[9] Rheumatoid Arthritis Flashcards
What is RA?
Rheumatoid arthritis is a chronic, systemic inflammatory disease, characterised by symmetrical, deforming, peripheral polyarthritis
What does RA cause?
Pain, swelling, and stiffness in the joints
How do the symptoms of RA vary?
There may be periods where the symptoms become worse, known as flare-ups
What causes RA?
The cause is unclear, however it is believed to be a combination of genetic and environmental factors
What does the underlying mechanism of RA involve?
The bodies immune system attacking the joints, resulting in inflammation and thickening of the joint capsule, as well as the underlying bone and cartilage
What are the risk factors for RA?
Family history
Smoking
Silica exposure
Female gender
What are the main symptoms of RA?
Joint pain, swelling, and stiffness
What joints are affected in RA?
It can affect any joint in the body, however small joints are often the first to be affected
Does RA affect joints symmetrically?
It typically does, however this isn’t always the case
How quickly do symptoms develop in RA?
They often develop gradually over several weeks, but in some cases can progress quickly over a number of days
Describe the pain associated with RA?
It is usually a throbbing and aching pain
When is the pain in RA worse?
Often in the morning and after a period of inactivity
What systemic symptoms may be present in RA?
Fatigue Fever Sweating Loss of appetite Weight loss
What can the inflammation associated with RA cause in other areas of the body?
Dry eyes
Chest pain
What investigations should be done in RA?
Examination Blood tests CXR Ultrasound MRI
What examination findings may be present in early RA?
Swollen MCP, PIP, wrist, or MTP joints
Tenosynovitis
Bursitis
What examination findings may be present in later RA?
Ulnar deviation
Subluxation of wrist and fingers
Swan-deck deformity of fingers, or Z-deformity of thumbs
Rupture of hand extensor tendons
What can be looked for on blood tests in RA?
Rheumatoid factor
Anti-cyclic citrullinated antibodies (Anti-CCP)
What % of cases of RA have positive rheumatoid factor?
70%
What is high amounts of RhF associated with in RA?
Severe disease
Erosions
Extra-articular disease
What is good about measuring anti-cyclic titrated antibodies in RA?
They are highly specific for RA with a reasonable sensitivity
What can anti-cyclic titrated antibodies be used for in RA?
Predict disease progression
What else may be found on blood tests in RA?
Anaemia of chronic disease
Increased platelets
Increased ESR
Increased CRP
What may be found on x-ray in RA?
Soft tissue swelling Juxta-articular osteopenia Decreased joint space Bone erosions Subluxation Complete carpal destruction
What is the advantage of ultrasound and MRI in RA?
They can detect synovitis more accurately than x-ray, and have a greater sensitivity in detecting bone erosions
What are the parameters in the diagnostic criteria of RA?
Joint involvement
Serology
Acute phase reactants
Duration of symptoms
What score is diagnostic in RA?
Over 6
How is ‘joint involvement’ scored in the diagnostic criteria for RA?
1 large joint = 0 ; 2-10 large joints = 1
1-3 small joints = 2
4-10 small joints = 3
>10 joints (at least 1 small joint) = 5
How is ‘serology’ scored in the diagnostic criteria for RA?
Negative RF and negative anti-CCP = 0
Low +ve RF, or low +ve anti-CCP = 2
Higher +ve RF, or high +ve anti-CCP = 3
How is ‘acute phase reactants’ scored in the diagnostic criteria for RA?
Normal CRP and ESR = 0
Abnormal CRP or abnormal ESR = 1
How is ‘duration of symptoms’ scored in the diagnostic criteria for RA?
<6 weeks = 0
>6 weeks = 1
What is involved in the management of RA?
Medication Pain relief Physiotherapy Occupational therapy Surgery
What medication is used in the management of RA?
Disease-modifying anti-rheumatic drugs (DMARDs)
Biological treatments
Jak inhibitors
Give 2 examples of DMARDs
Methotrexate
Sulfasalazine
Give 3 examples of biological treatments used in RA
Infliximab
Rituximab
Adalimumab
Give 2 examples of Jak inhibitors used in RA
Tofacitiib
Baricitinib
What may be used for pain relief in RA?
Painkillers such as paracetamol and codeine
NSAIDs
Corticosteroids
What is the purpose of physiotherapy in RA?
Improve fitness and muscle strength
Make joints more flexible
Help with pain relief
How can physiotherapy help with pain in RA?
Heat or ice packs
Transcutaneous electrical nerve stimulation (TENS)
How does a TENS machine work?
It applies a small pulse of electricity to the affected joint, which numbs the nerve endings and can help ease the pain of RA
When can occupational therapy be helpful in RA?
When RA affects a patients performance of everyday tasks
How can OT help in RA?
They can provide training and advice that will help protect the joints, both at home and at work
What devices/other stuff might OT recommend?
Some type of support for the joint, e.g. splints
Devices that can help open jars or turn on taps
What are the surgical options in the management of RA?
Arthroscopy
Joint replacement
Finger, hand, and wrist surgery
What finger, hand, and wrist surgery may be done in RA?
Carpal tunnel release
Release of tendons in the fingers to treat abnormal bending
Removal of inflamed tissue lining the finger joints
What is arthroscopy?
A procedure to remove inflamed joint tissue
How is an arthroscopy performed?
An arthroscope is inserted into the joint through a small incision to visualise the joint, then surgical instruments are inserted through other small incisions to remove damaged tissue
What is an arthroscope?
A thin tube with a light source and camera
What are the options for joint replacement in RA?
Partial or complete replacement of hip, knee, or shoulder
What is the down side of joint replacement in RA?
It is a major operation, which involves a several day inpatient stay and months of rehab
Joint replacements have limited lifespan
Do not restore all functions of damaged joints
What is the lifespan of a joint replacement?
10-20 years
What are the potential complications of RA?
Carpal tunnel syndrome Widespread inflammation, affecting lungs, heart, eyes, and blood vessels Joint damage Cardiovascular disease Cervical myelopathy
What can inflammation in the lungs or pleura caused by RA lead to?
Pleurisy or pulmonary fibrosis, leading to chest pain, a persistent cough, and shortness of breath
What can inflammation around the tissue of the heart caused by RA lead to?
Pericarditis, which causes chest pain
What can inflammation around the eyes caused by RA lead to?
Scleritis
Sjorgen’s syndrome
What is inflammation of the blood vessels caused by RA a form of?
Vasculitis
What can inflammation of the blood vessels caused by RA lead to?
Thickening, weakening, narrowing, and scarring of the blood vessel walls
What can inflammation of the blood vessels caused by RA lead to in severe cases?
Can affect blood flow to organs and tissues, and can be life threatening
What can happen if RA is treated early, or isn’t well controlled?
The inflammation in the joints could lead to significant and permanent damage
What significant and permanent damage can occur in RA?
Damage to nearby bone and cartilage
Damage to nearby tendons
Joint deformities
What are patients who have had RA for a long time at increased risk of?
Cervical myelopathy
What is cervical myelopathy?
A condition caused by dislocation of the joints at the top of the spine, which puts pressure on the spinal cord
What is the clinical importance of cervical myelopathy?
It is a serious condition that can greatly affect mobility and can lead to permanent spinal cord damage if not promptly treated with surgery
