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Flashcards in Rheumatoid Arthritis Deck (54)
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Rheumatoid arthritis - definition

A common seropositive inflammatory arthritis causing destructive polyarthritis with some systemic symptoms.
A major cause of disability, it can affect all synovial joints but particularly the small joints of the hands and feet


Rheumatoid arthritis - causes

Cause is unclear and there is some genetic component (15-20%) with a link to HLA DR4/DR1 in whites (65-80%) but others in different ethnic groups
Links to infectious agents or periods of stress have been suggested by evidence is lacking - EBV shares a epitope with type 2 collagen


Rheumatoid arthritis - clinical features

typically insidious onset pain and symmetrical morning stiffness in the small joints sparing the DIP
Patients can also present with subacute systemic symptoms without clear joint involvement
Patients may also show rheumatoid nodules, positive rheumatoid factor and joint erosions radiographically


Rheumatoid arthritis - epidemiology

Prevalence: 3.4/10,000 in women & 1.4/10,000 in men - 0.5-1% overall
Incidence increases with age up to 45, but in women the incidence plateaus at 45 and then decreases at 75
Life expectancy is reduced by 7 in men and 3 years in women


Rheumatoid arthritis - lymph node involvement

Often are found to be enlarged but rarely palpable
RA can rarely present with widespread swollen nodes which mimic hodgkins disease


Rheumatoid arthritis - pregnancy

Pregnancy has a beneficial affect on RA which usually returns 1-2 months post partum but my be more severe


Rheumatoid arthritis - pulmonary disease

Pleuritis, pericarditis and pleural effusions can occur, more likely in older patients
Sero-positive RA can present with asymptomatic pulmonary nodules which may require biopsy to exclude malignancy
Fibrosing alveolitis or diffuse interstitial fibrosis are rare complications, particularly when methotrexate has been used.


Rheumatoid arthritis - cardiovascular complications

RA has been shown to increase the risk of cardiovascular and atherosclerotic disease
1.3 increased risk in men and 1.9 in women
There is also a risk of pericardial effusion and constrictive pericarditis


Rheumatoid arthritis - skin

Palmar erythema is common
There is an association with raynaud's and associated infarcts and infection risk
Leukocyclastic vasculitis can be seen as a visible purpura but usually spontaneously resolves


Rheumatoid arthritis - ocular complications

Rheumatoid vasculitis an lead to severe scleritis leading to scleromalcia
Associated with sjogren's syndrome causing dryness


Rheumatoid arthritis - neurological involvement

Peripheral neuropathies can occur secondary to synovitis, particularly median nerve compression.
May be acute onset mononeuritis multiplex or motor neuropathy can indicate aggressive vasculitis
Cervical (atlano-axial) subluxation may also occur with neurological complications (cord compression)


Rheumatoid arthritis - ligament and tendon involvement

Spontaneous tendon rupture is common, most often at the wrist, hand and rotator cuff.
Tenosynovitis and ligament weakening can also often lead to joint instability and subluxation


Rheumatoid arthritis - fracture risk

Circulating Inflammatory cytokines may cause periarticular osteoporosis
This can be compounded by inactivity, nutritional deficiency and steroid/methotrexate use increasing the risk of spontaneous fractures


Rheumatoid arthritis - infection risk

RA patients are particularly at risk of septic arthritis
The risk is also compounded by immunosupressive drug use
This can be dangerous as the usual signs of sepsis will be absent


Rheumatoid arthritis - secondary amyloidosis

A severe but rare complication, most commonly affecting the kidneys
80% five year survival with intensive treatment


Felty's syndrome

RA + splenomegaly + neutropenia.
RF +ve in ~100%


Initial evaluation of RA

Degree/duration of morning stiffness, joint pain and fatigue
Functional impairment and patient assessment of severity
Number and distribution of swollen, painful and dis-functioning joints - including periodicity and the any extra-articular disease
Radiographic and blood markers


Radiographic features of RA

Marginal erosive changes to the joints -- also periarticular oestoporosis
May show early subluxation or distortion of the joints or bones
Joint space narrowing ad subchondral cysts


Blood markers in RA

IgM rheumatoid factor --> only 70-80% of patients are RF positive and a negative result shouldn't override a clinical diagnosis
Anti-cyclic citrullinated peptide antibodies (anti-CCP) --> surrogate marker for RA (98% specific) 50-60% of early pts will be anti-CCP positive


Blood tests in RA

RF and anti-CCP are useful disease markers
ESR and CRP is also a useful general inflammatory marker
FBC, LFT, U+Es and urinalysis to assess for systemic disease


Pharmacotherapy for RA - Pain relief

analgesia and NSAIDs


Treatments of systemic disease in RA

Anaemia (iron, erythropoietin)
Osteoporosis (oestrogens, bisphosphonates, strontium, teriparatide)
Vasculitis (glucocorticoid, cyclophosphamide)
Amyloidosis (chlorambucil, anti-TNF therapies)


ACR classification criteria for RA

Four or more for >6wks: Radiographic changes
Morning stiffness >1hr Arthritis in 3 or more joints
Arthritis in hand joints Symmetrical arthritis
Rheumatoid nodules Serum Rheumatoid factor


Articular complications of RA

Subluxation or destruction of joints
Fibrous or bony Ankylosis


Systemic complications of RA

Anaemia (iron loss or chronic disease)
Weight loss
Amyloidosis: kidney, liver, gut
Felty's syndrome
Increased mortality generally (CVS etc)


Rheumatoid nodules in RA

Rheumatoid nodules occur in 30% of pts on the extensor surface of the forearm, and correlate with disease progression & sero-positivity
Can lead to pain, ulceration or infection
Have a necrotic core and surrounded by fibroblasts and immune cells


Pharmacotherapy for RA - DMARDs

glucocorticoids (IV, oral or intra-articular rarely)
Common:methotrexate, sulfasalazine, hydroxychloroquine, leflunomide
Less common:D-penicillamine, cyclosporin, azothioprine & IM gold


Pharmacotherapy for RA - Biologics

anti-TNF (etanercept, influximab, adalimunab),
anti-B cell (rituximab) -- used on named patient basis
IL-1R antagonist (anakinra) -- not as effective and not recommended
SEs:infection, TB reactivation, worsening HF


Quantifying the severity of RA

Joint counts -- how many swollen and tender joints (out of 66 or 28)
Radiographic -- how many erosions can be seen
Disability -- Health Assessment Questionnaire scores
Composite score -- DAS-28 (combines tender, swollen, ESR and general health) - >5.1 is severe, 3.2-5.1 is medium, <3.2 is low


Rheumatoid factor

a IgM autoantibody to the Fc portion of IgG which leads to the immune complex formation leading to further joint damage and vasculitis
80% of RA patients and some without symptoms -- not central to pathogenesis