Rheumatoid Arthritis

Question 1

what is rheumatoid arthritis

Answer 1

inflammatory joint disease affecting joints with synovium in them

affects any age group

Question 2

what joints aren’t affected by rheumatoid arthritis and why

Answer 2

distal interphalangeal joints (DIP) as they dont have much synovium

Question 3

are men/women more likely to be affected

Answer 3

women (3x more likely)

Question 4

what happens when rheumatoid arthritis is left untreated

Answer 4

can lead to joint damage and irreversible deformities leading to loss of function

Question 5

what causes rheumatoid arthritis

Answer 5

Can be genetic
potential triggers: infections, stress, smoking

depends on genetic factors and the presence of autoantibodies

HLA-DR4 mediated (MHC2 receptor)

Question 6

what is the synovium

Answer 6

tissue inside the synovial joint capsule and tendon sheath.

makes direct contact with synovial fluid and acts as a joint lubricant.

Question 7

signs of rheumatoid arthritis

Answer 7

swollen inflamed synovial membrane leading to bone erosion

Question 8

what happens to the synovium in RA

Answer 8

swollen an inflamed > mass of spongy tissue>increased blood flow>more inflammation cells one osteoclasts>osteoclasts dissolve the bone

Question 9

What is pannus

Answer 9

hypervasculated swollen, inflamed synovium

Question 10

describe the pathogenesis of RA

Answer 10

unknown antigen presented to T cells> T cells activated>stimulated B cells and mactophages>macrophages releases cytokines and B cells release antibodies

This all leads to increased osteocyte stimulation leading to joint destruction

Question 11

when is the window of opportunity where the disease can be modified

Answer 11

first 3 months

Question 12

typical RA history

Answer 12

history - recent (short history) pain in the synovial joints, early morning stiffness that improves throughout the day

Question 13

what investigations do you do for RA

Answer 13

blood test for inflammatory markers, (normocytic) anaemia, raised platlets

autoantibodies

imaging

Question 14

Clinical examination findings in RA

Answer 14

bilateral, symmetrical swelling

difficulty forming fists

tenderness in joint

Question 15

criteria for RA

Answer 15

morning stiffness 
arthritis of 3 or more joint areas 
arthritis of hand joints 
symmetric arthritis 
rheumatoid nodules 
serum rheumatoid factor

Question 16

what is seen on an X ray

Answer 16

normal in early stages, changes only seen later when there is synovium swelling

Question 17

what is the squeeze test for

Answer 17

squeeze hands/feet gentle and if there is pain there is synovitis

Question 18

what is tenosyvonitis

Answer 18

swelling of the tendons, RA can present as this

Question 19

what is trigger finger

Answer 19

finger stuck in a flex position and straightens out with a click, can be a sign of RA

Question 20

possible clinical presentations of RA

Answer 20

tenosyvonitis
trigger finger 
carpal tunnel 
polymalalgia rheumatic 
palindromic rheumatism (comes and goes)
systemic symptoms 
poor grip strength

Question 21

what does extensor tenosynovisits look like

Answer 21

swelling on the back of the hand - wrist stays okay

must treat otherwise tendons fray and tear so patients cant extent their fingers anymore

DIP normal

Question 22

typical presentation of RA

Answer 22

DIP joints spared and synovium joints inflamed

Question 23

What autoantibodies are seen in RA

Answer 23

Rheumatoid factor
Anti-CCP antibodies (more specific)

some people with rheumatoid arthritis have no antibodies at all

Question 24

what is seen on Xray in RA

Answer 24

soft tissue swelling
erosions
inflammed synovium
periarticular osteopenia

no findings in early disease

Question 25

Ultrasound scans in RA

Answer 25

increases sensitivity for early disease constantly superior to clinical exam can detect up to 7 times more MCP erosions than plain x ray in early RA useful in making treatment changes

Question 26

MRI scans

Answer 26

bone marrow oedema on MRI associated with inflammatory joint disease and a forerunner of erosion integrity of tendons can be assent can distinguish synovitis from effusions can detect erosion early can monitor disease activity limited by cost

Question 27

what is DAS 28

Answer 27

score of joint disease severity lower DAS less likely joint will be damage, aim for <2.6

Question 28

Management

Answer 28

``` early recognition and diagnosis care by rheumatologist early treatment with disease modifying anti-rheumatic drugs NSAIDS and steroids Patient education multidisciplinary team involvement ```

Question 29

what are some disease modifying anti-rheumatic drugs (DMARDS)

Answer 29

``` methotrexate sulfasalazine hydrochloroquine combination with MTX,SASP and HCQ leflunomide penicillamine axathiprime ```

Question 30

what do DMARDS do

Answer 30

suppress bone marrow

Question 31

what are biologic agents

Answer 31

``` Anti-TNF agents T cell receptor blockers B cell receptor blockers IL6 blocker JAK2 inhibitor ``` (inhibit various parts of the immune pathway)

Question 32

common side effect of biological agent

Answer 32

infections

Question 33

complications of non-treated rheumatoid arthritis

Answer 33

deformity of thumb ulnar deviation of metacarpophalangeal joints swan neck deformity of fingers