challenging inflammatory disease. Hamdan Med J 2022;15:1-4

How to cite this URL:
Grisar J. Rheumatoid arthritis: A challenging inflammatory disease. Hamdan Med J [serial online] 2022 [cited 2022 May 28];15:1-4. Available from: http://www.hamdanjournal.org/text.asp?2022/15/1/1/340813




  Introduction – Prevalence and Pathophysiology of Rheumatoid Arthritis Top


Rheumatoid arthritis (RA) used to be a crippling disease for many of the affected patients until the late 20th century. However, an intense improvement and an expansion of the therapeutic armamentarium, especially during the past two decades, made it possible that the percentage of RA patients that suffer from immobility has been shrunken dramatically.

This is also reflected by the fact that the frequency of orthopaedic surgeries in RA in the past 13 years.[1]

This review will focus on the clinical manifestations and the pathophysiology of RA and highlight the therapeutic options.

RA is an autoimmune disease that occurs in any age of adulthood. A peak has been described around the age of 55 years, in the elderly, the disease has been named late-onset RA.[2]

Juvenile forms are referred to as an own disease i.e., juvenile idiopathic arthritis and differ from RA both with regards to the course of the disease and with respect to the therapeutic agents.[3]

Females are around four times more frequently affected from RA than males which led to the hypothesis that hormonal factors might play a role in the pathogenesis of the disease. The prevalence of the disease varies according to the literature and can be estimated between 0.5% and 1%.[4]

The pathogenesis of RA despite excessive investigations still remains not fully understood.[5],[6] Generally and most likely in most of the hypotheses, there is an autoantigen at the beginning of the cascade which kicks off the inflammatory process. Briefly, the antigen-presenting cells then activate T-cells which then lead to a vicious cycle with monocyte activation, secretion of proinflammatory cytokines and B-cell activation.

The effects of this process are reflected by synovial inflammation, pannus formation, cartilage and bone destruction, which are the leading pathophysiological correlates of the disease.

This process is likely to be driven by also by genetic an environmental factors.


  Clinical Features and Laboratory Findings Top


Regarding the clinical manifestations, one of the first symptoms is morning stiffness mainly in the fingers and toes but also less frequent in the wrists, ankles and knees, which can last several hours. One of the hallmarks of RA is the synovial swelling which occurs primarily in the pmetatarsophalangeal joints, the proximal interphalangeal joints, wrists and also the metatarsophalangeal joints. However, also knees, wrists, shoulders and hips can be affected. In contrast, RA never affects the distal interphalangeal joints, where osteoarthritis but also psoriatic arthritis can lead to inflammation. Those two diseases represent the most relevant differential diagnoses.

Moreover, most of the patients suffer from fatigue but also weight loss and depression can be observed.

With respect to relevant laboratory tests, there exists no marker which is specific for RA. However, the majority of patients exhibit slightly to extensively elevated parameters of inflammation, mainly measured with C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) but also fibrinogen, leucocytes and thrombocytes can be increased.

First described in 1948 by Rose and Ragan[7] rheumatoid factor (RF) represents an antibody against RF[8] and is positive in the serum of approximately 69% of all RA patients.[9] It is important to note that in early RA, only 33% of the patients have been shown to be RF positive indicating that a large proportion of patients exhibit a conversion of the RF during the course of disease. However, very important for clinical daily routine, RF can also be found in healthy patients or in other diseases. Moreover, RF has also been found more frequently in the elderly population not suffering from RA.

Another marker that is known to be more specific for RA are the antibodies against citrullinated peptide (ccP). These have been described around 20 years ago and differ in dependency of the stage of RA.[10],[11] It also was described that healthy individuals that are anti-ccP positive have a higher probability to develop RA. A positive anti-ccP status has been shown to be associated with a more severe course of the disease and radiographic progression.


  Diagnosis and Treatment Top


To facilitate and standardise the diagnosis of RA, joint classification criteria of the European League Against Rheumatism (EULAR) and the American College of Rheumatism have been published [Table 1].[16]
Table 1: 2010 EULAR/ACR classification criteria (16)

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Once the diagnosis has been performed, early treatment is regarded to be crucial. The long-term clinical outcome and the radiographic progression are driven by an early effective treatment.

