RA

Question 1

What is RA?

Answer 1

Systemic inflammatory disease

Question 2

What is RA characterised by?

Answer 2

symmetrical, deforming peripheral polyarthritis

Question 3

What system can RA cause increased risk to?

Answer 3

CV

Question 4

In which pt group is RA increased in?

Answer 4

Smokers

Question 5

What is the gender ratio of RA pts?

Answer 5

2:1 F:M

Question 6

When is the peak onset for RA?

Answer 6

5th and 6th decade

Question 7

What markers are associated with increased severity of RA?

Answer 7

HLA DR4/DR1

Question 8

What is the typical presentation of RA?

Answer 8

Symmetrical swollen, painful and stiff small joints of hands and feet
Worse in morning
Can fluctuate
Larger joints can become involved

Question 9

When are RA symptoms worse?

Answer 9

Morning

Question 10

Describe some less common presentations of RA?

Answer 10

Sudden onset widespread arthritis
Recurrent arthritis of various joints = palindromic arthritis
Persistent monoarthritis
Systemic illness with extra acicular symptoms
Recurrent soft tissue problems

Question 11

What happens in early RA?

Answer 11

Inflammation but no joint damage

Question 12

What are the signs of early RA?

Answer 12

Swollen MCP, PIP, wrist or MTP joint - often symmetrical

Question 13

What may you see in late RA?

Answer 13

Joint damage and deformity

Question 14

What are the signs of late RA?

Answer 14

Ulnar deviation
Subluxation of wristband fingers
Boutonniere and swan neck deformity of fingers
Z deformity of thumb
Hand extensor tendons may rupture
Rarely atlanto axial subluxation may threaten spinal cord

Question 15

What % of RA patients have extra articular features?

Answer 15

40%

Question 16

Describe some of the extra articular features of RA?

Answer 16

Nodules: elbows, lungs, cardiac, vasculitis
Lungs: interstitial fibrosis, organising pneumonia, pleural disease
CVS: IHD, pericarditis, pericardial effusion, CTS,
Eye: scleritis
Osteoporosis
Amyloidosis

Question 17

Investigations for RA?

Answer 17

Rheumatoid factor 
Anti-CCP
Anaemia of chronic disease: Increased platelets, ESR and CRP
Xray
USS/MRI

Question 18

What are high titres of rheumatoid factor associated with?

Answer 18

Severe disease, erosion and extra articular disease

Question 19

What can anti-CCP be used to predict?

Answer 19

Disease progression in RA

Question 20

What can be seen on a RA X-ray?

Answer 20

Soft tissue swelling
Juxta articular osteopenia
Decreased joint space
Bony erosions, subluxations, carpal destruction

Question 21

In which patients should you suspect RA?

Answer 21

Pts with one more more swollen joint, and a suggestive clinical history which is not better explained by another disease

Question 22

What is the diagnostic criteria for RA?

Answer 22

Joint involvement 
Serology 
Acute phase reactants (CRP and ESR)
Duration of symptoms 
Score of 6 or above is diagnostic

Question 23

What is important if you suspect RA?

Answer 23

Refer to rheumatologist early before irreversible damage

Question 24

How is disease activity measured in RA?

Answer 24

DAS28

Question 25

What is the treatment for RA?

Answer 25

DMARDs Biological agents Steroids NSAIDs - for symptom relief but no effect on disease progression PT/OT Surgery Accelerated risk of CV disease so treat risk factors

Question 26

What could you use in an exacerbation of RA?

Answer 26

Methylprednisolone IM 80-120mg

Question 27

Pro/Con of intra articular steroids?

Answer 27

Rapid but short term effects

Question 28

What may oral steroids be used for? at what dose?

Answer 28

Used to control difficult symptoms | oral prednisolone 7.5mg/day

Question 29

What is the chief biological event in RA?

Answer 29

Inflammation

Question 30

What leads to the systemic side effects seen in RA?

Answer 30

Over produced cytokines and cellular processes erode cartilage and bone

Question 31

What are DMARDs?

Answer 31

Disease modifying anti rheumatic drugs | First line of treatment in RA

Question 32

When should DMARDs be started?

Answer 32

After 3 months of persistent symptoms

Question 33

How long do DMARDs take to start working?

Answer 33

6-12 weeks

Question 34

What combination of DMARDs produces the best results in RA?

Answer 34

Methotrexate, sulfasalazine and hydroxychoroquine

Question 35

What SE can you get with use of methotrexate?

Answer 35

Pancytopenia, increased susceptibility to infection and neutropenic sepsis

Question 36

What tests should you do on people treated with methotrexate?

Answer 36

Regular FBC and LFT monitoring | Pre treatment Xray (pneumonitis)

Question 37

Side effects of methotrexate

Answer 37

Pneumonitis, oral ulcer, hepatotoxicity, teratogenic

Question 38

Side effects of sulfasalazine

Answer 38

Rash, decreased sperm count, oral ulcers, GI upset,

Question 39

SE of leflunomide

Answer 39

Teratogenic, oral, ulcer, increased BP, hepatotoxicity,

Question 40

SE of hydroxychloroquine

Answer 40

Retinopathy - do pretreatment and annual eye screen

Question 41

When could biological agents be considered in the treatment of RA?

Answer 41

Pts with active disease despite adequate trial of 2 DMARDs

Question 42

What tests should you do on a patient before starting biological therapy for RA?

Answer 42

Screen for TB, HIV, hepatitis b and c

Question 43

What are the 4 actions of biologicals in treating RA?

Answer 43

TNFa inhibitors B cell depletion IL1 and IL6 inhibitio Inhibition of T cell co stimulation

Question 44

Give an example of an TNFa inhibitor

Answer 44

Infliximab | Response is really good initially but may be unsustained

Question 45

Give an example of a biological agent that causes B cell depletion

Answer 45

Rituximab

Question 46

Give an example of an IL6 inhibitor- what should you monitor?

Answer 46

Tocilizumab | Monitor for hypercholesterolaemia

Question 47

What are the side effects of biological agents?

Answer 47

Serious infection, reactivation of TB and hep B, Worsening HF, hypersensitivity, injection site reaction, blood disorders, skin cancer