rheumatoid arthiritis

Question 1

define rheumatoid arthritis

Answer 1

Anautoimmune conditionthat causeschronic inflammationin thesynovial liningof thejoints,tendon sheathsandbursa.

Question 2

risk factors for rheumatoid arthritis

Answer 2

• women 30-50
• smoking
• genetics
• other autoimmune diseases

Question 3

what is the genetic link to rheumatoid arthritis?

Answer 3

HLADR4/HLADRB1 genes

Question 4

where does rheumatoid arthritis affect

Answer 4

affects multiple joints symmetrically across the body

Question 5

pathophysiology of rheumatoid arthritis

Answer 5

1. arginine to citrulline mutation in T2 collagen
2. results in formation of Anti-cyclic citrullinated peptide antibodies (anti-CCP antibodies)
3. INF alpha causes further pro-inflammatory recruitment to synovium
4. synovial lining expands and a tumour like mass (pannus) grows past joint margins
5. pannus destroys subchondral bone and articular cartilage

Question 6

what is rheumatoid factor (RF)

Answer 6

an autoantibody - is present in around 70% of RA patients.

It targets the Fc portion of IgG, and this causes immune system activation against the patient’s own IgG, which causes systemic inflammation.

Question 7

which antibody is RF

Answer 7

RF is mostly IgM, but it can be other types of immunoglobulins.

Question 8

difference between RF and anti CCP antibodies

Answer 8

1. anti CCP antibodies are more specific and sensitive
2. anti CCP antibodies pre-date the development of RA, meaning they can be used to indicate if a patient is likely to develop RA.

Question 9

general symptoms of rheumatoid arthiritis

Answer 9

• painful, swollen, stiff joints for more than an hour in the morning, better with movement
• Pain and stiffness in small joints (hands, feet, wrist, MCP, PIP) and larger joints (knees, shoulders, elbows)
• Fatigue
• Weight loss
• Flu like illness
• muscle aches
• weakness
• Synovial thickening of the affected joints (they feel “boggy”)

Question 10

what is Palindromic Rheumatism

Answer 10

periods of inflammatory arthritis that is likely to progress to RA.

Question 11

4 advanced RA signs

Answer 11

1. Z-shaped deformity of the thumb
2. Swan neck deformity (DIP joint flexes and the PIP joint extends)
3. Boutonniere deformity (DIP joint hyperextends and the PIP joint flexes)
4. Ulnar deviation

Question 12

extra-articular manifestations of RA

Answer 12

• RA with pulm nodules (Caplan’s syndrome)
• Felty’s Syndrome (RA, neutropenia, splenomegaly)
• Anaemia of chronic disease
• Lymphadenopathy
• Secondary Sjogren’s Syndrome
• Amyloidosis

Question 13

cervical spine signs of RA

Answer 13

Atlantoaxial subluxation -

synovitis/damage to ligaments causes the C2 vertebrae to shift within the C1 vertebrae, leading to spinal cord compression.

Question 14

describe how the joints are inflamed in RA

Answer 14

they are symmetrical, hot and inflamed

most common in wrist, hands and feet

Question 15

which joint is often spared in RA

Answer 15

DIPJ

Question 16

describe the speed of onset of RA

Answer 16

the speed of onset can vary from slowly over years, to rapidly overnight.

Question 17

what does NICE recommend regarding RA

Answer 17

NICE recommends urgent rheumatology referral for patients with persistent synovitis

Question 18

initial investigations for RA

Answer 18

1. Rheumatoid factor (sensitive)
2. Anti-CCP antibodies (specific)
3. Inflammatory markers (CRP and ESR)
4. X-rays of hands and feet
5. Ultrasound/MRI (to detect synovitis
6. gnetic testing

Question 19

what X ray changes are seen with RA

Answer 19

LESS
- lost joint space
- bony erosion
- Soft tissue swelling
- soft bones - periarticular osteopenia.

Question 21

give 3 scoring systems used to assess the severity of RA

Answer 21

1. ACR/EULAR classification
2. Health Assessment Questionnaire
3. Disease Activity Score 28 Joints

Question 22

what is the ACR/EULAR classification used for

Answer 22

the criteria can be used to make the diagnosis

Question 23

what is the Health Assessment Questionnaire used for

Answer 23

it measures functional ability.

Question 24

what is the Disease Activity Score 28 Joints

Answer 24

used to monitor disease activity and response to treatment.

Question 25

what is the aim of RA treatment

Answer 25

induce remission or get as close to remission as possible.

Question 26

whats used to monitor RA treatment

Answer 26

CRP and DAS28 are used to monitor the success of treatment.

Question 27

when are short term steroids used for RA

Answer 27

• at initial presentation
• when initiating new treatments
• or during flare-ups

Question 28

what do short term steroids do for RA

Answer 28

reduce inflammation and control symptoms.

Question 29

main treatment for RA

Answer 29

DMARDs:
- Monotherapy with methotrexate, leflunomide, or sulfasazine.
- Combination treatment with multiple DMARDs
- Biologic therapies, alongside methotrexate
- (Hydroxychloroquine –mildest DMARD- may be used in mild-disease and palindromic rheumatism)

Question 30

can NSAIDS be used for RA

Answer 30

NSAIDS are helpful for pain but have risks and side-effects.

Question 31

impact of pregnancy on RA

Answer 31

Pregnancy can either worsen or improve symptoms.

Methotrexate and Leflunomide are TERATOGENIC.

Question 32

most common anaemia present in RA

Answer 32

normocytic normochromic anaemia

Question 33

what is the 1st line biologics treatment

Answer 33

infliximab

given with methotrexate

Question 34

what is the 2nd line biologics treatment

Answer 34

rituximab

• is a B cell inhibitor