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Flashcards in Rheumatoid Arthritis Deck (57)
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What is rheumatoid arthritis?

An autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa.

It is inflammatory arthritis.


What is synovial inflammation called?



What is the pattern of Rheumatoid arthritis across the body?

Tends to be symmetrical and affects multiple joints


What does inflammation of tendon increase the risk of in RA?

Tendon rupture


Men or women more likely to be affected by Rheumatoid arthritis?

Three times more common in women than men


Which age group is most commonly affected by rheumatoid arthritis?

Most common in middle age although it can develop at any age


What are the genetic associations of Rheumatoid arthritis?

HLA DR4 - A gene present in RF positive patients

HLA DR1 - A gene occasionally present in RA patients


What antibodies can be present in rheumatoid arthritis?

Rheumatoid factor (RF):
- Present in 70% patients
- RF is often IgM which targets Fc portion of the IgG antibody. This cause activation of the immune system against IgG and systemic inflammation.

Anti-citrullinated cyclic peptide antibodies (anti-CCP antibodies):
- More sensitive and specific than RF
- Often pre-date the development of rheumatoid arthritis and give an indication the patient will go on to develop rheumatoid arthritis at some point.


Presentation within rheumatoid arthritis?

1) Symmetrical distal polyarthropathy, often small joints of the hand and feet:
- Pain, which is worsened with rest but improves with activity, morning pain.
- Swelling
- Stiffness

2) Systemic symptoms:
- Fatigue
- Weight loss
- Flu like illness
- Muscle aches and weakness


What is palindromic rheumatism?

Self limiting short episodes of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints.

Typically last 1-2 days

Having positive antibodies, RF and anti-CCP, may indicate that it will process to rheumatoid arthritis


Which joints are commonly affected in rheumatoid arthritis?

> Proximal interphalangeal (PIP) joints

> Metacarpophalangeal (MCP) joints

> Wrist and ankle

> Metatarsophalangeal (MTP) joints

> Cervical spine

> Large joints can also be affected such as the knee, hips and shoulders


Which joint in the hands if affected indicate osteoarthritis and not rheumatoid arthritis?

The distal interphalangeal (DIP) joints are almost never affected in rheumatoid arthritis.


What is atlantoaxial subluxation?

Atlantoaxial subluxation occurs in the cervical spine. It is due to local synovitis and damage to the ligaments and bursa around the odontoid peg of the axis.

The axis (C2) and the odontoid peg (C1) shift within the atlas. Subluxation can cause spinal cord compression, this is a medical emergency.

Changes can be visualised on MRI scans.


Signs in the hand of Rheumatoid arthritis?

1) Palpation of the synovial around the joint will give a boggy feeling

2) Z-shaped deformity to the thumb

3) Swan neck deformity (Hyperextended PIP with flexed DIP)

4) Boutonnieres deformity (Hyperextended DIP with flexed PIP)

5) Ulnar deviation of the fingers at the MCP joint


Extra-articular manifestations of rheumatoid arthritis?

1) Pulmonary fibrosis with pulmonary nodules (Caplan's syndrome)

2) Bronchiolitis obliterates (inflammation causing small airway destruction)

3) Fetty's syndrome (RA, neutropenia and splenomegaly)

4) Secondary sjogren's syndrome (AKA sicca syndrome)

5) Anaemia or chronic disease

6) Cardiovascular disease (Pericarditis, myocarditis, endocarditis and conduction defects)

7) Eye manifestations

8) Rheumatoid nodules

9) Lymphadenopathy

10) Carpel tunnel syndrome

11) Amyloidosis


Extra-articular manifestations of rheumatoid arthritis - Eye?

1) Scleritis
2) Episcleritis
3) Keratitis
4) Keratoconjunctivits sicca
5) Cataracts (secondary to steroid use)
6) Retinopathy (secondary to chloroquine)


Which eye manifestation can steroids lead to?



Which eye manifestation can chloroquine lead to?



Investigations used with rheumatoid arthritis?

A diagnosis of rheumatoid arthritis is clinical in patients with features of rheumatoid arthritis (symmetrical polyarthropathy affecting small joints)

Other diagnosis:
- Check Rheumatoid factor
- If RF negative, check anti-citrullinated cyclic peptide (Anti-CCP) antibodies
- Inflammatory markers (CRP and ESR)
- X-ray of hands and feet
- Ultrasound scan of joint to confirm synovitis


Which X-ray changes are seen in rheumatoid arthritis?

- Joint destruction and deformity
- Soft tissue swelling
- Periarticular osteopenia = "low bone density"
- Boney erosions


When does NICE recommend referral for adults even when they have negative rheumatoid factor, anti-CCP antibodies and inflammatory markers?

If there is persistent synovitis.

It should be urgent if the small joints of the hands or feet, multiple joints or symptoms have been present for more than 3 months


How is rheumatoid arthritis diagnosed?

1) American College of Rheumatology (ACR)/European League against rheumatism (ELAR) from 2010:
- Joints involved, more and smaller joints score higher
- Serology (RF and anti-CCP)
- Inflammatory markers (ESR and CRP)
- Duration of symptoms

2) DAS28 Score = Disease activity score. It is based on the assessment of 28 joints and joints are given for:
- Swollen joints
- Tender joints
- ESR/CRP raised

3) Health Assessment Questionnaire (HAQ) = this questionnaire measures functional ability.


Which factors effect prognosis in rheumatoid factor?

Worse prognosis when:
> Younger onset
> Male
> More joints involved
> More organs affected
> Presence of RF and anti-CCP antibodies
> Erosions seen on Xray


Management of rheumatoid arthritis?

1) Multidisciplinary team

2) First presentation and flare ups = Steroids. NSAIDs can help but with PPI to reduce risk or peptic ulcer

3) First line is monotherapy with:
- Methotrexate
- Leflunomide
- Sulfasalazine
- Hydroxychloroquine can be consider for mild disease

4) Second line = two of the above used in combination

5) Third line is methotrexate plus a biological therapy, usually a TNF inhibitor

6) Fourth line is methotrexate plus rituximab (Anti-CD20)


Management of rheumatoid arthritis - First presentation ?

1) Steroids
2) NSAIDs in combination with a PPI


Management of rheumatoid arthritis - Flare up?

1) Steroids
2) NSAIDs in combination with a PPI


Management of rheumatoid arthritis - first line?

First line is monotherapy with:
- Methotrexate
- Leflunomide
- Sulfasalazine
- Hydroxychloroquine can be considered for mild disease


Management of rheumatoid arthritis - second line?

A combination of the two:
- Methotrexate
- Leflunomide
- Sulfasalazine


Management of rheumatoid arthritis - third line?

Third line is methotrexate plus a biological therapy, usually a TNF inhibitor


Management of rheumatoid arthritis - fourth line?

Fourth line is methotrexate plus rituximab (Anti-CD20)