Rheumatoid Arthritis Part 1 (Kremer, 2/26/2020)

Dr. Lisa Kremer gave a wonderful Grand Rounds this week on Rheumatoid Arthritis. To be clear, RA is not a topic that normally gets me out of bed in the morning. But Dr. Kremer's presentation was so good that I found myself wishing for it not to end. Or for Part 2 to follow asap.  And even several hours later, in the chaos of a busy day in the hospital, I found myself considering this strange disease-- rarely seen before the 1600s, now quite common, terribly disabling, and brought about by a "perfect storm" of genetics, environment, and stress.


RA is characterized by symmetrical polyarticular swelling of the small and medium joints on more than one occasion, over more than six weeks, supported by lab and/or xray and absence of other diagnosis. Exact causes are unknown. Multiple triggers.

Dr. Kremer described RA as an autoimmune condition, with some genetic susceptibilities (e.g. HLA DR4), for which smoking doubles the risk. RA can be precipitated by infections, environmental toxins, social and physical stresses, and hormonal triggers.

• 1% of the the adult world has RA (1.5 million people in the US)-- the most common chronic inflammatory arthritis
• 4:1 female to male
• Peak age onset 40-60 years (but anytime after puberty is possible)
• All races and geographic areas are affected
• Specific populations with higher incidence (Native Americans, particularly: up to 10% of Sioux, Algonquian, Pima, Yakima, and Inuit peoples)

And while Dr. Kremer presented us with these data and more, she also presented the case of Pierre Aguste-Renoir (1841-1919), a French artist and a leading painter in the impressionist movement. She described him as a joyous and radical young man, struck by RA around age 50. His RA seems to have been precipitated by a fall from a bicycle and a resulting arm fracture. From which he never really recovered. And yet Renoir continued to paint long into his illness-- even designing his own wheelchair and equipment to be able to reach up to his large canvass painting surface. 

Dr. Kremer espouses that Renoir is a particularly excellent painter of hands. Perhaps he spent a lot of time thinking about hands. And looking at them. . .

Laboratory testing in RA is helpful but pretest probability determines the benefit of the test. 

• Rheumatoid factor (RF) is not specific
• Anti-CCP is more specific (can actually be positive a few years prior to onset of symptoms, but not always)
• ANA can be positive
• ESR and CRP really convey inflammatory cascade

RA vs. OA (from PPM here): 

Extra-articular complications of RA only occur only in seropositive patients (i.e. +RF ):

• fever and weight loss (can look like cancer)
• nodules (can be anywhere: eyes, heart, etc)
• interstitial lung disease
• pleuro-pericarditis
• CAD
• malignancy (specifically mymphoma)
• infections (like pneumonia)
• a variety of hematologic abnormalities (anemia, thrombocytopenia)
• osteoporosis

Prognosis:
Untreated RA shortens life by 5-10 years. Aggressive RA therapy decreases mortality risk due to CV disease, lung disease, and more (more on this next time). Treatment reduces need for joint replacement byup to 50%.

Disability:
Over 33% of RA patients working at the time of diagnosis will leave workforce within 5 years
Fatigue and unpredictable joint symptoms are frequently the most disabling issues

And finally, here are Dr. Kremer's pearls of wisdom:

• Deformity does not equal disability
• RA does not cause back pain
• Never order tests if you don't know what you are looking for
• Low SES is associated with onset and severity of RA
• Smoking DOUBLES the risk and worsens the progression
• RA is "soft and spongy" (not hard and bony like osteoarthritis)
• A positive RF is not diagnostic, it should prompt you to keep looking for a diagnosis
• DIP joints are almost always spared
• If after careful exam and lab testing, you suspect RA, refer early to rheum!

Stay tuned: Dr. Kremer will present Part 2 (Rheumatoid Arthritis: Treatment) in July or August of 2020. Keep your eyes out! And don't miss it.