Rheumatoid Arthritis and Ankylosing Spondylitis
Recent years have seen an extraordinary growth in our knowledge and understanding of the pathogenesis of inflammatory arthritis that has been reflected in the development of new therapies and changing clinical practice. This chapter will review two of the
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Douglas H. N. White
Introduction Recent years have seen an extraordinary growth in our knowledge and understanding of the pathogenesis of inflammatory arthritis that has been reflected in the development of new therapies and changing clinical practice. This chapter will review two of the most common forms of inflammatory arthritis, rheumatoid arthritis and ankylosing spondylitis and explore their epidemiology, pathogenesis, clinical features and treatment.
8.1
Rheumatoid Arthritis
Historical Perspective Rheumatoid arthritis (RA) has been recognised in Europe since the 17th century, with Sydenham publishing the first case report in 1676. The artwork of the Dutch painter, Peter Paul Rubens (1577–1640) is thought by some to show evidence of hand deformities that can occur in RA (Appelboom et al. 1981). Interestingly however, the typical erosive changes of RA have not been found within the European fossil record, yet the characteristic joint damage found with gout, osteoarthritis and ankylosing spondylitis has been well documented (Aceves-Avila et al. 1998). Similar evaluation of skeletal remains from indigenous North Americans has shown these characteristic changes and in these areas, prevalence of RA remains remarkDouglas White, BSc(Hons), MBChB(Hons), MRCP(UK), DipMSM, FRACP Consultant Rheumatologist and Honorary Senior Clinical Lecturer at the University of Auckland Rheumatology Department, Waikato Hospital, Pembroke Street, Hamilton, New Zealand [email protected] Pietschmann et al., Principles of Osteoimmunology, Molecular Mechanisms and Clinical Applications; DOI 10.1007/978–3–7091–0520–7, © SpringerWienNewYork 2012
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8 Rheumatoid Arthritis and Ankylosing Spondylitis
ably high at around 5 % (Rothschild et al. 1988). This has led to speculation that perhaps RA was brought from the New World back to the Old World by returning explorers. There is however no direct evidence supporting this hypothesis at the current time.
8.1.1 Epidemiology Rheumatoid arthritis has a worldwide distribution affecting all ethnic groups and although all ages can be affected, the peak incidence is between the 4th and 6th decades with females being affected 2–4 times more commonly than males. The gender ratio becomes less pronounced with increasing age. Prevalence varies considerably but published work suggests that ~0.5–1 % of European and North American adults are affected with rates being lower in Southern Europe than Northern Europe and highest in native North America (Alamanos et al. 2006). Several authors have suggested that RA appears to be becoming less common and less severe and there is evidence that the incidence of extra-articular features is declining (Turesson and Matteson 2009). The change in incidence appears to have begun before the advent of aggressive disease management strategies and remains unexplained.
8.1.2 Pathogenesis Insights into the pathogenesis of RA have been gained through the study of affected tissues, genetic studies and more modern molecular approaches. Nevertheless
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