Rheumatoid Arthritis

Question 1

what is it?

Answer 1

• Seropositive inflammatory arthropathy
• auto-immune inflammatory systemic polyarthropathy

Question 2

pathogenesis

Answer 2

immune response against synovium
-Inflammatory pannus forms - attack and denudes articular cartilage

Question 3

who gets it?

Answer 3

-Women (more common)
-Increasing with age 35-50yr
-Genetic factors (1st degree relatives are 2-3x more likely)
-Smokers

Question 4

how does it present?

Answer 4

-Symmetrical synovitis (doughy swelling)
- Mainly small joints of hands and feet
- MCP & PIP, wrists affected DIP spared
-Morning stiffness
-Extra-articular manifestations

Question 5

extra-articular manifestations of RA?

Answer 5

-Rheumatoid nodules - 25% extensor surfaces/
-Mechanical irritation Sites: lung - pleural effusion, interstitial fibrosis, pulmonary nodules
CV: morbidity and mortality increased
Occular involvement- keratoconjunctivitis sicca - episcleritis - uveitis - nodular sceritis - scleromalacia

Question 6

how is it investigated?

Answer 6

x -ray ultrasound - detecting synovial

inflammation serology

Question 7

how does it present on x-ray?

Answer 7

Often no joint abnormality

• peri-articular osteopenia (bone thinning)
• soft tissue swelling

Question 8

what is the serology presentation?

Answer 8

• Rheumatoid factor
• Anti-CCP
• more specific, 15-20% of patients with RA are seronegative!!!

Question 9

how is it diagnosed?

Answer 9

-Clinical presentation
-Radiographic findings
-Serological findings
ACR and EULAR RA criteria scoring system

Question 10

how is it managed?

Answer 10

• DMARD therapy within the 1st 3 months of symptom onset i

-If disease doesn’t respond 2 DMARDs (methotraxate and sulfalazine

-If still not responsive - biologic therapy (if high DAS28)

Question 11

what is methotrexate?

Answer 11

First line (teratrogenic) DO pregnancy test before starting
1 a week – 15mg start regular blood tests

Folic acid 1/week

• If you’re low on folate: nausea, alopecia
  If patient wants to be pregnant:* stop methotrexate for 3 months before conception - still need to take contraceptive pill*
  RA gets better during pregnancy* after pregnancy it gets worse, so you give them sulphalazine (not methotrexate because of breastfeeding)

Question 12

DMARD examples?

Answer 12

methotrexate
sulphalazine
hydroxychloroquine
leflunomideside

Question 13

biologic therapy examples?

Answer 13

• anti-TNF injection
• toxlizumab,
• rituximab,
• abatacept

Question 14

what is given for symptom relief?

Answer 14

simple analgesia NSAIDs intramuscular/ intra-articular and oral steroids