Rheumatoid arthritis

Question 1

What is rheumatoid arthritis?

Answer 1

Autoimmune, chronic (>6 weeks) and progressive inflammation of synovial lining, tendon sheaths & bursa

Question 2

What is the prevalence of RA?

Answer 2

0.24%-0.56%

Question 3

What can cause RA?

Answer 3

• Infection can trigger

- Genetics

Question 4

What are RF for RA?

Answer 4

1. Genetics
2. 2-4x increased risk if 1st degree relative
3. Heritability RA appears to be approximately 40%, and is higher for seropositive RA than for seronegative RA
4. Smoking

Question 5

What is the normal epid for RA?

Answer 5

50-55 years

Female sex

Question 6

What are key symptoms and signs for RA?

Answer 6

1. Active symmetrical arthritis lasting >6 weeks
2. Joint pain
3. Joint swelling
4. Morning stiffness
5. Tenosyvitis and bursitis
6. Fatigue
7. Weight loss
8. Recurrent soft tissue problems

Question 7

What joints are usually affected in RA?

Answer 7

small joint of hands and feet, MCP, PIP, wrist

Question 8

What are some DDx for RA?

Answer 8

1. Psoriatic arthritis (PsA)
2. Infectious arthritis
3. Gout
4. SLE
5. Osteoarthritis

Question 9

What test is used to diagnose RA?

Answer 9

• Clinical diagnosis
  1. Rheumatoid factor (RF)
  2. Anti-cyclic citrullinated peptide (anti-CCP) antibody
  3. Radiographye
  4. US

Question 10

What would RF be in RA?

Answer 10

-positive 60-70%

Question 11

What would Anti-cyclic citrullinated peptide (anti-CCP) antibody be in RA?

Answer 11

• positive 70%
• more sensitive and specific than
• can predate disease development

Question 12

What would radiography in RA show?

Answer 12

1. erosions

2. decreased joint space

Question 13

What would US show in RA?

Answer 13

synovitis of wrist and fingers

Question 14

What is 1st line acute treatment of RA?

Answer 14

1st line: Conventional synthetic disease-modifying anti-rheumatic drug (DMARD) e.g. hydroxychloroquine: 400-600mg/day

• Corticosteroid
• NSAID

Question 15

What is 1st line ongoing treatment for RA?

Answer 15

1st line: methotrexate 7.5mg

• Biological agent
• corticosteroid
• NSAID

Question 16

What is 2nd line ongoing treatment for RA?

Answer 16

2nd line: Triple DMARD therapy e.g. methotrexate plus hydroxychloroquine plus sulfasalazine

• corticosteroid
• NSAID

Question 17

What other management is possible in RA?

Answer 17

• physio

- surgery

Question 18

What are possible complications of RA?

Answer 18

1. Work disability
2. Increase joint replacement surgery
3. Increased coronary artery disease
4. Increased mortality
5. Interstitial lung disease (ILD)
6. TNF-alpha inhibitor-related infections
   Etc.

Question 19

What can RA cause?

Answer 19

Increased risk of cardiovascular and cerebrovascular disease as atherosclerosis is accelerated in RA

Question 20

What sort of condition is RA?

Answer 20

autoimmune

Question 21

What genes are associated with RA?

Answer 21

• HLA DR4 (often)

* HLA DR1 (occasional)

Question 22

What joint is usually spared?

Answer 22

DIP

Question 23

What are the chronic signs of RA?

Answer 23

1. Z deformity (thumb)
2. ulnar deviation at MCP
3. Radial deviation at wrist
4. Swan neck deformity
5. Boutonniere’s deformity

Question 24

What is Z deformity?

Answer 24

hyperextension of IP joint + fixed flexion and subluxation of MCP joint

Question 25

What is swan neck deformity?

Answer 25

hyperextension of PIP joint and flexion of DIP joint

Question 26

What is Boutonniere's deformity?

Answer 26

permanent flexion of PIP joint and overextension of DIP joint

Question 27

What are extrarticular manifestions of RA?

Answer 27

1. Nodules (40%) 2. Lung 3. Cardiac: pericardial effusion, pericarditis 4. Eye: episcleritis, scleritis 5. Secondary Sjogren’s/sicca 6. Carpel tunnel syndrome + rheumatoid nodules 7. Tenosynovitis, bursitis

Question 28

Where are nodules usally found?

Answer 28

elbows, lungs, cardiac, lymphadenopathy

Question 29

What are lung manifestations for RA?

Answer 29

1. plural disease 2. interstitial fibrosis 3. pulmonary fibrosis 4. Bronchiolitis obliterans

Question 30

What is needed for Clinical Diagnosis of RA?

Answer 30

1. Characterised by symmetrical polyarthritis (>4joints) 2. and extraarticular manifestations 3. Of rapid or chronic onset (months -years) +/- systemic upset – weight loss, fatigue, malaise

Question 31

Whta is RF in RA?

Answer 31

1 No neccssary for Dx 2. IgM antibody. Targets Fc portion of IgG antibody. 3. Immune activation leads to systemic inflammation

Question 32

What blood tests are done in RA?

Answer 32

1. ESR: raised esp w active polyarthritis but can be normal 2. Albumin low 3. Anaemia 4. Elevated CRP

Question 33

What would Positive Antibodies & raised inflammatory markers suggest?

Answer 33

o aggressive disease o worse prognosis May prompt more aggressive Tx e.g., biologics

Question 34

When do you refer for RA accoring to NICE?

Answer 34

Refer any adult with persistent synovitis | even if –ve RhF, anti CCP, inflammatory markers

Question 35

When is there an urgent referral for RA?

Answer 35

* Small joints of hands, feet * multiple joints * Sx >3 months

Question 36

What is the treatment prniciple in RA?

Answer 36

induce remission (or get as close as possible) & keep meds at “minimal effective dose” needed to control disease

Question 37

What is Felty's syndrome?

Answer 37

triad of RA, neutropenia and splenomegaly

Question 38

When do you used short course of steroids?

Answer 38

to get flares undercontrol

Question 39

What other medication can be used in RA?

Answer 39

NSAIDs / COX-2 inhibitors (remeber PPI)

Question 40

What is the stepwise treatment for DMARDs?

Answer 40

Hydroxychloroquine if mild) 1. Methotrexate, leflunomide, sulfasalazine 2. 2 of these in combo 3. Methotrexate + biologic (anti-TNF) 4. Methotrexate + rituximab

Question 41

Why is anti-TNF and rituximab dangerous?

Answer 41

Immunosuppression can cause serious infections and/or re-activation of TB, Hep B