Clinical Aspects of RA and Approach to Therapeutics

Question 1

What is the defining characteristic of rheumatoid arthritis that separates it from single joint arthritis?

Answer 1

It is symmetrical

Question 2

Who tends to get rheumatoid arthritis?

Answer 2

Females - 3:1

peaks in 4th / 5th decade but can occur from age 16 upwards

Question 3

What are the major cell types of the pannus during synovitis? Of the synovial fluid?

Answer 3

Pannus: T lymphocytes, macrophages, fibroblasts, plasma cells

Synovial fluid: neutrophils

Question 4

What is an important early investigation in suspected rheumatoid arthritis?

Answer 4

Immunology for autoantibodies:

• Rheumatoid Factor (IgG, IgM)
• Anti Cyclic Citrullinated Antibodies (anti CCP / ACPA)

Question 5

Investigations for suspected rheumatoid arthritis?

Answer 5

• Immunology (RhF / anti-CCP / ACPA)
• Bloods (ESR & CRP / anaemia / albumin / neutropenia)
• X-Ray
• Synovial fluid aspiration (high WBC & protein)

Question 6

Symptoms of rheumatoid arthritis?

Answer 6

• Pain (exacerbated by movement)
• Stiffness (esp. morning)
• Joint swelling / immobility
• Systemic effects

Question 7

Clinical signs of rheumatoid arthritis?

Answer 7

• Swollen, warm, tender joints
• Joint deformities (swan neck / Boutonniere)
• Limited joint movement
• Muscle weakness

Question 8

What types of joint deformities may be seen in the hands and fingers of rheumatoid arthritis patients?

Answer 8

• Ulnar drift (fingers lean away from thumb, towards pinky)
• Hitchhikers thumb (z shaped): thumb flexed at MCPJ, extended at IPJ)
• Swan neck (proximal IPJ hyperextended, distal IPJ flexed)
• Boutonnieres (proximal IPJ flexed, distal IPJ hyperextended)

Question 9

What are some systemic presentations of rheumatoid arthritis?

Answer 9

Non-specific: fatigue, weight loss anaemia

Specific: eyes, lungs, nerves, skin, kidneys

Long term: CVS, malignancy

Question 10

What is the RF RISES diagnostic criteria for rheumatoid arthritis?

Answer 10

Guideline to diagnose, need 4/7:

R - Rheumatoid factor 
F - Finger / hand involvement 
R - Rheumatoid nodules 
I - Involvement of 3 or more joints 
S - Stiffness (esp. early morning)
E - Erosions / decalcifications on x-ray
S - Symmetrical arthritis

Question 11

What are the four main methods of treatment of rheumatoid arthritis?

Answer 11

• Pharmaceuticals
• Steroid injections
• Occupational and physio - therapies
• Surgery

Question 12

What are the main classes of pharmaceuticals used to treat rheumatoid arthritis?

Answer 12

• NSAIDs (symptomatic relief)
• Disease Modifying Anti Rheumatic Drugs (DMARDs)
• Biologics (targeted therapy)
• Corticosteroids

Question 13

What are disease modifying anti rheumatic drugs? What are some commonly used examples?

Answer 13

A group of structurally unrelated molecules that have shown to have an effect on slowing disease progression

• Methotrexate***
• Sulfasalazine
• Hydroxychloroquine
• Leflunomide

Question 14

How is the treatment of rheumatoid arthritis approached? (stepwise progression or..?)

Answer 14

RA is treated early and aggressively

Don’t want to use a stepwise approach with a weak initial treatment as it allows the pathology of the disease to manifest itself further before more aggressive treatment is given

Question 15

What are some of the advantages of methotrexate as part of the treatment for rheumatoid arthritis?

Answer 15

• Effective, well tolerated and cheap

- Works well in combination with other DMARDs and biologics

Question 16

What are some of the pros and cons of biologics in the treatment of RA?

Answer 16

Cons:

• need to be given by injection due to large size
• are expensive
• may leave patients susceptible to infection

Pros:

• work rapidly
• generally well tolerated

Question 17

What are some of the classes of biologics that are used in the treatment of RA?

Answer 17

• TNF alpha inhibitors
• IL-1 inhibitors (anakinra)
• Anti B Cell therapies (Rituximab / CD20)
• Anti T Cell therapies
• IL-6 inhibitors (Tocilizumab
• Oral kinase inhibitors