Rheumatoid arthritis (O)

Question 1

What is RA?

Answer 1

AI condition causing chronic inflammation on synovial lining on joints, tendon sheaths and bursa

Question 2

What type of arthritis is RA?

Answer 2

Inflammatory

Question 3

What is synovitis?

Answer 3

Inflammation of synovial linings

Question 4

What is usual distribution of RA?

Answer 4

Symmetrical

Affects multiple joints

Question 5

Who is likely to get RA?

Answer 5

• Women
• Middle age
• Fam Hx

Genetic associations:

• HLA DR4
• HLA- DR1

Question 6

Presentation of RA?

Answer 6

Symmetrical Distal polyarthropathy 
Key symptoms: 
- Pain 
-Swelling 
-Stiffness 

Assoc symptoms:

• Fatigue
• Wt loss
• Muscle aches/weakness
• Flu-like

Question 7

Pain from OA different to pain from RA how?

Answer 7

Pain from OA: Better after rest, worse after activity

Pain from RA: Better after activity, worse after rest

Question 8

What is palindromic arthritis?

Answer 8

Short episodes of 1-2 days

Self-limiting inflammatory arthritis

Question 9

Atlanto-axial subluxation?

Answer 9

Caused by local synovitis and ligament/bursa damage
-In the cervical spine, Axis (C2) and odontoid peg, shift within atlas (C1)
Can cause spinal cord compression= emergency

Question 10

Signs on hands of RA?

Answer 10

On synovium palpation it feels boggy around joints

• Z-shaped thumb deformity
• Swan-neck deformity
• Boutonnieres deformity
• Ulnar deviation of fingers at MCP joints

Question 11

What is swan neck deformity?

Answer 11

Hyperextended PIP + flexed DIP

Question 12

What is Boutonnieres deformity?

Answer 12

Hyperextended DIP + Flexed PIP

Question 13

Extra-articular manifestations of RA?

Answer 13

• Pulmonary fibrosis + pulmonary nodules = Caplan’s
• Bronchiolitis Obliterans (Inflammation = Small airway destruction)
• Felty’s syndrome (RA, neutropenia and splenomegaly)
• Secondary Sjogren’s syndrome
• Anaemia
• CVD
• Rheumatoid nodules
• Lymphadenopathy
• Carpal tunnel syndrome
• Amyloidosis
• Eye manifestations

Question 14

Eye manifestations of RA?

Answer 14

• Scleritis
• Episcleritis
• Keratitis
• Keratoconjunctivitis sicca
• Cataracts (steroid caused)
• Retinopathy (secondary to chloroquine)

Question 15

Investigation for RA?

Answer 15

Clinical Diagnosis +

• Check RF
• If RF -ve, check anti-CCP antibodies
• Inflammatory markers (CRP & ESR)
• X-ray of hands & feet

US scan of joints confirms synovitis

Question 16

X-ray changes seen in RA?

Answer 16

• Joint destruction/deformity
• Soft tissue swelling
• Periarticular osteopenia
• Boney errosions

Question 17

Diagnosis of RA is based on?

Answer 17

• Joints involved (more and smaller score higher)
• Serology (RF and anti-CCP)
• Inflammatory markers (ESR & CRP)
• Duration of symptoms (6 weeks?)

Question 18

What does DAS Score monitor?

Answer 18

Disease activity:

Assessment for 28 joints and points for swelling, tenderness and ESR/CRP result

Question 19

Prognosis of RA is worse if?

Answer 19

You are:

• Male
• Young onset
• More affected joints
• Erosions on x-ray
• RF & anti-CCP antibodies

Question 20

Management of first presentation?

Answer 20

Short course of steroids (NSAIDs can be used but bleeding risk therefore + PPI)

Question 21

NICE guidelines for DMARDs?

Answer 21

1st line: Monotherapy with methotrexate, leflunomide or sulfasalazine

Hydroxychloroquine can be considered in mild disease

2nd line: 2 of these used in combo

3rd line: Methotrexate + biological therapy usually TNF inhibitor

4th line: Methotrexate + rituximab

Question 22

Methotrexate indications?

Answer 22

Once a week via tablet or injection
Alongside
Folic acid 5mg taken on one weekly on a day methotrexate isn’t taken in a week

Question 23

Side effects of methotrexate?

Answer 23

• Mouth ulcer/mucositis
• Liver toxicity
• Pulmonary Fibrosis
• Teratogenic
• Bone marrow suppression & leukopenia

Question 24

What is lefluonomide?

Answer 24

Immunosuppressant

Question 25

What does leflunomide do?

Answer 25

Interferes with pyrimidine production (component of DNA or RNA)

Question 26

Side effects of leflunomide?

Answer 26

- Mouth ulcers/mucositis - Increased BP - Liver toxicity - Peripheral neuropathy - Bone marrow suppression - Teratogenic

Question 27

What is sulfalsazine?

Answer 27

Immunosuppressive & anti-inflammatory

Question 28

Side effects of sulfasalazine?

Answer 28

- Temporary male infertility | - Bone marrow suppression

Question 29

What is hydroxychloroquine traditionally used as?

Answer 29

Antimalarial drug

Question 30

Side effects of hydroxychloroquine?

Answer 30

- Nightmares - Reduced visual acuity - Skin pigmentation - Liver toxicity

Question 31

What do anti-TNF drugs do?

Answer 31

Block TNF reduced inflammation

Question 32

Examples of anti-TNF drugs?

Answer 32

``` Adalimumab Golimumab Infliximab Certolizumab pegol -Etanercept ```

Question 33

Side effects of anti-TNF drugs?

Answer 33

- Vulnerability to sepsis and infections | - Reactivation of Hep B/TB

Question 34

What is ritixumab?

Answer 34

Monoclonal AB targetting CD20 protein on B cells surface

Question 35

Side effects of rituximab?

Answer 35

- Vulnerability to severe infections/sepsis - Night sweats - Thrombocytopenia - peripheral neuropathy - Liver and lung toxicity

Question 36

Unique side effect of methotrexate?

Answer 36

Pulmonary fibrosis

Question 37

Unique side effect of leflunomide?

Answer 37

HT | Peripheral neuropathy

Question 38

Unique side effect of Sulfasalazine?

Answer 38

Male infertility

Question 39

Unique side effect of hydroxychloroquine?

Answer 39

Nightmares | Reduced visual acuity

Question 40

Unique side effects of Anti-TNF meds?

Answer 40

Reactivation of Hep B/TB

Question 41

Unique side effects of rituximab?

Answer 41

Night sweats | Thrombocytopenia