002. Rheumatoid arthritis

Question 1

What is rheumatoid arthritis?

Answer 1

Chronic systemic inflammatory disease

Characterized by a symmetrical peripheral polyarthritis

Increases risk of cardiovascular disease by 2-3 fold

Question 2

What genes are associated with RA?

Answer 2

HLA

DR1/DR4

Question 3

What is a typical presentation of RA?

Answer 3

Symmetrical swollen painful joints in the hands and feet

Worse in the morning, larger joints may be involved

Question 4

What are some of the less common ways RA can present?

Answer 4

Persistant monoarthritis

Systemic illness with extra-articular symptoms e.g. fatigue, fever, weight loss

Recurrent soft tissue issues

Question 5

What extra-articular manifestations may occur in RA?

Answer 5

Nodules

Lungs- pleural disease, interstitial fibrosis, organizing pneumonia

Cardiac- IHD, pericarditis, pericardial effusions,

Eye- episcleritis, scleritism scleromalacia, keratoconjunctivitus

Question 6

What investigations are done for RA?

Answer 6

Rf, anti-ccp

Aneamia of chronic diseases

platelets (raised)

raised ESR and CRP

x-rays

Question 7

What are the treatment principles for RA?

Answer 7

Refer early

Treat to resolve symptoms and achieve control

Steroids rapidly reduce inflammation- acute exacerbations

NSAIDS good for symptom relief

smoking increases risk

Question 8

What drugs DMARDS are typically enough to combat RA?

What two further things must we consider about these drugs

Answer 8

Methotrexate
Sulfasalazine
Leflunomide
Hydroxychoroquine

may take 6-12 weeks to begin
Immunosupression common, wtach out for pancytopenia

Question 9

What are the side effects of methotrexate?

Answer 9

Pneumonitis
Oral ulcers
Hepatoxcicity
tetarogenic

Question 10

What are the side effects of sulfalsalazine

Answer 10

Rash
Decreased sperm count
Oral ulcers
Gi upset

Question 11

What are the side effects of leflunomide

Answer 11

Tetarogenecity (males and females)
oral ulcers
increased blood pressure
hepatatoxicicity

Question 12

What are the side effects of hydroxychloroquine?

Answer 12

Causes retinopathy (eye screening required)

Question 13

What are the biologic agents that can be used in the treatment of RA?

Answer 13

TNF-a (e.g. infliximab) First line

B cell depleters (only when dmards and TNF-a fail)

IL-1 and IL-6 inhibitors (e.g. tacilizumab)in combination with methotrexate when TNF-a fails)

Inhibition of T cell co-stimulation

Question 14

What are the side effects that biologics posses in the treatment of RA?

Answer 14

Serious infections (re-activation of TB)

Worsening heart failure
ANA and reversible SLE type illnesses may occur

Melanaomas are more common

elevated lymphomas