Rheumatoid Arthritis

Question 1

Describe the epidemiology of rheumatoid arthritis

Answer 1

Affects 1% of the population, more common in females (3:1 ratio), incidence between ages 20-50

Question 2

Give a definition of rheumatoid arthritis

Answer 2

A symmetrical, autoimmune polyarthritis commonly affecting the peripheral joints. It is an inflammatory disorder which can affect men and women of any age.

Question 3

Describe the ways in which the whole body can be affected in rheumatoid arthritis

Answer 3

Pericardium - Pericarditis
Lungs - Alveolitis
Dermis - Subcutaneous nodules
Liver - Hepatic dysfunction
Synovium - Synovitis
Bone marrow - Anaemia / Hypogammoglobulinaemia

Question 4

What are the clinical features of rheumatoid arthritis?

Answer 4

Pain - gradual onset
Early morning stiffness (lasting >30 minutes)
Swelling of the small joints in the hands and feet (PIPJ and MCP…not DIP)
Larger joint involvement as disease develops
Symmetrical presentation of symptoms
Weakness of joint capsules causes instability, subluxation, deformity
Effusions in the larger joints
Muscle wasting

Question 5

What signs might you see in a patient with rheumatoid arthritis?

Answer 5

Early (inflammation but no joint damage): Swollen PIPJ, MCP, wrist, MTP joints
Late (inflammation + joint damage): Swan-neck deformity, Boutonniere’s deformity, ‘Z’ deformity of thumb, ruptured extensor tendons

Question 6

What investigations should be done for rheumatoid arthritis?

Answer 6

Bloods - FBC (normocytic, normochromic anaemia), CRP and ESR raised, thrombocytosis
Auto antibodies - Anti CCP, rheumatoid factor
X-ray - Soft tissue inflammation, decreased joint space, erosions at joint margins
Synovial fluid - High neutrophil count

Question 7

What is the (broad) treatment for rheumatoid arthritis?

Answer 7

• Multidisciplinary approach, with early input from rheumatologist
• Symptomatic relief with NSAIDs, coxibs, and other analgesics including paracetamol
• Disease modifying anti rheumatic drugs (DMARDs) e.g. sulfasalazine, methotrexate, leflunamide
• Anti TNF-alpha monoclonal antibodies
• Corticosteroids

Question 8

Give some side effects of methotrexate

Answer 8

Liver fibrosis, pulmonary fibrosis, mouth ulcers, diarrhoea, renal impairment

Question 9

Give some side effects of sulfasalazine

Answer 9

Mouth ulcers, hepatitis, male infertility (reversible)

Question 10

Give some side effects of leflunamide

Answer 10

Diarrhoea, hypertension, hepatitis, alopecia

Question 11

Give some side effects of TNF-alpha blockers

Answer 11

Infections (TB and septicaemia), demyelinating disease, heart failure, lupus-like syndrome, autoimmune syndrome

Question 12

Give 3 examples of anti TNF-alpha drugs used in rheumatoid arthritis

Answer 12

Inflixmab, etanercept, adalimumab