IAs- Rheumatoid Arthritis

Question 1

Rheumatoid arthritis (3)

Answer 1

most prevalent seropositive inflammatory arthropathy.

an auto‐immune inflammatory symmetric polyarthropathy which most commonly affects the small joints of the hands and feet.

Larger joints such as the knees, shoulders and elbows can also be affected as the disease progresses.

Question 2

Risk factors (4)

Answer 2

Women 2‐3 times more commonly affected than men.

ages of 35 and 50 years.

Genetic factors 50%

First degree relatives 2- to 3-fold higher risk

Question 3

pathogenisis (4)

Answer 3

an immune response is initiated against synovium which lines synovial joints and some tendons.

triggers such as smoking, infection or trauma have been implicated.

inflammatory pannus forms which then attacks and denudes articular cartilage leading to joint destruction.

tendon ruptures and soft tissue damage can occur leading to joint instability and subluxation.

Question 4

presentation (2)

Answer 4

Diagnosis is based on the clinical presentation, radiographic findings and serological analysis.

The ACR and EULAR Rheumatoid Arthritis Criteria scoring systems assist in the diagnosis.

Question 5

clinical features (3)

Answer 5

symmetrical synovitis (doughy swelling)

pain

morning stiffness

Question 6

sites affected (6)

Answer 6

hands and feet tend to be involved early.

MCP and PIPs joints

wrists

the cervical spine- atlanto-axial subluxation which can result in cervical cord compression.

Question 7

Extra-articular manifestations (5)

Answer 7

Rheumatoid nodules occur in approx 25% of patients with RA.

Lesions on extensor surfaces or sites of frequent mechanical irritation.

Lung involvement - pleural effusions, interstitial fibrosis and pulmonary nodules.

Cardiovascular morbidity and mortality are increased in patients with RA.

Ocular involvement includes keratoconjunctivitis sicca, episcleritis, uveitis, and nodular scleritis that may lead to scleromalacia.

Question 8

Investigations (4)

Answer 8

Xrays at the onset of disease will often show no joint abnormality.

Early features can include peri-articular osteopenia (bone thinning) and soft tissue swelling.

Periarticular erosions can occur later in the disease.

Ultrasound may be useful in detecting synovial inflammation if there is clinical uncertainty.

Question 9

antibodies/ markers

Answer 9

Rheumatoid Factor

Anti‐CCP antibody!

CRP, ESR and plasma viscosity are usually raised.

Question 10

1st line Treatment

Answer 10

commence DMARD therapy within 3 months of symptom onset.

1st line methrotrexate

Question 11

2nd line treatment

Answer 11

2nd line DMARDS - sulphasalazine, hydroxychloroquine and leflunomide.

Question 12

not respond to DMARD therapy?

Answer 12

then the patient may be eligible for biologic therapy =

anti-TNF alpha drugs, all of which are given by injection.

other available biologics including toclizumab, rituximab and abatacept.

Question 13

DAS scores

Answer 13

The lower the DAS 28 score the better. Cut off values are as follows:

DAS 28 < 2.6 Remission

DAS 28 2.7-3.2 Low disease activity

DAS 28 3.3-5.1 Moderate disease activity

DAS 28 >5.1 High disease activity

Patients must have a DAS 28 score of >5.1 to be eligible for biologic therapy.

The DAS 28 score is a useful tool in monitoring disease activity over time.

Question 14

Other therapies

Answer 14

Physiotherapists, occupational therapists, podiatrists and orthotists also have a very important role.

Surgery can be used for resistant disease, to control pain from a particular joint or to improve or maintain function but increasingly this is less often the case . Operations performed for rheumatoid arthritis include:

Synovectomy
Joint replacement
Joint excision
Tendon transfers
Arthrodesis (fusion)
Cervical spine stabilisation