Progression and treatment of RA / Flashcards
What are the characteristics of inflammatory arthritis?
- Symptoms tend to lead to ease with activity
- Early morning stiffness present
- Onset often acute/sub-acute
- Systematic upset
- Raised blood tests of inflammation - ESR, CRP, PCT
What are the characteristics of non-inflammatory arthritis?
- Symptoms worse with activity
- Minor morning stiffness
- Usually gradual onset
- No systematic upset
- Blood tests usually normal
What is the most common type of arthritis?
Osteoarthritis
Is RA hereditary?
No, only the factors that increase your risk of having it can be hereditary
Which joints in the body does RA spare?
DIPs - distal interphalangeal joints
Vertebral joints especially the atlanto-axial joint
What are classical sub-acute presenting symptoms of new RA?
- Pain and stiffness in hands, wrists, feet +/- large joints
- 1 hour morning stiffness
- +/- joint swelling
- Undue fatigue
- Difficulties with certain activities - opening jars, bottles, keys
- Can have more prominent systematic symptoms e.g. weight loss
What are the special features to ask in history taking of RA? ***
Skin problems - scaly rash (psoriasis)
Eye problems - grittiness, acute red eyes, red eye + blurred vision
Dry mouth
Alopecia
Raynaurd’s
Preceding illness
Family history
What may be found in general examination of RA? ***
May be normal
Anaemia
Lymphadenopathy
Palmar erythema
Look for rashes, nail dystrophy, tophi
What may be found in joint examination in RA?
Articular tenderness - especially PIPs and MCPs, wrists, MTPs
Soft tissue swelling of joints +/- effusions
Functional impairment:
- Diminished grip strength
- Impaired fist formation
- Inability to extend elbows fully
What does this picture show?
Fusiform swelling
What does this picture show?
Subcutaneous nodule
What blood tests will be ordered to investigate RA?
FBC
ESR - erythrocyte sedimentation rate
CRP - C reactive protein
U&Es - K+, Na+, urea, creatinine
LFTs
Serum urate
Consider thyroid function, glucose
Autoantibodies
What is more sensitive and specific to RA: RHF or anti CPP?
Anti CPP is more specific and sensitive
What can RF also be found in?
2-4% of normal pop
Other autoimmune conditions
Chronic infections e.g. TB, syphilis
Viral infections e.g. EBV
B cell lymphoproliferative disease
What autoantibodies are present with RA?
Anti CPP - sensitivity 50-70%, sensitivity 90-95%. May be present years before arthritis onset
Anti-nuclear antibody (ANA) - stronger associations with other diseases. also in pulmoanry diseases, infections and malignancies. Low positives in normal
What X-rays may be taken to assess for RA?
Chest x-ray: check for conditions that may present with joint problems. Look for RA lung involvement
Hands and feet: tend to be earliest sign - soft tissue swelling, juxta-articular osteopenia, erosions
Why is US used to assess for RA?
Sensitive way of detecting synovitis and tenosynovitis
Can detect erosions sensitively
What does uncontrolled RA lead to?
Increasing joint damage and deformity
Increasing disability - many unable to work after 5 yrs of RA
Increased mortality - inflammatory impact in cardiovascular system
What are the joint manifestations of RA?
Subluxation
Swan neck deformity
Bountonniere deformity
Protruding metatarsal heads
Reduced joint space
Erosions
What are some extra-articular manifestations of RA?
Eyes: dry eyes, slceritis, episcleritis
Skin: ulcers
NS: carpal tunnel syndrome, peripheral neuropathy
Blood vessels: premature atherosclerosis, vasculitis
Lungs: pulmonary fibrosis, pulmonary nodules
Heart: pericarditis
Blood: anaemia
What are the main principles of RA treatment?
Control symptoms
Minimise impact
Minimise joint damage
Maximise function
What drug treatments are given to patients with RA?
Analgesics: including NSAIDs - but significant side effects
DMARDs: improves symptoms and may slow progression. Serious side effects. Methotrexate, hydroxychloroquine, sulfasalazine
Corticosteroids: relief for inflammation
Biologic agents: target specific immune molecules, expensive. Anti-TNF
