10: Rheumatoid arthritis

Question 0

Rheumatoid arthritis- sx

Answer 0

Joint swelling with

• malaise, weight loss, lung fibrosis, pericarditis, peripheral neuropathy, vasculitis, nodules, haematologic abnormalities, pleural effusions, chest pain, shortness of breath, dry eyes, skin changes
• Symmetric involvement
• Morning stiffness

Question 1

types of inflammatory arthritis

Answer 1

• Rheumatoid arthritis
• SLE
• Psoriatic arthropathy
• IBD, Stills disease, Scleroderma, Juvenile idiopathic arthritis

Question 2

RA- joints

Answer 2

MC

-PIP, MCP, Wrist

Question 3

Chronic RA- sx

Answer 3

Chronic synovitis, tenosynovitis

• Swan neck deformities (flexion at DIP)
• Boutonniere’s sign (flexion at PIP)
• Ulnar deviation (flexion at MCP)
• Cock-up toes
• Hammer toes

Question 4

Rheumatoid nodules

Answer 4

Seen in: subcutaneous, pulmonary, myopericardial

Question 5

RA- Criteria (4 or more for dx+ exclusion of other joint disorders)

Answer 5

1: morning stiffness for at least one hour and present for at least 6 weeks
2: swelling of three or more joints for at least 6 weeks
3: swelling of wrist, MCP, PIP for 6 or more weeks
4: symmetric joint swelling
5: hand x-ray changes typical of rheumatoid arthritis that must include erosion or unequivocal bony decalcification
6: rheumatoid nodules
7: serum rheumatoid factor by a method that yields positive results in less than 5% of normals

Question 6

RA- labs

Answer 6

• Rheumatoid factor* (IgM, IgG, IgA)
• Citrulline containing proteins (anti-CCP)*
• Erythrocyte sedimentation rate
• C-reactive protein

Question 7

RA- rx

Answer 7

• NSAIDS (adjunctive)
• Glucocorticoids (before onset of DMARD therapy)
• DMARDS

Question 8

Conventional DMARDS

Answer 8

• Methotrexate (synovitis, myositis)
• Sulphasalazine (RA synovitis, seronegative spondyloarthropathies)
• Hydroxychloroquine (dermatitis, alopecia, synovitis in SLE and RA)
• Leflunomide

Question 9

Biological DMARDS; anticytokines

Answer 9

• TNFa inhibitor: Etanercept, Infliximab, Adalimumab, Glimumab, Certolizumab pegol
• Interleukin inhibitor: Anakinra, Tocilizumab
• B cell directed therapy: Rituximab, Abatacept

Question 10

Surgical management of RA

Answer 10

• carpal tunnel release
• synovectomy
• surgical joint fusion of wrist and thumb
• cervical spine fusion of C1, C2 for subluxation of >5mm with neurological deficits

Question 11

Complication of RA

Answer 11

-Interstitial pneumonitis-> restrictive lung disease
Pulmonary nodules
-Caplan’s syndrome (rheumatoid pneumoconiosis/ pulmonary fibrosis that develops in Coal miners who have RA)
CV: coronary artery disease, pericarditis, cardiomyopathy, mitral regurgitation
-Sjogren’s syndrome