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Flashcards in Rheumatoid arthritis Deck (18):

What is rheumatoid arthritis?

A chronic systemic inflammatory disease, characterised by potentially deforming symmetrical polyarthritis and extra-articular features (systemic disease).


What is the epidemiology of rheumatoid:
-age affected
-females:males ratio

¥ Prevalence is 1 %
¥ Incidence ~20 000 per year in UK
¥ 30-50 years of age
¥ Females to males ratio 3:1


What is the aetiology of rheumatoid arthritis?

¥ ? Genetic susceptibility (multiple genes – HLA DR 4 and DR 1)
- Up to 30% concordance rates in identical twins

¥ Environmental triggers in susceptible individuals
- Disease of the New World - not seen until late 18th century in Europe

¥ ?Cigarette smoking

¥ ?Infective aetiology


Describe the pathology of rheumatoid arthritis

Immune response is initiated against synovium which lines synovial joints and tendons

Synovium becomes laden with macrophages, fibroblasts and multi-nucleated giant cells (resemble osteoclasts) = pannus

The inflammatory pannus then expands, actively invade and erodes the surrounding articular cartilage and bone, leading to joint destruction

Tendon rupture and soft tissue damage can occur leading to joint instability and subluxation


What articular symptoms are described in rheumatoid arthritis?

¥ joint pain
¥ stiffness (esp morning)
end of day = degenerative diseases
¥ joint swelling
¥ general symptoms (malaise, fatigue etc)


How common is extra-articular manifestations of rheumatoid arthritis?

Extra articular features – seen in 30%(respiratory, neurological, skin, eye, hematological)


What are the signs seen on examination of rheumatoid arthritis?

¥ swelling
¥ tenderness
¥ reduced range of movement – with muscle wasting around joints
¥ (deformities- later stage)

Clinical features include symmetrical synovitis (doughy swelling), pain and morning stiffness. The hands and feet tend to be involved early.

MCP and PIPs joints are affected, as well as wrists, but DIP joints are not.

Over time larger joints can become affected. One important area is the cervical spine. In longstanding disease were may be atlanto-axial subluxation which can result in cervical cord compression.

Nodules and other extra-articular features:
scleritis, anaemia, pleural effusion, and leg ulcers
may be experienced by some patients. (if sero-ve don’t get nodules)

Lung involvement includes pleural effusions, interstitial fibrosis and pulmonary nodules.
Cardiovascular morbidity and mortality are increased in patients with RA.
Ocular involvement is common in individuals with RA and includes keratoconjunctivitis sicca, episcleritis, uveitis, and nodular scleritis that may lead to scleromalacia.


What are rheumatoid nodules?

rheumatoid nodules are centres of vasculitis with fibroblasts around them


What is involved in the diagnosis of rheumatoid arthritis?

Diagnosis is based on the clinical presentation, radiographic findings and serological analysis.

The ACR and EULAR Rheumatoid Arthritis Criteria scoring systems assist in the diagnosis.


what is the New EULAR/ACR Rheumatoid Arthritis Classification Criteria 2010?

¥ Definite RA defined by:
¥ Presence of synovitis in at least 1 joint
¥ Absence of alternative better diagnosis explaining synovitis
¥ Achievement of total score of 6 or greater (of total 10)
- Number and site of involved joints (0-5)
- Serological abnormality (rheumatoid factor and ACPA) (0-3)
- Elevated acute phase response (CRP and ESR) (0-1)
- Symptom duration (6weeks or longer) (0-1)


What investigations are carried out for rheumatoid arthritis?

¥ Anti CCP (cyclic citrullinated peptide) 70% sensitive & 97% specific; RF (rheumatoid factor) 70% & 90% respectively
¥ Inflammatory markers - PV, CRP
¥ Anaemia of chronic disease
¥ (Radiology – ultrasound)

Xrays at the onset of disease will often show no joint abnormality. Early features can include peri-articular osteopenia (bone thinning) and soft tissue swelling. Periarticular erosions can occur later in the disease.
L – loss of joint space
E – erosions
S – soft tissue swelling
S – soft bones (osteopenia)


What is the aim for treatment of rheumatoid arthritis?
-within what time period should DMARD therapy be commenced?

Treatment is aimed at relieving symptoms and preventing disease progression. With early and aggressive treatment patient's outcomes can be dramatically improved. The goal is to commence DMARD therapy within 3 months of symptom onset.


What treatment are used short term for rheumatoid arthritis?

Treatments which are used short term for symptom relief include simple analgesia, NSAIDs and Intramuscular/intra-articular and oral steroids.


How is disease activity measured in rheumatoid arthritis?

DAS 28 score.


What does the DAS 28 score comprise?

his is a composit score of 4 domains, which are: tender joint count, swollen joint count, CRP/ESR and visual analogue score (patients own assessment of their disease activity). A DAS 28 calculator then generates a figure which correlates with disease activity.


what are the cut off values for das 28?

The lower the DAS 28 score the better. Cut off values are as follows:

DAS 28 < 2.6 Remission

DAS 28 2.7-3.2 Low disease activity

DAS 28 3.3-5.1 Moderate disease activity

DAS 28 >5.1 High disease activity

Patients must have a DAS 28 score of >5.1 to be eligible for biologic therapy.

The DAS 28 score is a useful tool in monitoring disease activity over time.


What DMARD is used first line for RA?



If DMARDs do not work what is used?

If the disease does not respond to standard DMARD therapy then the patient may be eligible for biologic therapy.

The most commonly used biologics are anti-TNF alpha drugs, all of which are given by injection. There are other available biologics including toclizumab, rituximab and abatacept