Arthritis

Question 1

define rheumatoid arthritis

Answer 1

autoimmune chronic inflammation of the joints

Question 2

what is the cause of RA

Answer 2

individuals are genetically predisposed and the inflammation is triggered by an environmental factor e.g. smoking

Question 3

development of RA inflammation

Answer 3

arginine > citrulline due to loss of positive change. This antigen is recognised by ant-citrullinated peptide antibodies (anti-CCP) which forms immune complexes in the synovial.

Question 4

presentation of RA

Answer 4

• pain usually in small joints of hands and feet
• symmetrical distribution
• DIP spared due to small amount of synovium compared to PIPs and MCPs
• prolonged morning stiffness (> 30 minutes)
• rapid onset
• swelling

Question 5

extra-articular manifestations of RA

Answer 5

• pleural effusion
• interstitial lung disease
• rheumatoid nodules
• scleritis
• osteoporosis
• increased cardiovascular risk

Question 6

diagnosis of RA

Answer 6

• history and examination (positive compression test on MCP and MTP- tenderness)
• inflammatory markers (CRP)
• autoantibodies e.g. Rf and anti-CCP
• imaging

Question 7

what does the anti-CCP titre correlate with?

Answer 7

disease activity, associated with erosive damage and history of smoking

Question 8

what does imaging show in RA

Answer 8

USS- superior for synovitis

MRI early disease swelling and periarticular osteopenia but late disease shows erosion and subluxations

Question 9

criteria for RA

Answer 9

2010 ACR/EULAR with a score above 6

Question 10

management for RA

Answer 10

• DMARDs

- biological agents (DAS28 score above 5.1 for this)

Question 11

examples of DMARDS

Answer 11

• methotrexate (FIRST LINE, but teratogenic so explain stopping in pregnancy)
• sulfasalazine
• leflunomide
• hydroxychloroquine
• steroids

Question 12

adverse of DMARDS

Answer 12

bone marrow suppression
infection
liver derangement
pneumonitis
nausea

Question 13

example of biological agent

Answer 13

infliximab

Question 14

adverse of biologic agents

Answer 14

risk of infection (TB)
malignancy (skin cancer)
contraindicated in pulmonary fibrosis and heart failure

Question 15

what can DAS28 asses?

Answer 15

need for biologics

success of current RA management

Question 16

define osteoarthritis

Answer 16

this is articular cartilage thinning or loss

Question 17

primary OA cause

Answer 17

idiopathic, cause of ageing

Question 18

secondary OA cause

Answer 18

predisposing condition e.g. injury

Question 19

what increases the risk of OA

Answer 19

females

obesity

Question 20

presentation of OA

Answer 20

• pain, worse on activity and relieved by rest (can progress to be present at rest/night)
• stiffness (less than 30 minutes)
• involve any joint with osteophytes, crepitus, varus/valgus, Baker’s cyst

Question 21

diagnosis of OA

Answer 21

history and examination (crepitus, swelling, bony enlargements, tenderness and effusions)
XR

Question 22

criteria for OA used in XR

Answer 22

Kellgren-Lawrence to grade:
Loss of joint space
Osteophytes
Subchondral cysts
Sclerosis

Question 23

management for OA

Answer 23

• physiotherapy, occupational therapy and behavioural e.g. weight loss, exercise, insoles, etc.
• analgesia (start simple and low) then move to modulators such as amitriptyline or gabapentin
• NSAIDS and HA
• surgery e.g. joint replacement