2+ Rheumatoid Arthritis

Question 1

What is rheumatoid arthritis?

Answer 1

A chronic, auto-immune inflammatory joint condition characterised by symmetrical synovitis of the small joints

Question 2

What is the epidemiology of rheumatoid arthritis?

Answer 2

F>M
Age 40-60

Question 3

What is the aetiology of rheumatoid arthritis?

Answer 3

Interplay between genetic, environmental and host factors

Genetic: HLA-DR4, PTPN22, PADI-4

Environmental: smoking, vitamin D, infection (EBV, HHV8)

Host: female, 12 months post-partum

Question 4

What is the pathophysiology of rheumatoid arthritis?

Answer 4

Inflammatory-mediated attack on the synovium of the joint
- Self-reactive T cells, MAC and fibroblast
- IL-1, TNFalpha

Hyperplasia/hypertrophy of the synovium –> panus

Destruction of the internal joint structures: erodes bone, cartilage, joint capsule, ligaments

Question 5

What is the textbook presentation of rheumatoid arthritis?

Answer 5

Synovitis (inflammation, tenderness, erythema) of the peripheral, small joints. Symmetrical

= Symmetric polyarthritis of small joints of hands and feet

Question 6

What is the history of rheumatoid arthritis?

Answer 6

Systemic: fatigue, malaise, depression

• Morning stiffness, eased with activity
• Pain, swelling, redness of joints
• Insidious/sub-acute onset (>6 weeks)
• Symmetrical, peripheral, small joints of hands and feet

Question 7

Inflammatory vs mechanical joint pain:

Answer 7

Inflammatory: sub-acute, morning stiffness, eases with activity

Mechanical: chronic, progressive, worse with activity, better at rest

Question 8

What are the signs on examination of rheumatoid arthritis?

Answer 8

Synovitis:
- Swelling
- Tenderness
- Bogginess

Joint effusion:
- Reduced ROM
- Erythema
- Warmth

Question 9

What are the late signs on examination of rheumatoid arthritis?

Answer 9

• Swan neck deformity: flex DIP, hyper-ext PIP
• Boutonniere deformity: hyper-ext DIP, flex PIP
• Z-thumb deformity: flex MCP, hyper-ext IP
• Ulnar deviation
• Hammer toe

Question 10

What are the extra-articular features of rheumatoid arthritis?

Answer 10

• Rheumatoid nodules
• Cutaneous: pyoderma gangrenosum, palmar erythema
• Lung: pleuritis, pleural effusion, alveolitis
• Cardiac: pericarditis, valvular heart disease, pericardial effusion
• Ocular: scleritis, episcleritis, keratoconjunctivitis sicca
• Neuro: peripheral neuropathy, nerve entrapment
• Haematology: neutropenia/splenomegaly (Fenty’s), anaemia of chronic disease
• Vasculitis: nailfold, systemic

Question 11

What are the ACR criteria for RA?

Answer 11

Question 12

What lab Ix do you do for RA?

Answer 12

Auto-antibodies:
- RF
- Anti-CCP (98% specific for RA)

Disease activity:
- CRP
- ESR
- Plts (thrombocytosis)

Question 13

What imaging Ix do you do for RA?

Answer 13

X-Ray
- Early= soft tissue swelling
- Late = erosions, joint deformity, ankylosis

USS and MRI increasingly used:
- Show bony erosions, synovitis and soft tissue swelling that is otherwise not seen on plain radiologic film

Question 14

What is the non-pharmacological management of RA?

Answer 14

• Physiotherapy/OT
• Psychological support
• Quit smoking
• Reduce alcohol intake

Question 15

What is the goal of RA treatment?

Answer 15

To get remission
- No active inflammation, no erosion, no functional disturbance

Question 16

What is the early treatment of RA?

Answer 16

Low dose prednisolone + DMARD

+ NSAID for symptomatic

Question 17

What is the escalating treatment of RA?

Answer 17

1. Add an additional DMARD/change DMARD
2. Biologic

Question 18

What are the traditional DMARDs?

Answer 18

MTX
Hydroxychloroquine
Leflunomide
Sulfasalazine

Question 19

What are the biologic DMARDs?

Answer 19

TNFalpha inhibitiors: infliximab, adalimumab
IL-6 inhibitors: tocilizumab
Cell adhesion molecule inhibitors: abatacept
B cell inhibitors: rituximab

Question 20

What are the complications of RA treatment?

Answer 20

Cytopenias
Increased infection risk
GIT disturbance
Liver function: cirrhosis
Malignancy risk?