Rheumatoid Arthritis

Question 1

what is rheumatoid arthritis (RA)?

Answer 1

a chronic, systemic inflammatory disease characterised by inflammation of the synovial joints, with a predilection for the small joints in the hands

Question 2

which specific antibodies are involved in RA?

Answer 2

• cyclic citrullinated peptide (anti-CCP)
• rheumatoid factor (RF)

Question 3

what is rheumatoid factor (RF) and what does it target?

Answer 3

an autoantibody targeting the Fc portion of the patient’s IgG antibody

Question 4

what are the risk factors for RA?

Answer 4

• smoking
• obesity
• HLA DR4, DR1
• female

Question 5

what are the symptoms of RA?

Answer 5

• symmetrical joint pain and swelling
• small joints of hands and feet such as the proximal interphalangeal (PIP) joint, metacarpophalangeal (MCP) joint, wrist, knee, ankle, metatarsophalangeal (MTP) joint, and cervical spine
• fatigue
• low-grade fever

Question 6

what are the deformities associated with RA?

Answer 6

• swan neck deformity (e.g. hyperextension of the proximal interphalangeal joint (PIP) and flexion of the distal interphalangeal joint (DIP))
• boutonnière’s deformity (e.g. proximal interphalangeal joint (PIP) is flexed, and the distal interphalangeal joint (DIP) is hyperextended)
• Z deformity of thumb
• ulnar deviation
• piano key deformity of wrist

Question 7

what are the systemic and extra-articular manifestations of RA?

Answer 7

• eyes: dry eyes, scleritis, episcleritis, uveitis
• skin: leg ulcers, rashes (e.g. pyoderma gangrenosum and cutaneous vasculitis)
• heart: pericarditis
• lungs (caplan’s syndrome): pulmonary nodules, pulmonary fibrosis
• kidneys: amyloidosis
• rheumatoid nodules: commonly found on the extensor surface of the forearm and dorsum of the foot
• liver: hepatomegaly
• muscle wasting and tendon rupture
• nerves: peripheral nerve entrapment, polyneuropathy
• raynaud’s phenomenon
• depression

Question 8

what is felty’s syndrome?

Answer 8

a rare extra-articular manifestation of rheumatoid arthritis characterised by the triad of:

• rheumatoid arthritis
• splenomegaly
• neutropenia

Question 9

what are the investigations for RA?

Answer 9

• FBC
• ESR/CRP
• LFTs
• RF
• anti-CCP
• ANA
• uric acid
• urinalysis
• XR
• MSK US

Question 10

what is the minimum score required for a diagnosis of RA according to the 2020 ACR-EULAR classification criteria?

Answer 10

≥6

Question 11

what is the DAS28 score?

Answer 11

comprises the number of tender or swollen joints involved (total out of 28), ESR or CRP, and the patients ‘assessment of global health’ (0-100)

Question 12

what is the management of RA?

Answer 12

• DMARDs (e.g. methotrexate, leflunomide, sulfasalazine, hydroxychloroquine)
• biologic (e.g. anti-TNF (adalimumab, etanercept, certolizumab, golimumab, infliximab), anti-CD20 (rituximab), anti-IL6 (tocilizumab))
• corticosteroids (e.g. oral prednisolone, intramuscular depo-medrone)
• NSAIDs