Rheumatoid Arthritis

Question 1

sero positive or negative

Answer 1

seropositive inflammatory arthropathy

Question 2

define RA

Answer 2

symmetrical inflammatory arthritis affecting mainly the peripheral joints, which if untreated can lead to joint damage and irreversible deformities leading to loss of function

Question 3

epidemiology

Answer 3

women>men. can occur in any age group. the prevalence is increased in smokers

Question 4

aetiology

Answer 4

cause is unknown, potential triggers include smoking, infections and stress

Question 5

is there a genetic predisposition

Answer 5

yes - HLA-DR4 mediated

Question 6

pathology

Answer 6

immune response is initiated against the synovium which lines the synovial joints and some tendons.

inflammatory pannus forms and then attacks and denudes cartilage leading to joint destruction.

Question 7

what joints in the spine are lined by synovium

Answer 7

C1 and C2

Question 8

what phalangeal joint is not lined by synovium

Answer 8

DIP

Question 9

what can happen to the tendons

Answer 9

can rupture and soft tissue damage can occur - joint instability and subluxation

Question 10

what scoring system is used for diagnosis

Answer 10

ACR/EULAR

Question 11

what is early RA defined as

Answer 11

less than 2 years since symptom onset

Question 12

when is the therapeutic window of opportunity

Answer 12

first 3 months

Question 13

clinical features

Answer 13

prolonged morning stiffness that improves with exercise

symmetrical synovitis (doughy swelling)

involvement of small joints of hands and feet

Question 14

what is a compression test

Answer 14

positive for MCP and MTP

painful if joints are squeezed

Question 15

what is it called when synovitis occusr in tendon sheath

Answer 15

tenosynovitis

Question 16

name some more features of RA

Answer 16

tenosynovitis

trigger finger

carpal tunnel syndrome (compression of medial nerve by synovial tissue bilaterally)

polymyalgia rheumatica

Question 17

what is palindromic rheumatism

Answer 17

RA that comes and goes, patient is fine between episodes

Question 18

name 2 late features in aggressive/untreated disease

Answer 18

swan neck deformity

Boutonniere’s

Question 19

describe the nodules that can be found as an extra articular manifestation

Answer 19

rheumatoid nodules found on extensor surfaces or areas of frequent mechanical irritation

Question 20

describe other organ features

Answer 20

lung - pleural effusions, interstitial fibrosis or pulmonary nodules

CVS morbidity and mortality increased

occular involvement

Question 21

Caplan’s syndrome

Answer 21

rheumatoid arthritis and pneumoconiosis

combination of inhaled dust and disturbed immunity of RA that manifests as intrapulmonary nodules

occurs particularly in coal worker’s pneumoconiosis

Question 22

auto antibodies

Answer 22

rheumatoid factor

anti-CCP

Question 23

anti-CCP antibodies after treatment and associations

Answer 23

can remain positive despite treatment, also associated with current or previous smoking

Question 24

inflammatory markers

Answer 24

CRP, ESR and PV normally raised

Question 25

imaging options

Answer 25

x ray US MRI

Question 26

x ray

Answer 26

at onset of disease will show no joint abnormality can sow peri articular osteopaenia (bone thinning), soft tissue swelling, joint space narrowing and erosions later in disease

Question 27

US

Answer 27

useful in detecting synovial inflammation if there is uncertainty useful for making treatment changes

Question 28

MRI

Answer 28

bone marrow oedema can precede erosion in inflammatory joint disease can distinguis synovitis from effusions detect erosions early monitor disease activity but expensive

Question 29

what are the aims of treatment

Answer 29

relieving symptoms and preventing disease progression

Question 30

when should DMARD therapy be commenced

Answer 30

within 3 months of symptom onset steroids can be used in the time that DMARDs take to have effect

Question 31

what scoring system is used to determine whether patients qualify for therapy

Answer 31

DAS 28 score composite score of tender and swollen joint count, CRP/ESR and visual analogue score

Question 32

what DAS 28 score suggests remission

Answer 32

\<2.6

Question 33

what DAS 28 score suggests active disease

Answer 33

\>5.1 3. 2-5.1 moderate 2. 6-3.2 low

Question 34

outline treatment

Answer 34

DMARDs given - methotrexate is first line steroids, NSAIDs, analgesia given while DMARD is taking time to work if DMARD doesnt work (patient has tried 2 different types) patient may qualify for biologic therapy

Question 35

what does DMARD therapy include

Answer 35

methotrexate is first line also sulphasalazine, hydroxychloroquine, leflunomide

Question 36

what side effects can DMARDs have

Answer 36

mostly IS can inc risk of infection and cause bone marrow suppression regular blood monitoring is therefore required

Question 37

what effect on pregnancy do DMARDs have

Answer 37

methotrexate is teratogenic - must be stopped 3 months before conceiving, and appropriate contraception advised. has no effect on fertility however sulphasalazine can be used throughout pregnancy

Question 38

if patient doesnt respond to DMARD therapy

Answer 38

biological therapy - anti - TNF alpha drugs

Question 39

what can untreated RA lead to

Answer 39

joint damage and deformities: swan necking and Boutonniere's atlanto-axaial subluxation resulting in cervical cord compression

Question 40

trigger finger

Answer 40

tendon becomes swollen and inflamed and catches in the tendon sheath - difficult to move and clicking sensation

Question 41

what is the first line DMARD

Answer 41

methotrexate sulphasalazine is added on

Question 42

how is patient disease monitored

Answer 42

DAS 28 score

Question 43

what must be taken with methotrexate

Answer 43

folic acid

Question 44

adverse effects of methotrexate

Answer 44

pneumonitis teratogenic alcohol intake must be limited as methotrexate also affects the liver rash/mouth ulcers

Question 45

what qualifies patients for biologic therapy

Answer 45

disease doesnt respond to DMARD therapy - 2 drugs tried DAS 28 score \> 5.1

Question 46

what are the adverse affects of biologic drugs

Answer 46

reactivate latent TB inc risk of skin cancer inc risk of infection