Rheumatoid arthritis Flashcards
What is RA?
Autoimmune condition that causes chronic inflammation of the synovial lining of joints, tendon sheaths and bursa
Is symmetrical and affects multiple joints
What is the pathogenesis?
Presence of circulating antibody called rheumatoid factor targets antibodies
Antibodies migrate to the joint and attack it causing rheumatoid synovitis and there is effusion of joint-boggy and swollen
All inflammatory markers present leads to bone erosion and formation of vascular granulation tissue (pannus)
Pannus is formed by the osteoclasts and macrophages which grows from the peripheries inwards destroying cartilage
All cartilage can be replaced by pannus causing secondary OA changes
Morning stiffness is thought to be due to build up of inflammatory markers during periods of non-activity
What are symptoms?
Gradual onset and progression over weeks/months
Symmetrical joint involvement
Pain worse in the morning and with rest but improves with activity
Red, warm, swollen, tender joint
Decreased range of movement
Muscle wasting
Systemic features- tiredness, malaise, fever, poor sleep
What are non-articular features of RA?
Rheumatoid nodules- seen in 20% of patients with RA, in seropositive disease and more common in smokers
Pulmonary
-pulmonary fibrosis can occur due to RA or methotrexate tx
Vasculitis
- nailfold infarcts due to cutaneous vasculitis
- bowel infarction due to mesenteric vasculitis
Cardiac
- pericarditis
- increased rates atherosclerosis
Neuro
-entrapment neuropathies e.g. carpal tunnel syndrome
Eyes
- keratoconjunctivitis
- Scleritis
- Episcleritis
- Sjogrens
- in seropositive
Renal
-associated amyloidosis can lead to nephrotic syndrome and renal failure
Haem
-splenomegaly and normocytic anaemia
What can be found on examination inRA?
Warm, swollen, tender joints
Hands
- Ulnar deviation at MCPs
- Boutonniere deformity- hyperflexed PIP and hyperextended DIP
- Swan neck- Hyperflexed DIP and hyperextended PIP
- Z deformity- in thumbs, flexed MCPJs and extended IPJ
- rupture of little/ring finger extensor tendons
Feet -MTPH swelling- early sign -Broad foot _hammer toes -Ulcer/callosus due to movement of fat pad exposing metatarsal head to increased pressure
Large joint involvement
- valgus deformity in knees
- large joints require replacement nce severely affected
What investigations are needed in RA?
Bloods
-FBC- leucocytosis and thrombocytosis in acute phase, normocytic anaemia in chronic
- CRP/ESR elevated
Rheumatoid factor- elevated in 70% but non specific
-Anti CCP antibody- more specific, increased before disease develops
-ANA- positive in 30% but non specific
-Consider uric acid levels to exclude gout
XR
-initially normal
-may have soft tissue swelling around MCP and PIP
-joint space narrowing develops
Osteopenia around joints
-periarticular erosions at extremities of joints as pannus develops
-Subluxation and dislocation can occur
What is conservative management of RA?
Stop smoking
Lose weight
regular exercise
What is medical management of RA?
Pain relief- paracetamol/NSAIDs
Disease modifying Rheumatic drugs
1) Methotrexate once weekly with folic acid
- SE nausea, bone marrow suppression, live/pulmonary toxicity, teratogenic
2) methotrexate plus either leflunomide or sulfasalazine
3) methotrexate plus biological therapy e.g. tnf inhibitor
- biologics only used if 2 DMRMs used (one being methotrexate) and disease activity score >5.5
4) methotrexate plus rituximab
Short term glucocorticoids until DMRMs become effective and for acute flare ups
What is surgical management of RA?
Important for long term management
Synovectomy
-to remove inflamed tissue in monoarticular disease
Excision arthroplasty
- of ulnar styloid process to reduce risk of extensor tendon damage
- of metatarsal heads to reduce pain and pressure points
Total joint replacement
What is the disease activity score?
Out of 28 To assess need for biologics To calculate -CRP/ESR Number of tender sites -number of swollen sites -patient perception of disease activity
What is atlanto axial subluxation due to RA?
Occurs in 50-80% of all patients with cervical RA
Transverse and apical ligaments destroyed by pannus
Localised pain and deformity
Must surgically decompress the spinal cord and stabilise the involved segment of spine
