Inflammatory Arthritis in Clinical Practice

226 Pages·2015·3.5 MB·English

by  Ian C. Scott

Ian C. Scott
James B. Galloway
David L. Scott
Inflammatory Arthritis
in Clinical Practice
Second Edition
123
Inflammatory Arthritis
in Clinical Practice

Ian C. Scott (cid:129) James B. Galloway
David L. Scott
Inflammatory Arthritis
in Clinical Practice

Second Edition
Ian C. Scott David L. Scott
Molecular and Cellular Biology Rheumatology
of Inflammation King’s College Hospital
King’s College London London
London UK
UK
James B. Galloway
Rheumatology
King’s College Hospital
London
UK
ISBN 978-1-4471-6647-4 ISBN 978-1-4471-6648-1 (eBook)
DOI 10.1007/978-1-4471-6648-1
Springer London Heidelberg New York Dordrecht
Library of Congress Control Number: 2015932095
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Pref ace
The inflammatory arthropathies are a group of conditions
characterised by pain and swelling of the joints. The common-
est types comprise rheumatoid arthritis (RA), psoriatic arthri-
tis (PsA), ankylosing spondylitis (AS) and reactive arthritis.
In most instances they represent long-term conditions, which
require treatment with immunosuppressive drugs. Unless
adequately managed they can have major impacts on patients
resulting in pain, disability and an impaired quality of life.
Over the last three decades the assessment and diagnosis
of inflammatory arthritis has rapidly and radically changed.
This has accelerated in the last few years with a series of
major developments. These span new diagnostic tests such as
antibodies to citrullinated protein antigens (ACPA) in RA,
novel imaging approaches such as the high-resolution ultra-
sound power Doppler modality, and new treatments, particu-
larly biologics.
There has also been a major shift in the manner in which
inflammatory arthritis is viewed and treated. The historical
Spa hospital ethos of bed rest and hydrotherapy has been
completely cast aside in favour of early intensive treatment
with combination disease-modifying anti-rheumatic drugs
(DMARDs) and biologics. The end result has been improved
patient outcomes.
There are still many challenges to overcome in the man-
agement of inflammatory arthritis patients. Firstly, as early
treatment results in better outcomes, an improved ability
to diagnose and treat these diseases at an early stage is
needed. Secondly, as patients have a variable disease course,
biomarkers are required that predict an individual’s likely
v
vi Preface
disease severity; such markers could guide decisions on treat-
ment intensity. Thirdly, different patients respond to different
drugs; methods are therefore needed that can predict what
medications someone is likely to benefit from, providing tai-
lored treatment. Finally, as current tools to measure disease
activity and severity in routine clinics have limitations, such
as the “floor-effect” of joint counts, improved methods to
measure the impact of inflammatory arthritis are required.
U nderstanding the key components of the diagnosis,
assessment and management of inflammatory arthritis
patients is essential to improving patient care. This book
aims to cover these areas. It places inflammatory arthritis
into a historical context; deals with the epidemiology, pathol-
ogy, clinical assessment and investigation of inflammatory
arthritis patients; and provides a comprehensive overview
of currently available treatment options. It provides insight
into stratified medicine, an area of emerging importance in
the management of heterogeneous diseases like RA. Finally,
it provides an overview of what treatment strategies are in
development.
London, UK Ian C. Scott
London, UK James B. Galloway
London, UK David L. Scott
Contents
1 An Overview of Infl ammatory Arthritis. . . . . . . . . . . 1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
What Are the Infl ammatory Arthropathies? . . . . . . . 2
Historical Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . 3
Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
The Concept of Classification Criteria . . . . . . . . . 4
Rheumatoid Arthritis. . . . . . . . . . . . . . . . . . . . . . . . 5
Ankylosing Spondylitis . . . . . . . . . . . . . . . . . . . . . . 5
Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Other Spondyloarthropathies. . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2 Epidemiology and Pathology. . . . . . . . . . . . . . . . . . . . 13
Epidemiology of Rheumatoid Arthritis . . . . . . . . . . . 14
Epidemiology of Seronegative Arthritis. . . . . . . . . . . 14
Aetiology of Infl ammatory Arthritis. . . . . . . . . . . . . . 16
Rheumatoid Arthritis. . . . . . . . . . . . . . . . . . . . . . . . 16
Seronegative Spondyloarthropathies. . . . . . . . . . . 17
Pathology of Infl ammatory Arthritis. . . . . . . . . . . . . . 17
