MSPA: Rheumatology- OA and RA

Question 1

What is the epidemiology of OA ?

Answer 1

OA is the most common type of arthritis, there are > 400,000 people with OA lives in Ireland. 50% affected are over the age of 65 with a female predominance.OA related joint replacements are expected to Quadruple by 2030.

Question 2

What is the pathophysiology of OA ?

Answer 2

*The pathogenesis is driven by the mechanical degeneration of the articular cartilage, which in the early stage stimulate the chondrocytes to increase production of proteoglycans and type 2 collagen. However, the chondrocytes produces fragile type 01 collagen which are easily broken down and causes chondrocyte apoptosis.

*Further damage of the joint leads to the development of joint mice, synovitis due to leukocytic infiltration, cartilage fibrillation and erosion.

*This ultimately leads to bone eburnation, osteophyte formation and subchondral cysts.

Question 3

What are the risk factors for OA ?

Answer 3

*Age
* Inflammation
* Joint injury
* Mechanical stress
* Obesity
* Neurologic disorders
* Genetics
* Medications
* Altered walking patterns

Question 4

What is the clinical presentation of OA ?

Answer 4

*Asymmetrical sharp or burning pain of weight bearing joints and DIP. MCPs are rarely affected.

*The pain is often worse with prolonged activities, evening hours and the morning joint stiffness < 1 hour which may get worse at rest due to gelling phenomenon.

*Patients may often experience joint instability and crepitus.

Question 5

What are the clinical signs of OA ?

Answer 5

Reduced ROM, Crepitus, tenderness to the first CMC, genu varus( bowing of the knee), Heberden’s nodes (DIP) Bouchard’s nodes (PIP).

Question 6

What are the laboratory findings in OA ?

Answer 6

The laboratory blood works will show normal FBC, ESR,RF, ACPA. CRP may be slightly elevated. The sinovial fluid analysis should show clear, viscous, < 2,000 WBC per μL.

Question 7

What are the radiological findings in OA ?

Answer 7

*Loss of joint space (narrowing)
* Osteophytes
* Subarticular sclerosis
*Subchondral cysts
( LOSS)

Question 8

what is the key consideration in OA weight bearing joint X-Ray ?

Answer 8

Plain films of the knee
should be “weight-bearing”.

Question 9

What is the best way to see joint effusion in OA knee X-Ray ?

Answer 9

lateral x-ray of the kneewill show “Well-defined rounded homogenous
soft tissue density in suprapatellar
recess”.

Question 10

What is the appearance of the subchondral cyst in X-ray of the hip with OA ?

Answer 10

It appears as a Large cyst in the pressure zone of the femoral head.

Question 11

What is the non-pharmacological Tx for OA ?

Answer 11

*Weight loss
* Exercise
* Physical therapy

Question 12

What are the medical and surgical interventions for OA ?

Answer 12

*Paracetamol or NSAIDs (topical or oral)
* Topical capsaicin
* Hyaluronic acid joint injections
* Corticosteroid joint injections
* Surgical replacement of joint

Question 13

What are the genes linked to RA ?

Answer 13

HLA DR1 and 4

Question 14

What is the environmental risk factor for RA ?

Answer 14

Cigarette smoking.

Question 15

What is the pathogenesis of RA?
https://youtu.be/nYjzl3Xc_0E?si=vO2t6yq9VtuI0nSJ

Answer 15

Genetic and environmental risk factors triggers an immune complex mediated type III hypersensitivity reaction which leads to synovial cell proliferation known as pannus formation it damages bones and cartilages through proteases. In addition, bone to bone articulation incurs T-cell mediated RANKL activation which binds to RANK on osteoclasts accelerating bone resorption. The joint damage is further enhanced by chronic inflammatory angeogenesis mediated immune response.

Question 16

What is the composition of the immune complex in RA?

Answer 16

It consist of Fibrinogen,Type II collagen,Alpha-enolase, and Vimentin

Question 17

What are the antibodies in RA ?

Answer 17

RF against the Fc region of IgG and Anti-citrullinated peptide antibody (ACPA)

Question 18

What are the Extra-articular manifestations of RA?

Answer 18

*General: Fever
* Muscles: Protein breakdown
* Skin: Rheumatoid modules
* Blood vessels: plaque formation
* Liver: decreased iron absorption
* Lung: fibrosis and decreased gas
exchange

Question 19

What is the epidemiology of RA ?

Answer 19

*1% prevalence
* About 40,000 in Ireland with severe RA
* M:F 1:2
* Peak onset 30s-50s
* More common in smokers

Question 20

What is the clinical presentation of RA ?

Answer 20

It affects multiple joints in a symmetrical fashion. It starts with small joints such as MCP, PIP, MTP and as the disease progress it goes on to affect larger joints.

