RA - Presentation & Treatment

Question 1

What joints are affected by RA?

Answer 1

Potentially any synovial joint, however:

• Symmetrical!
• Mostly peripheral
• Mostly small joints
• Mostly multiple joints

Question 2

Signs of RA?

Answer 2

Tenderness
Swelling
Restriction of Movement
Sometimes heat/redness

Question 3

Symptoms of RA?

Answer 3

Pain
Stiffness
Functional Impairment and poor mobility
Fatigue

Question 4

What are some potential systemic features of RA?

Answer 4

• Weight loss
• Anaemia
• Scleritis
• Interstitial lung disease & fibrosis
• Nerve disease
• Cutaneous vasculitis & ulceration of skin
• Kidney disease
  Long term CVD

Question 5

What tests can we run for RA?

Answer 5

Anti-CCP* antibodies
X-ray
Doppler US (to see inflammation)
ESR, CRP

RF - not really done anymore

*Anti-CCP - anti-cyclic citrullinated peptide antibody
aka ACPA

Question 6

How do we perform ongoing assessments to monitor our RA patients?

Answer 6

Calculate a Disease Activity Score (DAS)
<2.4 = clinical remission
>5.1 = eligible for biologics

Question 7

How does RA affect peoples ability to work?

Answer 7

According to the NAO report 2009:

• 33% will be off work within 2 yrs
• 50% within 10yrs

Question 8

Early & Aggressive is the modern mantra for RA therapy, why?

Answer 8

Treating RA early and aggressively instead of starting small is shown to have the best outcome and effect on the DAS.
Earlier treatment suppresses inflammation and prevents damage being done to the joint and bone.

Question 9

What drug categories can be prescribed for RA?

Answer 9

• NSAIDs
• Disease Modifying Anti-rheumatic Drugs (DMARD)
• Biologics
• CCS

Question 10

When are NSAIDs used for RA?

Answer 10

As symptomatic medication, not a long-term treatment

Question 11

What drugs are used as DMARDs?

Answer 11

Mainly Methotrexate
Also:
- Sulfasalazine
- Hydroxychloroquine
- Leflunomide

Question 12

Whats the benefit of Biologics vs traditional DMARDs?

Answer 12

Biologics act faster, DMARDs take a few months to show effect.
Biologics are less dangerous

Most effective when combined with MEthotrexate

Question 13

List some biologic agents used for RA?

Answer 13

• TNF-Alpha inhibitors
• IL-1 Inhibitors (Anakinra)
• IL-6 inhibitors (Tocilizumab)
• Anti-B cell Therapy (Rituximab)
• Anti-T Cell Therapy (Abatacept)

Question 14

When and how are CCS used for RA?

Answer 14

Short term therapy for flare ups etc.

Oral / IM / IA / IV infusion

Question 15

Mnemonic for the features of RA = ANTICCP OR F

Answer 15

Arthritis
Nodules
Tenosynovitis
Immunology (ACCP & RF)
Carpal Tunnel
Cardiac
Pleural effusion
Opthalmology
Raynaud's
Felty Syndrome

Question 16

Mnemonic for x-ray findings of RA = LESSS

Answer 16

Loss of joint space
Erosions
Soft bones (periarticular arthritis)
Soft tissue Swelling
Subluxation