Rheumatoid arthritis

Question 1

What is Rheumatoid arthritis?

Answer 1

• Initially a disease of the synovium with gradual inflammatory joint destruction
• Different patterns of joint involvement depending whether Rheumatoid factor is present in blood or not
• Sero-positive RA (Rheumatoid factor present)
• Sero-negative RA (Rheumatoid factor not present)

Question 2

What is the incidence of RA?

Answer 2

• Most serious joint disease
• 1% prevalence
• 6:1 female pre-menopause
• 3:1 female post-menopause
• Peaks in 3rd-5th decades (20-50yrs)

Question 3

What joints can be affected by RA?

Answer 3

• All synovial joints in body including toes, ankles, knees, all of arm and shoulder and neck
• Is a symmetrical polyarthritis

Question 4

What are the symptoms of RA?

Answer 4

Slow onset
- Initially hands and feet
- Proximal spread
- Potentially all synovial structures

• Fatigue
• Morning stiffness
• Joint stiffness
• Joint pain
• Minor joint swelling
• Fever
• Numbness and Tingling
• Decrease in range of motion

Question 5

What are early signs of RA?

Answer 5

• Symmetrical synovitis of MCP joints (Metacarpophalangeal)
• Symmetrical synovitis of PIP joints (proximal inter-phalangeal)
• Symmetrical synovitis of wrist joints

Question 6

What are late signs of RA?

Answer 6

• Ulnar deviation of fingers at MCP joints
• Hyperextension of PIP joints (swan neck deformity)
• Z deformity of thumb due to hyperflexion of MCP and hyperextension of IP joint
• Subluxation of wrist
• Loss of abduction and external rotation of shoulders
• Flexion of elbows and knees
• Deformity of feet and ankles

Question 7

What are some extra-articular features of RA?

Answer 7

• Inflammation of blood vessels due to systemic vasculitis
• Psoriasis in some patients which give much more aggressive form of RA and in younger patients deemed ‘Psoriatic arthritis’
• Eye involvement like scleritis and episcleritis/ dry eyes, Sjogrens syndrome
• Subcutaneous nodules
• Amyloidosis
• Pulmonary inflammation
• Neurological

Question 8

How do you investigate RA?

Answer 8

Radiographs
- Check for erosions, loss of joint space and deformity
- Check for joint destruction and secondary osteoarthritis

Bloods
- Normochomic, normocytic anaemia

Question 9

How is RA treated?

Answer 9

• Has to be holistic management
• Aim to improve quality of life
• Combo of physiotherapy/ occupational therapy/ drug therapy/ surgery

Question 10

What is the purpose of Physiotherapy for treatment of RA?

Answer 10

• Aim to keep patient active for as long as poss and delay onset
• Use combo of active and passive exercises
• To maintain muscle activity
• To improve joint stability
• To maintain joint position

Question 11

What is purpose of Occupational therapy for RA?

Answer 11

• Maximise residual function
• Provide aids to independent living
• Assessment and alteration of home
• To provide safe and liveable home

Question 12

What drug therapy is used for most RA patients?

Answer 12

Analgesics
- Paracetamol, co-codamol for pain

NSAIDs
- Often combo with anti-PUD agents
- Slow down immune process and damage to drugs

Disease modifying drugs
- Hyroxychloroquine, methotrexate
- Less common now sulphasalzine, penacillamine

Steroids - Intra-articular

Question 13

What drug therapy is used for moderate to severe cases of RA?

Answer 13

Use immune modulators
- Azathioprine
- Mycophenolate
- Biologics (TNF inhibitors: infliximab) (Lucocyte :Rituximab)

Steroids - Oral prednisolone

Question 14

What is surgery for RA?

Answer 14

• Excision of inflamed tissues
• Joint replacement
• Joint fusion
• Osteotomy

Patients often have poor medical condition for surgery

Question 15

What is the prognosis of patients with RA?