Question 21

What is the symptomatology of RA ?

Answer 21

> 1 hour of joint stiffness in the morning and after prolonged rest. Flares presents with joint edema, warmth, erythema and pain.

Question 22

What are the clinical signs of RA ?

Answer 22

*Ulnar deviation of the MCPs and radial deviation of the wrist.
*BOUTONNIERE DEFORMITY and SWAN NECK DEFORMITY of the digits.
* Baker’s cyst in the popliteal fossa and RA nodules.

Question 23

What is Felty syndrome ?

Answer 23

It is a rare condition consisting of
triad of:
1. Rheumatoid arthritis
2. Splenomegaly
3. Granulocytopenia
It can Can lead to life-threatening
infections.

Question 24

What are the laboratory and clinical findings in Felty syndrome?

Answer 24

Splenomengaly, anaemia, neutropenia, thrombocytopenia and RA arthritis. Hepatomegaly and Lymphadenopathy may be seen.

Question 25

what is the highly specific and sensitive antibody pannel for RA ?

Answer 25

ACPA + RF

Question 26

What is the highly specific marker of RA severity ?

Answer 26

elevated ACPA.

Question 27

What are the laboratory findings other than RF and ACPA in RA?

Answer 27

• Anaemia of chronic disease
• ESR and CRP elevation.

Question 28

What are the radiological findings in RA ?

Answer 28

*Soft tissue swelling
* Juxta-articular osteopaenia
* Decreased joint space
* Bony erosions
* Subluxation
* Complete carpal destruction

Question 29

What is the diagnostic criteria for RA ?

Answer 29

Diagnosis is made based on the 2020 ACR-EULR classification of RA. A score of greater than or equal to 6 in it is diagnostic of RA.

Question 30

What should be the diagnostic approach to RA symptoms of only one joint, which is not better explained by other conditions?

Answer 30

Rule out Psoriatic arthritis, viral polyarthritis, Gout, CPPD and SLE.

Question 31

What are the non pharmacological Tx in RA ?

Answer 31

*Physical therapy and Occupational therapy
* Splints and orthotics
* Therapeutic exercise programs
* Joint protection and energy-conservation techniques
* General patient education
* Assistive equipment
* Environmental audit

Question 32

What is the management of acute flares of RA ?

Answer 32

Anti-inflammatories such as NSAIDs, Glucocorticoids.

Question 33

What is maintenance therapy in RA ?

Answer 33

start early the use of Disease Modifying Anti-rheumatic Drugs (DMARDs) either non-biologic or biologic agents.

Question 34

What are the non biologic Disease Modifying Anti-rheumatic Drugs (DMARDs)?

Answer 34

*Methotrexate
*Hydroxychloroquine
* Sulfasalazine

Question 35

What are the biologic Disease Modifying Anti-rheumatic Drugs (DMARDs)?

Answer 35

Abatacept - T cell inhibitor
Rituximab- B cell inhibitor
Adalimumab, etanercept, infliximab: All TNF alpha inhibitors.
Anankinara- IL-1 inhibitor
Tocilizumab- IL-6 inhibitor

Question 36

What are the difference between the symptomatology of OA vs RA

Answer 36

• Joint pain: OA worse with activity and in the evening. Whereas in RA worse with rest and in the morning.
• Joint stiffness: <30 min in the morning in OA and >30 min in RA.
  Signs of joint inflammation: none in OA and all in RA.

Question 37

What are the X-ray differences between OA vs RA ?

Answer 37

• In OA subchondral sclerosis and in RA periarticular osteopenia is seen.
• Osteophytes in OA and subluxation in RA.
• Subchondral cyst in OA vs soft tissue swelling in RA.
• Asymmetric joint narrowing in OA vs symmetric in RA.
• central erosion in OA vs Marginal erosion in RA.

Question 38

What is stage 01 RA ?

Answer 38

It is the early stage of RA which involves the initial inflammation in the joint capsule and swelling of synovial tissue. The swelling causes the symptoms of joint pain and stiffness.

Question 39

What is Stage 2 RA ?

Answer 39

It is the moderate stage of RA in which there is the inflammation of the synovial tissue becoming severe enough that it creates cartilage damage. In this stage, symptoms of loss of mobility and decreased joint range of motion become more frequent

Question 40

What is stage 03 RA ?

Answer 40

It is the severe stage of RA in which Inflammation in the synovium destroys cartilages and bones. Pain, edema, reduction in ROM and muscle strength increases. The physical deformities of the joints starts to emerge.

Question 41

What is stage 04 RA ?

Answer 41

It is the end stage of RA, the inflammatory process ceases and joints stop functioning altogether. Pain, swelling, stiffness and loss of mobility are still the primary symptoms in this stage.