Rheumatic Arthritis

Question 1

What is RA?

Answer 1

Chronic auto immune system illness characterised by symmetrical poly arthritis and other systemic features

Question 2

Where does RA affect?

Answer 2

Most commonly the small joints of the hands, wrists and feet

Question 3

What is the ration of females to males?

Answer 3

3:1

Question 4

What is the typical age of onset?

Answer 4

4th/5th decade but may occur at any age from 16

Question 5

What factors contribute to the aetiology?

Answer 5

Genetics
Environmental
Hormonal

Question 6

How does genetic cause RA?

Answer 6

Rises 2-4% in sibling and 12-15% in monozygotic twins
Genetic contribution is estimated to be 50-60%
HLA-DRB1
Sequence of amino acids at postions 70 to 74 termed the shared epitope and consistent identified as a risk factor

Question 7

What are environmental risk factors?

Answer 7

Cigarettes smoking
Chronic infection eg periodontal disease, EBV and parvovirus B19

Question 8

What are hormonal risk factors?

Answer 8

Earl age at menopause
Low testosterone

Question 9

What are symptoms?

Answer 9

Pain
Morning stiffness > 30 mins
Immobility
Poor function
Systemic symptoms

Question 10

What are signs of RA?

Answer 10

Swelling
Tenderness
Warmth/ redness
Limitation of movement

Question 11

What are non specific clinical signs of RA?

Answer 11

Fatigue/ lassitude
Weight load
Anaemia

Question 12

What are specific clinical signs of RA?

Answer 12

Eyes, lungs, nerves, skin, kidneys

Question 13

What are long term clinical signs?

Answer 13

CVS, malignancy

Question 14

What are investigations for RA?

Answer 14

Baseline bloods
Immunology
Xray
Ultrasound

Question 15

What blood investigations should be done?

Answer 15

FBC, kidney function, livers function, CRP and ESR

Question 16

What immunology investigations should be done?

Answer 16

Rheumatoid factor
Anti cyclic citrullinated antibodies

Question 17

What assessment should be done>

Answer 17

Disease activity score

Question 18

What do different DAS scores show?

Answer 18

<2.6 represents clinical remission
>5.1 represents eligibility for biological therapy

Question 19

What is the approach to management?

Answer 19

Early and aggressive intervention is the key to obtaining optimal outcomes
Effective suppression of inflammation will improve symptoms and prevent joint damage and disability

Question 20

What are the different parts of management?

Answer 20

Pharmacological therapy
MDT
Management of flares
Surgery

Question 21

What classes of drugs can be used for symptomatic treatment?

Answer 21

NSAIDS
-naproxen, ibuprofen, coxibs
GCs
-prednisone, prednisolone, hydrocortisone, dexamethasone

Question 22

How to NSAIDs work?

Answer 22

Exert their pharmacological effect by inhibiting cyclooxygenase, especially COX-2

Question 23

How do GCs work?

Answer 23

Complex mechanisms of anti-inflammatory and immunosuppresion effects

Question 24

What are different disease modifying management?

Answer 24

Conventional, biological and targeted synthetic DMARDs

Question 25

What are examples of conventional synthetic DMARDs?

Answer 25

Methotrexate, leflunomide, hydroxycholoroquine and sulfasalazine

Question 26

How do csDMARDs work?

Answer 26

Non-targeted suppression of the overactive immune system

Question 27

How do targeted synthetic DMARDs work?

Answer 27

Inhibitors with low selectivity, inhibiting the signalling of a broad range of cytokines

Question 28

How do biologic DMARDs compare to transitional DMARDs?

Answer 28

Work rapidly
Well tolerated
Important toxicities

Question 29

What are biologic classes?

Answer 29

TNFa inhibitors
IL-1 inhibitors
Anti B cell therapies
Anti T cell therapies
IL-6 inhibitors
Oral kinase inhibitors

Question 30

What are issues with biologics?

Answer 30

Toxicity: minor eg injection site reaction
Increased risk of infection
Malignancy
Expensive

Question 31

Who are part of the mdt?

Answer 31

Specialist nurse
Physiotherapist
OT
Podiatrist
Pharmacist
Psychologist