Rheumatoid Arthritis

Question 1

What is the classic age for rheumatoid arthritis?

Answer 1

30s - most people with inflammatory conditions are younger

Question 2

What is the pattern for inflammatory arthritis?

Answer 2

Peripheral, symmetrical, polyarthritis

Question 3

What are the differential diagnoses for rheumatoid arthritis?

Answer 3

Psoriatic arthritis
Post-infective arthritis
Lupus, especially if symptoms affecting other systems present

Question 4

What are the symptoms of mechanical joint pain?

Answer 4

Chronic pain = months-years
Slowly worsening
Worse with movement
Improved by rest
Not much swelling
Little stiffness = 10-15 mins

Question 5

What are the symptoms of inflammatory joint pain?

Answer 5

Acute/subacute pain
May worsen quickly
Better after movement
Worse after rest
Swelling often noticeable and may be prominent
Stiffness may be prolonged (hours) and worse in morning

Question 6

Which joint is usually first to be affected in rheumatoid arthritis?

Answer 6

2nd metacarpo-phalangeal (MCP) joint

Question 7

Which joints are usually affected in rheumatoid arthritis?

Answer 7

Proximal interphalangeal (PIP) joints of hands
MCP joints
Joints of wrist
Elbow joints
Acromioclavicular (AC) joints
Cervical spine
Hips
Knees
Metatarsophalangeal (MTP) joints
PIP joints of feet

Question 8

What are the risk factors for rheumatoid arthritis?

Answer 8

Family history

Smoking

Question 9

What is the role of pregnancy in rheumatoid arthritis?

Answer 9

Pregnancy protective

Post-childbirth causes flare

Question 10

What are the signs of rheumatoid arthritis?

Answer 10

Affected joints

• Puffy and swollen
• Tender
• Range of movement can be affected

Question 11

Can larger joints be affected in rheumatoid arthritis?

Answer 11

Yes, they can, but usually later on in disease

Question 12

Which joints are usually affected in osteoarthritis?

Answer 12

1st carpo-metacarpal (MCP) joints
Distal interphalangeal (DIP) joints of hands
AC joints
Cervical spine
Lumbar spine
Hips
Knees
1st tarso-metatarsal (TMT) joints

Question 13

What investigations are useful in rheumatoid arthritis?

Answer 13

Ultrasound and MRI useful in early presentation for picking up subclinical synovitis
Also useful in monitoring treatment
Ultrasound used more often than MRI due to access and expense

Question 14

What is the utility of measuring anti-citrullinated protein antibody (ACPA) and rheumatoid factor?

Answer 14

Very relevant for prognosis

Diagnostic value lower

Question 15

What are the treatment goals for rheumatoid arthritis?

Answer 15

Reduction of joint inflammation
Prevention of joint damage
Prevention of long-term associated complications
Avoid drug complications
Maintenance of quality of life

Question 16

How and why is remission aimed for in the treatment of rheumatoid arthritis?

Answer 16

Early aggressive treatment > remission ASAP
If you can get patient into remission for 1st 6 months, their prognosis much better, as a lot of erosive damage will occur within this time

Question 17

What are the pharmacological therapies available for rheumatoid arthritis?

Answer 17

NSAIDs
Disease modifying anti-rheumatic drugs (DMARDs)
Corticosteroids
Analgesics

Question 18

What is the first line DMARD used?

Answer 18

Methotrexate

Question 19

What is the efficacy of NSAIDs in the treatment of rheumatoid arthritis?

Answer 19

Good short- and long-term efficacy

Question 20

What are the biologic DMARDs available?

Answer 20

TNF inhibitors - mainstay of treatment
B cell inhibitor
Cell adhesion inhibitor
IL-6 inhibitor

Question 21

How does the route of administration of corticosteroids affect their efficacy and side effects?

Answer 21

Oral prednisolone
- Efficacious
- Side effects
   - Hypertension
   - Weight gain
   - Skin changes
   - Hyperglycaemia
   - Osteoporosis
Intra-articular steroids
- Efficacious in accessible joints
- Few side effects if used intermittently

Question 22

How is disease activity measured in rheumatoid arthritis?

Answer 22

Patient and physician global assessment
Swollen and tender joint count O/E
Measures of inflammation
- CRP
- ESR

Question 23

How is disease damage measured in rheumatoid arthritis?

Answer 23

Bone and cartilage damage slower than soft tissue swelling
MRI more sensitive than x-ray for detecting
- Synovitis
- Cartilage damage
- Bone oedema
- Bone erosions
X-rays usually not needed in early management