Histology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Lymphocytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Cytokines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Chemokines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Metalloproteinases. . . . . . . . . . . . . . . . . . . . . . . . . . 20
Adhesion Molecules, Angiogenesis
and Other Mediators . . . . . . . . . . . . . . . . . . . . . . . . 20
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
vii
viii Contents
3 Clinical Features. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Synovitis of Peripheral Joints. . . . . . . . . . . . . . . . . . . . 24
Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Joint Swelling and Tenderness. . . . . . . . . . . . . . . . . 24
Peripheral Joints Involved . . . . . . . . . . . . . . . . . . . . . . 25
Rheumatoid Arthritis. . . . . . . . . . . . . . . . . . . . . . . . 25
Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Other Forms of Spondyloarthropathies. . . . . . . . . 29
Enthesitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Spinal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Ankylosing Spondylitis . . . . . . . . . . . . . . . . . . . . . . 30
Other Types of Spondyloarthritis. . . . . . . . . . . . . . 31
Rheumatoid Arthritis. . . . . . . . . . . . . . . . . . . . . . . . 31
Systemic Features. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Clinical Course. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Onset of Rheumatoid Arthritis. . . . . . . . . . . . . . . . 32
Established Rheumatoid Arthritis . . . . . . . . . . . . . 33
Other Inflammatory Arthropathies . . . . . . . . . . . . 33
Undifferentiated Early Arthritis. . . . . . . . . . . . . . . 33
Extra-articular Disease . . . . . . . . . . . . . . . . . . . . . . . . . 34
Rheumatoid Arthritis. . . . . . . . . . . . . . . . . . . . . . . . 34
Other Inflammatory Arthropathies . . . . . . . . . . . . 36
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
4 Clinical and Laboratory Assessments. . . . . . . . . . . . . 39
Role of Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Clinical Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Joint Counts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Global Assessments. . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Pain Scores. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Functional Assessments. . . . . . . . . . . . . . . . . . . . . . 46
Generic Health Status Measures . . . . . . . . . . . . . . 47
SF-36. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
EuroQol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Laboratory Assessments. . . . . . . . . . . . . . . . . . . . . . . . 49
Acute Phase Response. . . . . . . . . . . . . . . . . . . . . . . 49
Multi-biomarker Disease Activity
(MBDA) Tests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Contents ix
Rheumatoid Factor. . . . . . . . . . . . . . . . . . . . . . . . . . 51
Antibodies to Citrullinated Protein Antigens. . . . 52
Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
X-Rays in Rheumatoid Arthritis . . . . . . . . . . . . . . 53
Ultrasound in Rheumatoid Arthritis . . . . . . . . . . . 55
Magnetic Resonance Imaging in Rheumatoid
Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Imaging in Psoriatic Arthritis . . . . . . . . . . . . . . . . . 56
Imaging in Ankylosing Spondylitis
and Reactive Arthritis . . . . . . . . . . . . . . . . . . . . . . . 57
Combined Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Core Data Set in Rheumatoid Arthritis . . . . . . . . 57
Composite Disease Activity Indices: Disease
Activity Score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Simplified Indices. . . . . . . . . . . . . . . . . . . . . . . . . . . 59
American College of Rheumatology (ACR)
Response Criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Other Forms of Arthritis . . . . . . . . . . . . . . . . . . . . . 60
Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Rheumatoid Arthritis. . . . . . . . . . . . . . . . . . . . . . . . 61
Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Ankylosing Spondylitis . . . . . . . . . . . . . . . . . . . . . . 63
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
5 Symptomatic Drug Treatment . . . . . . . . . . . . . . . . . . . 67
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Simple Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Paracetamol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Opioids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Tramadol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Buprenorphine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Codeine and Dihydrocodeine. . . . . . . . . . . . . . . . . 72
Compound Analgesics . . . . . . . . . . . . . . . . . . . . . . . 72
Non-steroidal Anti-infl ammatory Drugs
(NSAIDs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Mechanism of Action and Cox I/Cox II Effects. . 73
Classification of NSAIDs. . . . . . . . . . . . . . . . . . . . . 74