2- rheumatoid arthritis

Question 1

how would you describe rheumatoid arthritis? (classification of arthritis)

Answer 1

chronic symmetrical polyarthritis
- affects peripheral joints and not central joints (like spine)
- only synovial joints affected

Question 2

how would rheumatoid arthritis present?

Answer 2

• pain & stiffness in synovial joints
• prolonged early morning stiffness (gets better as day goes on, takes more than 1 hour and gets better with movement)
• inflammation of tendon sheaths in asymmetrical distribution, if sheath around tendon inflamed then can’t move tendon so reduction in grip strength (can’t make fist) (rheumatoid arthritis does affect joints symmetrically but the joints on each side can be affected different severities)
• swelling of joints (as inflammation)

Question 3

who can get RA?

Answer 3

anyone! any age! any gender! more common in females

Question 4

what is the pathogenesis behind rheumatoid arthritis?

Answer 4

synovial membrane (synovium) is inflamed. it’s to do with proteins citrullination making antibodies that act & cause synovitis

• needs both genetics & triggers for RA
  (trigger like infection & cigarette smoking)

Question 5

what are components of rheumatoid arthritis diagnosis?

Answer 5

1. good history taking (important)
2. clinical exam (important)
3. inflammatory markers (CRP & plasma viscosity)
4. autoantibodies
5. imaging

Question 6

what is the s factor? (thing that tells patient to go to GP)

Answer 6

stiffness, swelling, squeezing joints is painful (main one)

Question 7

what autoantibodies good to check for RA diagnosis?

Answer 7

• Rheumatoid Factor (RF): Often found in RA but can also be positive in other diseases or even healthy people.
• Anti-Cyclic Citrullinated Peptide (Anti-CCP): More specific for RA. (absence does not disclude disease, could still have RA)

Question 8

what imaging can be done for RA? are they any good? what do they show?

Answer 8

x-ray = not that good, can show erosion and subluxation but until later stage
ultrasound = same as x-ray
MRI = gold standard and much better but expensive

• mostly imaging just isn’t really needed for diagnosis

Question 9

what are extra-articular manifestations?

Answer 9

main one is interstitial fibrosis (interstitial lung disease) but loads of things like rheumatoid nodules and increased cardiovascular mortality etc

Question 10

what is treatment for rheumatoid arthritis?

Answer 10

• early recognition & treatment
• tight control with monitoring
• patient education
• DMARDS (short course of steroid first)

Question 11

what are DMARDS?

Answer 11

disease modifying anti-rheumatic drugs

metheotrexate = 1st line

also sulfasalazine, leflunomide, hydroxychloroquine

Question 12

how do you treat rheumatoid arthritis with DMARDS?

Answer 12

start with methotrexate then if not work add drugs in combination like add sulfalasazine, hydroxychloroquine

negative of DMARDS is take long time to work as modify immune pathway so for quick effect use steroid at start until DMARDS start to work

Question 13

what are some side effects of DMARDS?

Answer 13

• bone marrow suppression
• infection
• liver function derangement
• pneumonitis (especially with methotrexate)
• nausea

Note about methotrexate! - must be stopped at least 3 months before conception (causes miscarriage)

Question 14

what is DAS 28 score?

Answer 14

assessment of disease activity (assess which joints are tender, swollen etc)

Question 15

when are biologics used for rheumatoid arthritis?

Answer 15

if tried 2 DMARDS and have DAS 28 score >3.2 (as more expensive etc)

• leave until later as side effects like reactivating TB, infection, risk of malignancy etc and also more expensive

Question 16

who gets rheumatoid nodules? management?

Answer 16

they’re nodules that appear around joints in RA patients (associated with repetitive trauma)

• often more severely affected RA patients and +ve rheumatoid factor

manage = they don’t respond to DMARDs, recurrence high but can excise if problematic