RA

Question 1

Rheumatoid Arthritis?

Answer 1

• chronic inflammatory, autoimmune disease
Persistent symmetric polyarthritis

Question 2

Which membrane is affected?

Answer 2

Synovial membrane

Question 3

Clinical presentation?

Answer 3

• onset of fever and malaise

S&S:
• synovitis
• progressive worsening of joint
• difficulty in performing daily activities

Question 4

Which upper extremists affected?

Answer 4

• shoulders
• elbows
• wrists

Question 5

Which lower extremists affected?

Answer 5

• hips
• knees
• ankles
• feet

Question 6

Epidemiology?

Answer 6

• women are 3 times affected
• 1st degree relativise of RA with 2-3 folds

Question 7

Genetic causes?

Answer 7

• HLA- DR4 (increases severity and development)

Question 8

Lifestyle Causes?

Answer 8

• increased smoking
• read meat intake
• vit D deficiency
• excessive coffee consumption
• high salt intake

Question 9

Hormonal Causes?

Answer 9

Prolactin - disproportionate between male and female

Question 10

Stages of RA?

Answer 10

• Phase I - interaction (genetis and environmental risk)
• Phase Il - production of Ra
autoantibodies - RF & anti-CCP
• Phase III - begin joint stiffness
• Phase IV - development of arthritis
• Phase V - established RA

Question 11

Which Immune cells are involved?

Answer 11

B-cells & T-cells
• these cells inappropriately enter the joint and release cytokines
• cytokines cause the synovium to release proteolytic - destroying bone & cartilage

Question 12

Diagnosis?

Answer 12

• blood test
• history
• symptoms
• X-ray

Question 13

Differential diagnosis?

Answer 13

• gout
• tuberculosis
• psoriatic arthritis

Question 14

Lab test - serology

Answer 14

• CRP & ESR - raised in active disease
• IgM- FR
• anti-CCP

Question 15

DAS-28 assessment

Answer 15

DAS28 >5.1 = active disease
DAS28 >3.2 = low disease activity
DAS28 >2.6 remission

Question 16

Non-pharmacological Management?

Answer 16

• physiotherapy
• exercise, diet
• surgery
• educating stress management

Question 17

Pharmacological Management?

Answer 17

• Analgesics
• NSAIDs
• Glucocorticoids
• DMARDS
• Biologicals

Question 18

Analgesics?

Answer 18

• paracetamol
• opioid

Question 19

NSAID?

Answer 19

• traditional
• cox-2 selective inhibitors

Consider:
• pro thrombotic affect - cox-2
• worsen cardiac risk
• GI, rental and hepatic toxicity

Question 20

Glucocorticoids?

Answer 20

• prednisone
• methylprednisolone

Only short term
Long term - if other treatments have been offered

Question 21

Examples of DMARDs

Answer 21

First line!

• methotrexate
• sulfasalazine
• leflunomide
• hydroxychloroquine

Offer combination if target has not been achieved

Question 22

Side effects Of DMARDs ?

Answer 22

Methotrexate- liver impairment
Sulfasalazine - cough, diarrhoea, fever
Leflunomide - diarrhoea
Hydroxychloroquine - ocular impairment

Question 23

Biologicals?

Answer 23

• used in combination with methotrexate - in DAS28 > 5.1 (disease has not responded to DMARDS)

• can be used in mono therapy if methotrexate is C/I

Question 24

Which parts of the body can also be affected?

Answer 24

• skin
• lungs
• nervous system
• musculoskeletal

Question 25

Patients typical journey

Answer 25

• Patient presents to their GP
• Initiation with analgesics/NSAIDs and refereed to a Rheumatology specialist
• If diagnosed with RA - treatment with one or two DMARDs starts
• If patients DAS28 remains above 5.2 after fix months then start treatment with a biologicals