Define RA
Systemic inflammatory disease Characterised by deforming peripheral polyarthritis 1% prevalence Peak onset 50 to 60 years HLA-DR4/1 linked
Signs and symptoms ( common )
Symmetrical swollen painful stiff small joints of hand and feet
Worse in the morning
Can fluctuate and larger joints may be involved
Less common signs and symptoms
Sudden onset widespread arthritis
Palindromic rheumatoid arthritis
Persistent mono arthritis e.g. Knee shoulder hip
Systemic illness with an extra articular signs and symptoms
Polymyalgia onset eg. Vague limb girdle aches
Recurrence of soft tissue problems e.g. frozen shoulder, carpal tunnel, de quervains tenosynovitis
Early signs
Swollen Mcpj, pip, wrist, mtp(red, hot, swollen, typically asymmetrical)
** positive squeeze test
Look for tenosynovitis or bursitis
Late signs
Ulnar deviation Subluxation of wrists and fingers Boutonniers Swan neck finger deformity Z deformity of thumbs Ruptured hand extensor tendons Atlanto axial subluxation
Resp (extra articular manifestations)
Pleurisy Pleural effusion Pleural nodules Pull fibrosis Caplans syndrome looks like cavitating tb nodules Obliterating bronchiolitis
Cardiac (extra articular manifestations)
Pericarditis
Pericardial effusion
Myocarditis
Cardiac nodules causing : valvular disease, conduction defects
Heamatological
Marrow depression due to folate deficiency
Anemia of chronic disease
Coombs positive hemolytic anemia
Hyper viscosity
Thrombocytosis
Leukocyosis ie. High wcc (Nb.Leucopenic in feltys syndrome)
Ocular (extra articular manifestations)
Keratotoconjunctivitis sicca Episcleritis Iritis Tenosynovitis of occular muscles Sjögren's syndrome Scleritis
Systemic (extra articular manifestations)
RhF nodules
Peripheral entrapment myopathies eg. Carpal,cubical, radial
Cutaneous vasculitis w. Increased risk of building up atherosclerotic plaque
Tendon rupture
AA amyloidosis of kidneys
Lymphoreticular (extra articular manifestations)
Lymphadenopathy
Splenomegaly
Feltys syndrome (splenomegaly, lymphadenopathy, anemia-neutropenia-thrombocytopenia—-presenting as recurrent infections and leg ulcers)
Ix
- Fbc normocytic normochromic anemia + reactive thrombocytosis in active RA
- Raised esr/crp
- U&es goof for baseline cos mess can affect renal function
- Lfts- mild raised alp+ggt seen in RA
- Rheum factor, most are positive
- Ana, anti ccp
- Radiography of hands and feet if see synovitis here clinically
- Cxr to exclude chest involvement common in RA
- Us or mri of joints that accurately identifies synovitis and bony erosions more than X-rays …
Suspected RA normal rheum referral
For peeps with persistent synovitis with no known cause
Urgent two week referral only if
Small joints o chandler and feet affected
More than one joint affected
If there’s been delay of 3 month between onset of symptoms and when started seeking medical advice
Nb don’t delay if blood tests are normal or if awaiting lab results
Suspected RA rx
Pain relief paracetamol and codeine Still not controlled? Nsaid eg naproxen, ibuprofen, diclofenac and PPI Orrrrrrr Coxib eg. Celecoxib,etoricoxib and PPI
Use lowest effective dose for shortest period of time
Never prescribe corticosteroid in gp
Mx of confirmed RA flare
Exclude septic arthritis, hot swollen single joint?
Suspect RA flare if stiffness,pain,swelling,fatigue,synovitis,joint tenderness, loss of joint function, raised inflam markers
Mx other causes of worsening symptoms eg. Osteoporotic fractures, stress fracture, avascular necrosis
Symptom control with :
💕nsaid and paracetamol and or codeine
💕Intra articular corticosteroid injection
💕Im corticosteroid methyl pred into gluteal region
💕oral corticosteroids
Specialist drug rx
Combo of dmards and st corticosteroids
1st line methotrexate and at least one other dmard from (sulfasalazine, hydroxycholoroquine)
When to refer to surgery
If don’t respond to optimal non surgical rx
Persistent localised synovitis,pain,worsening joint function
Should get surgical option before gets more deformed eg.nerve compression, carpal tunnel, stress fracture
Ddx for worsening joint symptoms
2ry osteoarthritis if minimal or no synovitis, muscle wasting, instability, crepitus, decreased rom
Osteoporotic fracture if he of minimal trauma, pain, immobility
Avascular necrosis if sudden onset pain in pt taking corticosteroids, absence of synovitis
Cervical myelopathy or nerve root compression if neck pain, weakness, parasthesiae
Psychosocial problems
Failure to adhere to Meds…
Dmard examples
Methotrexate
Sulfasalazine
Hydroxycholoroquine
Leflunomide
Se of all dmards
Immunosuppression
Pancytopenia
Increased susceptibility to infection
Neutropenic sepsis
Methotrexate se
Pneumonitis
Oral ulcers
Hepatotoxic
Teratogenic male and female…
Sulfasalazine se
Rash
Decreased sperm count
Oral ulcers
Gi upset
Leflunomide
Teratogenic Its
Oral ulcers
High bp
Hepatotoxic
Hydroxycholoroquine
Retinopathy
Therefore need annual eye screen
Moa abatacept
Suppress T cells
Moa retuximab
Suppress B cells
Moa adalimumab, etanercept, infliximab (1st line, others are 2nd line)
Block chemokines eg tnf alpha
Anakinra moa
Block IL-1 receptor
Tocilizumab moa
Block il-6 receptor
Biologicals SEs
Serious infection TB reactivation Hepatitis B Worsening heart failure Hypersensitivity Injection site reactions Cancers may be more common
What is the disease activity score
Looks at 28 joints How many out of 28 are swollen How many out of 28 are tender Recent esr crp levels Pts global assessment using 10cm line between good and v bad