Besides the effective reduction of pain and swelling, halt or inhibition of the radiographic progression, remains the goal of therapy.

Since the millennium, the available therapeutic options have been dramatically improved.

The agents used for the treatment of RA can be divided into conventional synthetic (cs) disease-modifying drugs (DMARDs), biologic (b) DMARDs and targeted synthetic (ts) DMARDs which are (currently) similar to Janus kinase (JAK) inhibitors [Table 2].
Table 2: Overview of the most commonly used drugs in RA

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CsDMARDs have been long in use and methotrexate (MTX), which has been approved by the Food and Drug Administration in the 1980s, still represents the anchor drug of RA therapy and should be initially administered if there are no contraindications existing.

Moreover, the current guidelines recommend short-term glucocorticoid treatment at the very beginning of the RA treatment in order to dampen the disease activity. However, during the course of treatment, glucocorticoids ideally should be avoided indicating that an efficacious therapy does not require co-medication with glucocorticoids. This is an important aspect since glucocorticoids are known for their side effects if given over a longer period.

Other csDMARDs are sulfasalazine, which in contrast to MTX could also be given before and during pregnancy as well as lactation. Leflunomide can also be given to patients with impaired renal function.

The bDMARDs that are in use in RA therapy are tumour necrosis factor-alpha (TNF) blockers, the IL-6 receptor antagonist tocilizumab and the co-stimulation antagonist abatacept. These agents represent antibodies or receptor antagonists against TNF or the other above-mentioned cytokines and are administered intravenously or subcutaneously in distinct intervals.

The most recent expansion of therapeutic agents are the JAK inhibitors. These orally administered drugs aim at the signal transduction casacade, which is driven by JAK. There are 4 JAK inhibitors existing (JAK 1–3 and Tyrosine Kinase 1 = Tyk1) and currently, 4 JAK inhibitors have been approved for RA treatment. Those four agents inhibit the different JAK inhibitors to different extent [Table 2]. Several phase 3 studies indicate higher remission rates for patients treated with JAK inhibitors when compared to those performed with TNF blockers, although these were no head-to-head studies. Moreover, for baricitinib and upadacitinib superiority against the most common TNF blocker adalimumab in combination with MTX could be shown in direct comparison.[12],[13]

Since many years, the EULAR publishes treatment recommendations for RA which are updated every few years according to recent scientific insights. Briefly, RA patients immediately after diagnosis should receive a therapy with MTX accomplished by short-term glucocorticoids to dampen inflammatory activity rapidly. If this therapy fails after 3–6 months, a therapy with either bDMARDs or JAK inhibitors is recommended when diagnostic unfavourable factors (erosions, positive anti-ccP/RF or increased parameters of inflammation) are present. TNF blockers usually should be combined with MTX, since it has been shown that this improves their efficacy, whereas JAK inhibitors and anti-IL-6 blockade can also been administered as monotherapy showing good efficacy. [Table 2] gives an overview of the immunomodulating therapies used in RA.

Before starting a therapy, it is important to explain the patient the possible side effects associated with the disease as well as an awareness for infections. Distinct laboratory parameters should be checked depending on the drug prescribed.

In daily clinical routine, disease activity is measured using validated composite scores which include swollen joint count, tender joint count, parameters of inflammation as well as the patients rating of his pain. Among those, DAS28 (CRP or ESR),[14] CDAI and SDAI[15] are the most common instruments.

Around a decade ago, the 'treat to target' principle has emerged, which is meanwhile state of the art in several inflammatory rheumatic diseases.[16] Briefly, the target of treatment is to reach remission as measured by the distinct composite scores. If this is not possible, due to several reasons, the goal should be at least low disease activity. The level of disease activity should be assessed every 3 months and if a therapy fails, it should be switched after 3–6 months.

Several studies have shown that a treatment strategy aiming for rapid depletion of disease activity is associated with a better outcome on the long term.


