Rheumatoid arthritis

Question 1

What investigations should be done for rheumatoid arthritis?

Answer 1

Bloods:

• FBC - low Hb and high plt
• CRP/ESR - raised
• Rheumatoid factor (RF) - +ve in 60-70%, but also seen in Hep C, chronic infection and rheumatological conditions.
• Anti-cyclic citrullinated peptide (anti-CCP) antibody - +ve in 80%

Imaging:

• X ray of hands and feet - erosions affecting subchondral bone first then causing joint space narrowing then.
• US/MRI - synovitis of the wrist and fingers

Other:

• Disease activity score - ARC score which includes tender joint count, swollen joint count, functional sttays , pain, global assessment and CRP/ESR

Question 2

What is the management of a patient with suspected RhA?

Answer 2

NSAID at lowest effective dose for shortest possible time with PPI until a rheumatology appointment is available

Question 3

Which biological treatments are used for RhA?

Answer 3

Inhibitors of:

• TNFalpha - Adalimumab, Etanercept
• IL-6 - Tocilizumab
• CD20 - Rituximab
• JAK-stat - Upadacitinib

NB: IL-17 (Secukinumab) is NOT effective.

Question 4

Summarise the specialist medical management of RhA, including what can be offered when stepping up therapy.

Answer 4

Conventional DMARDs e.g. methotrexate, lenoflumide, sulfasalazine

Step up therapies:

• Dose escalation
• Switching therapies*
• If despite dose escalation targets not achieved then cDMARDs may be used in combination as step-up therapy

*When switching DMARDs glycocorticoids may be used to treat interim symptoms

Biological DMARDs

• Used in severe disease, non-responsive to combination of cDMARDs.
• May be useed alone or in combination with methotrexate

Question 5

What instances would you refer RhA to surgeons?

Answer 5

• Pain due to joint damage or other soft tissue cause
• Worsening function of the joint
• Deformity
• Localised synovitis which persists
• Complications
  
  • Nerve compression
  • Fractures from stress
  • Imminent or actual tendon rupture

Question 6

What is rheumatoid arthritis? How common is it?

Answer 6

Chronic systemic inflammatory disease which typically presents as arthritis of the small joints of hands and feet (equally and symetrically) and progresses to affect any body system.

1% of UK population affected with peak onset at 30-50yrs. 2-4:1 F>M

Question 7

What are the 3 main clinical features of RhA?

Answer 7

Pain — usually this is worse at rest or during periods of inactivity.

Swelling — around the joint (not bone swelling) giving a ‘boggy’ feel on palpation.

Stiffness — early morning stiffness usually last over 1 hour (a history of prolonged morning stiffness is more helpful when forming a diagnosis than currently having morning stiffness for early RA).

Question 8

What is the onset of RhA?

Answer 8

Most people have an insidious onset, but others can have a rapid, or relapsing and remitting course (such as a palindromic presentation).

Question 9

What are some differentials for RhA?

Answer 9

• Connective tissue disorders e.g. SLE
• Fibromyalgia
• Infectious arthritis e.g. viral/bacterial
• OA
• PMR
• Polyarticular gout
• PsA
• ReA
• Sarcoidosis
• Septic arthriti s
• Seronegative spondyloarthritis

Question 10

Give examples of NSAIDs used in RhA.

Answer 10

• ibuprofen
• naproxen
• diclofenac
• -coxib e.g. celecoxib or etoricoxib

Question 11

Should glucocorticoids be prescribed in primary care in suspected RhA?

Answer 11

“Do not prescribe a glucocorticoid in primary care before a specialist assessment is carried out — glucocorticoids may mask key clinical features of rheumatoid arthritis and delay diagnosis”

• NICE

Question 12

What do patients with RhA use their GPs for ?

Answer 12

• Manegement of flares
• Drug monitoring e.g. methotrexate
• Check for comorbidities/complications e.g. HTN, IHD, osteoporosis and depression
• Vaccination - pneumococcal and influenza

Question 13

Which glucocorticoids are used to manage flares of RhA?

Answer 13

IM glucocorticoids into gluteal muscle:

• Methylprednisolone acetate 40mg in 1ml
• Triamcinolone acetonide 40 mg in 1 ml

Oral prednisolone may also be offered usually 2-4 week course with 5mg descalations each week.

NSAID

Question 14

What are the complications of drug treatment in RhA?

Answer 14

• GI problems - NSAIDs
• Infection - steroids
• Liver toxicity - methotrexate
• Malignancy - esp skin with TNF-a inhibitors
• Osteoporosis - steroids, although RhA alone increases risk of this too

Question 15

What eye syndrome is seen in RhA?

Answer 15

keratoconjunctivitis sicca

peripheral ulcerative keratitis

Question 16

What is Felty’s syndrome?

Answer 16

Triad of RhA, enlarged spleen and low WCC - affects <1% with RhA

Question 17

What is the leading cause of death in people with RhA?

Answer 17

Cardiovascular disease especially accelerated atherosclerosis

Question 18

How is methotrexate prescribed? What is the frequency of monitoring bloods?

Answer 18

Once weekly regimen with folic acid on the days when not taking methotrexate (or one 5mg folic acid dose the day after)

FBC, U&Es and LFTs

• every 2 weeks initially for 6 weeks
• then montly for 3 months
• then 3 monthly

Question 19

What bloods should be done to monitor biologic DMARD?

Answer 19

• FBC, U&E, LFTs - at 3-4 months, then every 6 months
• Lipid profile - 4 to 8 weeks after beginning treatment
• Infections - Hep B, C and HIV, tuberculosis
• Urinalysis
• Skin examination

Question 20

Which cytokines are most targetted by DMARDs in RhA?

Answer 20

• IL17/23
• TNF-alpha
• JAK pathway

Question 21

Which cDMARDs may be used in pregnancy?

Answer 21

Safe:

• Low dose prednisolone
• Hydroxychloroquine
• Azathioprine
• Tacrolimus
• Ciclosporin

Teratogenic:

• Methotrexate
• MMF

Question 22

Which calculator is used in RhA to monitor disease activity?

Answer 22

DAS28

Question 23

How many cDMARDS must be used before biological treatment?

Answer 23

NICE: methotrexate and at least one other cDMARD must be used long enough to have activity before moving onto adalimumab/rituximab.

Question 24

Which steroid injection is used in active RhA?

Answer 24

IM depomedrone

Question 25

What investigations must be used for monitoring in RhA on methotrexate?

Answer 25

3 monthly FBC, U&Es and LFTs only - prescription cannot be repeated unless this is done

Question 26

What does the primary care review of rheumatoid arthritis include?

Answer 26

Reviews in primary care help address this, and also can include the following:

1. Assessment of any flares – treatment, need for referral etc.
2. Ensuring patient is aware of how and when to access specialist help – e.g. rheumatology specialist nurse, physiotherapist, OT etc.
3. Drug monitoring – especially blood tests for DMARDs, ensure safe prescribing etc.
4. Assessing disease activity and damage, and screen for extra-articular complications – clinician may want to use health assessment questionnaires here.
5. Screen for co-morbidities – hypertension, osteoporosis, depression, ischaemic heart disease – using tools such as QRISK2 and FRAX score etc.
6. Health promotion – smoking cessation, encouraging exercise where possible, advice on healthy diet etc.
7. Offer vaccinations – pneumococcal and yearly influenza vaccination.