Osteoarthritis + Rheumatoid Arthritis

Question 1

What are the four subtypes of inflammatory arthritis?

Answer 1

Seropositive
Seronegative
Infectious
Crystal induced

Question 2

What are the seropositive inflammatory arthritis?

Answer 2

Rheumatoid arthritis
Connective tissue diseases:
- Lupus
- Scleroderma
- Vasculitis
- Sjogren's

Question 3

What are the seronegative inflammatory arthritis?

Answer 3

Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
IBD arthritis

Question 4

Describe the pain + stiffness seen in osteoarthritis

Answer 4

Mechanical pain–> worse on activity, relieved by rest
(may eventually be present at rest or at night)

Usually morning stiffness lasting < 30 minutes
–> inactivity gelling

Question 5

What are the common sites for OA?

Answer 5

Cervical spine, lumbar spine, hip, knee
Foot –> MTP joint
Hand –> DIP, PIP, 1st IP, 1st MCP, CMC

Question 6

Which general findings may bee seen on examination of an OA joint?

Answer 6

Crepitus
Joint swelling –> bony enlargements due to osteophytes
Joint tenderness/effusion

Question 7

Which bony enlargements may be seen in OA fingers?

Answer 7

DIPs –> Heberdens nodes

PIPs –> Bouchards nodes

Question 8

Which findings may been seen on examination of an OA knee?

Answer 8

Effusion
Crepitus
Reduced ROM
Bakers cyst

Question 9

How might pain present in an OA hip?

Answer 9

Pain in groin, radiating to the knee

Question 10

How is OA diagnosed?

Answer 10

Clinical + xray

Question 11

What are the X-ray findings in an OA joint?

Answer 11

Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts

Question 12

What are the non-pharmacological management options for OA?

Answer 12

Explanation
Physio --> muscle strengthening
Weight loss
Exercise
Trainers, insoles, walking stick

Question 13

What is the step wise approach to pharmacological management of OA?

Answer 13

• Paracetamol + topical NSAIDs
• Topical capsaicin for knee or hand
• Oral opioids
• Oral NSAIDs/COX-2 inhibitor
• Intra-articular steroids

Question 14

What are the cardinal features of an inflammatory arthritis?

Answer 14

Joint pain + swelling
Morning stiffness > 30 mins
Improvement with exercise 
Synovitis on examination 
Raised inflammatory markers (CRP +PV)
Extra-articular symptoms

Question 15

What is the main structure involved in RA?

Answer 15

Synovium (lines joint capsules and tendon sheaths)

Question 16

Describe the pathophysiology in RA?

Answer 16

Inflammation of synovium –> joint destruction, tendon ruptures and soft tissue damage –> joint instability and subluxation

Question 17

What are the primary clinical features in RA?

Answer 17

Rapid onset
Symmetrical synovitis (doughy swelling)
Morning stiffness > 30 mins

Question 18

Which joints are most commonly affected in RA?

Answer 18

Small joints of hands and feet

–> PIPs, MCPs and MTPs (NOT DIPs)

Question 19

What are some examination features of RA?

Answer 19

Doughy swelling of affected joints
Positive compression tests of MCP and MTP joints
Later:
- Deformities
- C-spine affected –> altlanto-axial subluxation
- Tendon ruptures

Question 20

Which deformities may develop in the hands of someone with RA?

Answer 20

Boutonniere deformity

Swan-neck deformity

Question 21

What are some of the extra-articular features of RA?

Answer 21

Rheumatoid nodules (extensor surfaces or sites of frequent mechanical irritation)
Lungs –> effusions, interstitial fibrosis, pulmonary nodules
Increased risk of CVD
Eyes –> keratoconjunctivitis sicca, episcleritis, uveitis

Question 22

Which blood test results may be seen in RA?

Answer 22

Autoantibodies:
- anti-CCP (most specific so preferred test)
- rheumatoid factor
Increased inflammatory markers:
- CRP, ESR and plasma viscosity

Question 23

What are the xray findings in RA?

Answer 23

Early –> normal, soft tissue swelling, peri-articular osteopenia
Late –> erosions, subluxations

Question 24

Which mode of imaging may be useful in RA before xray features are present?

Answer 24

USS –> shows synovitis in early disease

Question 25

What are the principles of RA management?

Answer 25

``` Early DMARDs --> within 3 months of symptom onset Education Symptom relief STOP SMOKING Screen for CVD and osteoporosis ```

Question 26

What is the first line DMARD used in RA and name 3 others?

Answer 26

Methotrexate first line | Sulfasalazine, leflunomide, hydroxychloroquine

Question 27

What are some side effects associated with the DMARDs used in RA?

Answer 27

``` Bone marrow suppression Infection Deranged LFTs Pneumonitis Nausea ```

Question 28

Which drugs are used for symptom relief in RA?

Answer 28

Paracetamol NSAIDs IM/intra-articular steroids Oral steroids (short term for flares)

Question 29

What is the criteria for starting biologic therapy for RA?

Answer 29

Tried 2 DMARDs + DAS 28 score > 5.1

Question 30

What are some of the risks associated with biologics?

Answer 30

Increased risk of infection especially TB | ? risk of skin cancer

Question 31

In which conditions are biologics contraindicated?

Answer 31

Pulmonary fibrosis | HF

Question 32

What is the DAS 28 score and which 4 domains are included?

Answer 32

Measure of disease activity in RA - tender joint count - swollen joint count - CRP/ESR - visual analogue score (patient's own assessment)

Question 33

Which DAS28 score indicates remission and which indicates high disease activity?

Answer 33

Remission - < 2.6 | High disease activity - > 5.1