RA

Question 1

RA

Answer 1

A chronic systemic autoimmune inflammatory disease characterised by
a symmetrical, deforming, peripheral polyarthritis that relapses and remits.

Question 2

Genetic link

Answer 2

HLA-DR4/DR1

Question 3

RA presentation

Answer 3

• Symmetrical, polyarthritis of MCPs, PIPs of hands and feet → pain, swelling, deformity
  1. Swan neck
  2. Boutonniere
  3. Z-thumb
  4. Ulnar deviation of the fingers
  5. Dorsal subluxation of ulnar styloid
  6. Rheumatoid nodules

Question 4

Typical hx of RA

Answer 4

Morning stiffness >1h
Improves with exercise
Starts with smaller joints
Larger joints may become involved

Question 5

Other associated immune conditions

Answer 5

AI haemolytic anaemia
Vasculitis
Amyloidosis
Lymphadenopathy

Question 6

Associated conditions

Answer 6

Cardiac: Pericarditis + pericardial effusion

Carpal Tunnel Syndrome

Pulmonary

• Fibrosing alveolitis
• pleural effusion

Raynauds

Sjogren’s syndrome

Question 7

Felty’s Syndrome

Answer 7

RA + splenomegaly + neutropenia

Question 8

To diagnose RA

Answer 8

Dx – 4/7 of:

1. Morning stiffness >1h (lasting >6wks)
2. Arthritis ≥3 joints
3. Arthritis of hand joints
4. Symmetrical
5. Rheumatoid nodules
6. +ve RF
7. Radiographic changes

Question 9

Ix of RA

Answer 9

Bloods:

• FBC (anaemia),
• ↑ESR, ↑CRP (may not be raised)
• RF +ve in 70%

Radiography:

• Xray - erosions
• USS
• MRI

Question 10

RA antibodies

Answer 10

If -ve = “seronegative rheumatoid”

Anti-CCP: 98% specific

ANA: +ve in 30%

Question 11

Conservative mx

Answer 11

Conservative:

• Refer to rheumatologist
• Regular exercise
• Physiotherapy
• OT: aids, splints

Question 12

Medical mx

Answer 12

DMARDs and biologicals: use early
Steroids: for exacerbations
(Avoid giving until seen by rheumatologist)

NSAIDs: good for symptom relief

Mx CV risk: RA accelerates atherosclerosis

Prevent osteoporosis and gastric ulcers

Question 13

DMARDs

Answer 13

Early DMARD use assoc. with better long-term outcome

Main agents:

• Methotrexate
• Sulfasalazine
• Hydroxychloroquine

Question 14

DMARDs general s/e

Answer 14

All DMARDs can → myelosuppression → pancytopenia

Question 15

Methotrexate

Answer 15

Teratogenic
Hepatotoxic - cirrhosis - do LFTS first
Pulmonary fibrosis

Question 16

Sulfasalazine

Answer 16

MOA: T cell apoptosis and inhibition of proliferation

• Inhibits IL -2
• Reduced chemotaxis and degranulation of neutrophils

Side effects:
Don't give if aspirin allergy 
Hepatotoxic
Steven Johnson syndrome ↓ sperm count
Rash 
N/V

Question 17

Hydroxychloroquine

Answer 17

Retinopathy

Seizures

Question 18

Anti-TNF

Answer 18

Severe RA not responding to DMARDs
- Screen and Mx TB first

Infliximab:
SEs: ↑ infection (sepsis, TB), ↑ AI disease, ↑ Ca

Question 19

Rheumatoid Arthritis on Xray

Answer 19

Loss of joint space
Soft tissue swelling
Peri-articular osteopenia - erosions
Deformity
Subluxation