  Conclusion Top


Taken together, RA represents the most common inflammatory rheumatic disease that nowadays can be effectively treated in many patients. The diagnosis, however, can be challenging. Treatment should be initiated rapidly according to the EULAR criteria and the treat to target principle to optimise the outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hanly JG, Lethbridge L, Skedgel C. SAT0077 change in frequency of arthroplasty surgery in rheumatoid arthritis: A 13 year population health study. 2018.  Back to cited text no. 1
    
2.
Soubrier M, Mathieu S, Payet S, Dubost JJ, Ristori JM. Elderly-onset rheumatoid arthritis. Joint Bone Spine 2010;77:290-6.  Back to cited text no. 2
    
3.
Lee JJ, Schneider R. Systemic juvenile idiopathic arthritis. Pediatr Clin North Am 2018;65:691-709.  Back to cited text no. 3
    
4.
Myasoedova E, Crowson CS, Kremers HM, Therneau TM, Gabriel SE. Is the incidence of rheumatoid arthritis rising?: Results from Olmsted County, Minnesota, 1955-2007. Arthritis Rheum 2010;62:1576-82.  Back to cited text no. 4
    
5.
McInnes IB, Schett G. The pathogenesis of rheumatoid arthritis. N Engl J Med 2011;365:2205-19.  Back to cited text no. 5
    
6.
McInnes IB, Schett G. Cytokines in the pathogenesis of rheumatoid arthritis. Nat Rev Immunol 2007;7:429-42.  Back to cited text no. 6
    
7.
Rose HM, Ragan C. Differential agglutination of normal and sensitized sheep erythrocytes by sera of patients with rheumatoid arthritis. Proc Soc Exp Biol Med 1948;68:1-6.  Back to cited text no. 7
    
8.
Pike RM, Sulkin SE, Coggeshall HC. Serological reactions in rheumatoid arthritis; factors affecting the agglutination of sensitized sheep erythrocytes in rheumatid-arthritis serum. J Immunol 1949;63:441-6.  Back to cited text no. 8
    
9.
Nishimura K, Sugiyama D, Kogata Y, Tsuji G, Nakazawa T, Kawano S, et al. Meta-analysis: Diagnostic accuracy of anti-cyclic citrullinated peptide antibody and rheumatoid factor for rheumatoid arthritis. Ann Intern Med 2007;146:797-808.  Back to cited text no. 9
    
10.
Suzuki K, Sawada T, Murakami A, Matsui T, Tohma S, Nakazono K, et al. High diagnostic performance of ELISA detection of antibodies to citrullinated antigens in rheumatoid arthritis. Scand J Rheumatol 2003;32:197-204.  Back to cited text no. 10
    
11.
Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO 3rd, et al. 2010 rheumatoid arthritis classification criteria: An American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis 2010;69:1580-8.  Back to cited text no. 11
    
12.
Taylor PC, Keystone EC, van der Heijde D, Weinblatt ME, del Carmen Morales L, Reyes Gonzaga J, et al. Baricitinib versus placebo or adalimumab in rheumatoid arthritis. N Engl J Med 2017;376:652-62.  Back to cited text no. 12
    
13.
Fleischmann R, Pangan AL, Song IH, Mysler E, Bessette L, Peterfy C, et al. Upadacitinib versus placebo or adalimumab in patients with rheumatoid arthritis and an inadequate response to methotrexate: Results of a phase III, double-blind, randomized controlled trial. Arthritis Rheumatol 2019;71:1788-800.  Back to cited text no. 13
    
14.
Prevoo ML, Van'T Hof MA, Kuper HH, van Leeuwen MA, van de Putte LB, van Riel PL. Modified disease activity scores that include twenty-eight-joint counts development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum 1995;38:44-8.  Back to cited text no. 14
    
15.
Aletaha D, Nell VP, Stamm T, Uffmann M, Pflugbeil S, Machold K, et al. Acute phase reactants add little to composite disease activity indices for rheumatoid arthritis: Validation of a clinical activity score. Arthritis Res Ther 2005;7:R796-806.  Back to cited text no. 15
    
16.
Smolen JS, Aletaha D, Bijlsma JW, Breedveld FC, Boumpas D, Burmester G, et al. Treating rheumatoid arthritis to target: Recommendations of an international task force. Ann Rheum Dis 2010;69:631-7.  Back to cited text no. 16
    



 
 
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