Rheumatoid Arthritis

Question 1

Presentation of RA?

Answer 1

Systemic inflammatory disease with symmetrical, deforming peripheral polyarthritis. Genetic element in 70% of cases (HLA-DR4)

Articular features:

• Pain, swelling and morning stiffness mostly in small joints but can affect larger joints
• deformity in the chronic setting

Non-articular features: 
(more common) 
- Secondary sjogren's 
- R. nodules
- Anaemia + fatigue 
- Fibrosis 
- Carpal Tunnel (10%) 

(rarer)
- Skin = raynauds, ulcers
- eyes = epi/scleritis, cataracts (from steroids)
- lungs = dyspnea (pleural effusion), pleuritic chest pain
- Heart = pericarditis
- C1/C2 subluxation = hoarness, sore throat, neck pain
- neuro = peripheral neuropathy

Systemic features

• anorexia
• weight loss
• polymyalgia

Question 2

Important Hx elements

Answer 2

Onset

• when was diagnosis made
• how long after Sx was diagnosis made

Current

• symptoms, flares
• main concerns
• functional impairment

Question 3

Examination - hands

Answer 3

General
- Cushingoid features (from steroid use)

Hands
- Dorsum = wrist swelling and radial deviation, dorsum wasting and nodules. MCP swelling, ulnar deviation and subluxation
- Deformity = swan-neck and boutonniere’s, Z thumb
- Nails = vasculitic changes (splitting, oncholysis, clubbing, ventral pterygium)
Volar = palmar erythema, carpal tunnel scar, fixed flexion

feel
- temperature, creps, swelling, tenderness, nodules

move
- ROM in all joints

FUNCTION:
- grip strength, key strength, opposition strength, buttom, pen etc

Question 4

Examination other

Answer 4

Face

• eyes for episcleritis, cataracts and pallor
• anlarged parotids in sjogrens
• TMJ crepitus

Neck

• cervical spine tenderness and reduced ROM
• cervical lymphadenopathy

Chest

• Lungs for pulmonary fibrosis or effusion
• pericardial rub or regurg murmur

Abdomen

• hepato/splenomegaly
• inguinal lymph nodes

Question 5

Serology testing

Answer 5

1. Rheumatoid factor in 70% (sensitive, not specific)

2. Anti-CCP in 50% (more specific)

Question 6

Other investigations

Answer 6

FBC
X-ray - (can be normal) = soft tissue swelling, juxta-articular osteopenia, reduced joint space, boney erosion, subluxation
USS + MRI - looking at synovitis more accurately

DAS28 score to monitor disease - 6 monthly

• <2.6 indicates remission
• > 5.1 is high level of disease

Question 7

NP management

Answer 7

Education 
Regular exercise 
PT and OT for aids, splints
Manage CV risk - RA accelerates athersclerosis
measure DAS28

Question 8

P management

Answer 8

DMARDS
1st line = Methotrexate
- Folate inhibitor
- SE of GI intolerance, fatigue, mouth ulcers, abn LFT
- causes myelosuppression
2. Sulfazaline
- prostaglandin inhibition
- N+V, diarrhoea, dizziness, mood changes and hallucinations
3. hydroxychloroquine
- immune suppression (targeted)
- can cause irreversible retinopathy ( check VA)
4. Leflunomide
- diarrhea, HTN, abnormal LFTs, peripheral neuropathy

BIOLOGIC AGENTS

• Anti-TNF inhibitors = Adulimumab and Etanercept
• Sub cut administration
• or Infliximab IV every 8 weeks
• eligibility criteria including no active infection, severe heart failure, malignancy, MS, Hep B, TB

Question 9

Symptomatic relief for RA

Answer 9

Steroids = prednisone
- good in acute flares but should be given by a rheumatologist and not for long term management. Oral or IM

NSAIDs
- good symptomatic relief, but should not be taken long term as DMARDs will fill this role