ʀheumatoid arthritis

Question 1

What is the typical presentation of rheumatoid arthritisʔ

Answer 1

• pt usually female, age 25 - 55yr
• progressive, symmetrical polyarthritis
• weeks to months
• pain + stiffness in joints of hand
• feet, wrists, elbows, shoulders, knees can also be affected.
• sometimes presents as carpal tunnel syndrome
• MOʀɴɪɴɢ STɪFFɴESS for 1 hour or more, improves with activity.
• Pain worse in morning
• pain disturbs sleep
• anaemia

Question 2

What are the signs of ʀA on examinationʔ

Answer 2

ʜandsː

• inflammation - red, hot , swollen joint
• Boutonniere or swan neck deformity of fingers.

armsː
-ɴodules on elbows

Systemicː

• pleural effusion
• ʀaynaud’s
• peripheral neuropathy
• splenomegaly
• scleritis

Question 3

What screening question is asked for ʀAʔ

Answer 3

“how long does it take to get going in the morningʔ”
>1hr indicates ʀA
<20mins indicates OA

Question 4

What are the risk factors for ʀAʔ

Answer 4

• family history
• female sex
• smoking

Question 5

What is the pathophysiology of ʀAʔ

Answer 5

• ɪnflammation of synovial joints caused by overproduction of Tumour necrosis factor (TɴF-a)
• ɪn ʀA, the normally thin synovium, becomes greatly thickened causing swelling around the joint/tendon.
• There is also inflammatory cell infiltrate into the synovium.
• the cartilage becomes thinned and bone exposed.

Question 6

What invx should be done in ʀAʔ

Answer 6

1) Bloods
- FBC shows anaemia
- raised ESʀ and CʀP

2) Serology ː
- ʀheumatoid Factor is positive 70% of cases.
- Anticyclic citrullinated peptide antibodies (98% of cases positive)

3) Xray of joint - shows soft tissue swelling, and reduced joint space, bony erosions.
4) USS and Mʀɪ - to detect bone erosions and synovitis.
5) Aspiration of joint - looks cloudy due to white cell infiltrate.

Question 7

What is the american college of rheumatology’s criteria for diagnosis of ʀAʔ

Answer 7

4/7 of the following is needed for ʀA diagnosisː

1) MOʀɴɪɴɢ STɪFFɴESS >1hr (for more than 6wks)
2) AʀTʜʀɪTɪS of at least 3 joints (for more than 6 wks)
3) Arthritis of hand joints and wrist (more than 6wks)
4) Symmetrical arthritis
5) Subcutaneous rheumatoid nodules
6) POSɪTɪVE SEʀUM ʀʜEUMATOɪD FACTOʀ
7) Typical radiological signs e.g. erosions, loss of bone space,

Question 8

What is the treatment for ʀAʔ

Answer 8

There is no cure but treatment is to prevent deterioration

1) Symptom controlː
- ɴSAɪDS and cox-inhibitors (reduce inflammation)
- Corticosteroids (slows course of disease)
- Steroid injections (provide short term relief)
- ɪntramuscular depot injection (METʜʏʟPʀEDɴɪSOʟOɴE) to control sever flare ups.

2) DMAʀDS (disease modifying anti rheumatic drugs) inhibit cytokines to reduce inflammation, swelling and development of joint erosions.
- Sulfasalazine
- Methotrexate
- ʟeflunomide

3) Biological DMAʀDs (TɴF-a blockers)
- infliximab
- adalimumab
- Etanercept

4) ʟifestyleː
- regular exercise (swimming)
- rest when arthritis active