Rheumatoid Arthritis

Question 1

What is Rheumatoid Arthritis (RA)?

Answer 1

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease.

Question 2

Briefly describe early RA

Answer 2

Early RA is defined as disease duration of 5 years or less from the onset of symptoms.

Question 3

What are the risk factors for RA?

Answer 3

• Genetic predisposition
• Smoking
• Female
• Age 50-55

Question 4

Which joints are commonly affected in RA?

Answer 4

Bilateral, symmetrical pain and swelling of the small joints of the hands and feet.

Wrists, elbows, and ankles are also affected.

Question 5

What are the symptoms of RA?

Answer 5

• Joint pain
• Joint stiffness

Question 6

What are the signs of RA?

Answer 6

• Joint stiffness (particularly in the morning)
• Rheumatoid nodules
• Swan neck deformity
• Boutonniere’s deformity
• Erythema nodosum
• Ulnar deviation

Question 7

Briefly describe swan neck deformity in RA

Answer 7

Distal interphalangeal (DIP) hyperflexion with proximal interphalangeal (PIP) hyperextension.

Question 8

Briefly describe Boutonniere’s deformity in RA

Answer 8

Proximal interphalangeal (PIP) flexion with distal interphalangeal (DIP) hyperextension.

Question 9

Briefly describe ulnar deviation in RA

Answer 9

Ulnar deviation, due to inflammation of the metacarpophalangeal (MCP) joints, causes the fingers to become dislocated. As the tendons pull on the dislocated joints, the fingers tend to drift towards the ulnar side.

Question 10

What deformity is shown in the picture?

Answer 10

Swan neck deformity.

Question 11

What deformity is shown in the picture?

Answer 11

Boutonniere’s deformity.

Question 12

Briefly describe rheumatoid nodules in RA

Answer 12

Hard, firm swellings over extensor surfaces.

Question 13

Identify some multi-system signs and symptoms that can occur in RA

Answer 13

• Constitutional symptoms: fever, myalgia and fatigue
• Lungs: fibrosis, pleuritis and effusion
• Eye: scleritis and uveitis
• MSK: vasculitis lesions

Question 14

How long does active symmetrical arhtitis have to occur for before RA can be diagnosed?

Answer 14

> 6 weeks.

Question 15

What investigations should be ordered for RA?

Answer 15

• Rheumatoid factor (RF)
• Anti-cyclic citrullinated peptide (anti-CCP) antibody
• Radiographs
• Ultrasonography

Question 16

Why investigate rheumatoid factor (RF)? And what may this show?

Answer 16

• Positive (60% to 70% of patients).

Question 17

Why investigate anti-cyclic citrullinated peptide (anti-CCP)? And what may this show?

Answer 17

• Positive (70% of patients).

Question 18

Why invetigate radiographically? And what may this show?

Answer 18

• Identifies erosions that start at the margins of the joint, affecting the subchondral bone first, and later progress to cause joint space narrowing.
• Radiographs are done at baseline and then annually to monitor progress of disease.

Question 19

Why investigate using ultrasonography? And what may this show?

Answer 19

• May be useful at initial presentation to detect synovitis of the wrist and fingers.

Question 20

What is the role of disease activity scores in RA?

Answer 20

• Determining disease activity and presence of poor prognostic factors (functional limitation, extra-articular disease, positive rheumatoid factor [RF], positive anti-cyclic citrullinated peptide [anti-CCP], bony erosions on radiograph) at diagnosis helps to inform initial treatment decisions.

Question 21

Briefly describe the management of RA

Answer 21

• Conventional disease modifying anti-rheumatic drug (cDMARD) as monotherapy. For example, oral methotrexate, leflunomide or sulfasalazine.
• Adjunct to DMARDS may include corticosteroids and NSAIDs.
• If the patient does not respond to initial treatment, or has an inadequate response, a biological agent (e.g., a tumour necrosis factor [TNF]-alpha inhibitor, an interleukin-6 [IL-6] inhibitor, abatacept, or rituximab), or a targeted synthetic DMARD such as an oral Janus kinase (JAK) inhibitor, can be added to methotrexate.

Question 22

Briefly describe the treat-to-target strategy for treating RA

Answer 22

• A treat to target strategy is used — the aim is to achieve a target of remission or low disease activity if remission cannot be achieved.

Question 24

What is the first-line drug used to treat RA?

Answer 24

• Methotrexate.

Question 25

What drug is given in conjunction with methotrexate? And why?

Answer 25

* Give folic acid to reduce side-effects. Folic acid decreases mucosal and gastrointestinal side-effects of methotrexate and may prevent hepatotoxicity.

Question 26

Why must patients taking methotrexate have routine blood tests? And how often does monitoring take place?

Answer 26

* Reports of blood dyscrasias (including fatalities) and liver cirrhosis with low-dose methotrexate patients should. * Full blood count and renal and liver function tests repeated every 1–2 weeks until therapy stabilised, thereafter patients should be monitored every 2–3 months.

Question 27

What complications are associated with RA?

Answer 27

* Work disability * Joint replacement surgery * Coronary artery disease * Increased mortality * Interstitial lung disease (ILD)

Question 28

What differentials should be considered for RA?

Answer 28

1. Psoriatic arthritis (PsA) 2. Infectious arthritis 3. SLE 4. Osteoarthritis

Question 29

How does RA and psoriatic arthritis (PsA) differ?

Answer 29

* Differentiating signs and symptoms: PsA commonly involves small joints of the hands and feet but is less often symmetrical. Fewer than 5 joints are commonly affected. Unlike RA, the distal interphalangeal (DIP) joints may be involved in psoriatic arthritis. Psoriasis is present in \>90% of PsA patients, but is unusual in RA patients. * Differentiating investigations: PsA is for the most part seronegative, even though there are patients with low levels of rheumatoid factor (RF) diagnosed with PsA because of presence of psoriasis. Skin biopsy of suspicious lesions can show psoriasis, supporting the diagnosis

Question 30

How does RA and infectious arthritis differ?

Answer 30

* Differentiating signs and symptoms: direct infection of a joint is rare, and urgent specialist advice should be obtained if suspected. Reactive arthritis, where there is no direct infection in the joint, can cause symmetric hand and feet arthritis and can be seen after viral/bacterial infections. * Differentiating investigations: most resolve within 6 weeks and leave no long-term effects.

Question 31

How does RA and SLE differ?

Answer 31

* Differentiating signs and symptoms: SLEcan present with polyarthritis in the small joints of the hands and feet.SLE arthritis is usually non-deforming. * Differentiating investigations: high antinuclear antibody (ANA) titre, anti-extractable nuclear antigen (ENA) autoantibodies are seen rarely in RA.

Question 32

How does RA and osteoarthritis differ?

Answer 32

* Differentiating signs and symptoms: prevalence increases with age. The most commonly affected joints are the knee, hip, hands, and lumbar and cervical spine. Patients present with joint pain and stiffness that is typically worse with activity. * Differentiating investigations: radiographs show loss of joint space, subchondral sclerosis, and osteophytes.