rheumatoid arthritis

Question 1

is RA seropositive or seronegative?

Answer 1

seropositive

Question 2

what is inflammatory arthritis?

Answer 2

clearly defined group of conditions where the joint or tendon is inflamed

Question 3

how does RA present?

Answer 3

• morning stiffness in small joints (usually hands and feet)
• reduction in grip strength
• rapid onset
• swelling of affected joints
• usually symmetrical

Question 4

who is more affected men or women?

Answer 4

women 3x more affected than men

Question 5

what type of joints are usually affected by RA?

Answer 5

synovial joint

Question 6

what are some triggers to RA?

Answer 6

• smoking
• stress
• infection

Question 7

how to diagnose RA?

Answer 7

• clinical diagnosis (morning stiffness <30 mins)
• 6 or >6= definite RA of 2010 ACR/EULAR
• positive compression tests of MCP and MTP joints
• anti CCP antibody (99%) or RF factor (70%)

Question 8

what antibodies can be tested for in RA?

Answer 8

rheumatoid factor
Anti-CCP

however, not all patients with RA have this
RF 70% sensitive
Anti-CCP 99% sensitive

Question 9

what antibody is more likely found in a patient who smoked and has RA?

Answer 9

Anti-CCP

Question 10

What will be seen on an Xray of a patient with early RA?

Answer 10

• can be normal
• soft tissue swelling
• periarticular osteopenia

Question 11

what will be seen on an Xray of a patient with late RA?

Answer 11

• erosions

- subluxation

Question 12

what can be seen on an ultrasound of a patient with RA?

Answer 12

• erosions in joint

- increased synovial fluid and thickening (dark)

Question 13

what investigation is best for looking for erosions?

Answer 13

ultrasound

Question 14

what is gold standard investigation for looking at joint pathology?

Answer 14

MRI scan

Question 15

what are some extra-articular manifestations of RA?

Answer 15

• dry eyes, dry mouth
• lymphadenopathy
• pericarditis, myocarditis
• interstitial fibrosis, pleuritis
• amyloidosis, renal failure
• rheumatoid nodules in the skin
• myositis
• tenosynovitis
• rheumatoid vasculitis
• peripheral edema

Question 16

what are some complications of RA?

Answer 16

• increased cardiovascular risk

- osteopenia/ osteopeniasis

Question 17

what is the first line drug for RA?

Answer 17

methotrexate and short term glucocortisteroids

Question 18

what drugs should the patient use if they have contra indications to methotrexate?

Answer 18

-leflunomide or sulfasalazine

Question 19

what are the side effects of DMARDs?

Answer 19

• bone marrow suppression
• infection
• liver function derangement
• pneumonitis
• nausea

Question 20

what is the RA scoring system?

Answer 20

DAS28

Question 21

what medication are patients put on if theyve already been on 2 DMARDs and have a DAS28 score >5.1?

Answer 21

Biologics

Question 22

what are examples of biologics?

Answer 22

• Anti TNF agents (infliximab)
• T cell recepto blocker (abatacept)
• B cell depletor (rituximab)
• IL 6 blocker (tocilizumab)
• JAK inhibitor (tofacitinib)

Question 23

what alleles does RA have a strong connection with?

Answer 23

HLA-DRB1 alleles

Question 24

when should methotrexate not be taken?

Answer 24

• when pregnant

- if trying to conceive the patient should remain on contraception for 3 months since stopping the methotrexate

Question 25

what type of hypersensitivity reaction is RA?

Answer 25

Type IV T cell mediated autoimmune reaction

Question 26

what type of joints does RA affect?

Answer 26

synovial joints

Question 27

what is the basic pathology of RA?

Answer 27

the mutation causes the immune cells to get confused causing the antigen-presenting cells to pick up self antigens and take them to the lymph nodes, activating CD4 T helper cells, causing B cells to proliferate and then differentiate into plasma cells to then go on to produce specific autoantibodies against these self antigens. The CD4 T helper cells and autoantibodies enter the circulation and reach the joints. Once in the joints T. cells secrete cytokines such as IL- gamma and IL-17 to recruit macrophages into the joint, producing TNF alpha, IL-1 and IL-6 causing synovial cell proliferation. The increase in synovial cells and immune cells causes a PANNUS (thick, swollen synovial membrane with granulation tissue). Over time the pannus destroys the bone. Active Synovial cells also produce proteases which break down cartilage, meaning the bones from the synovial joint rub together. Anti-CCP and RF form immune complexes and activate the complement system causing joint inflammation. Chronic inflammation causes angiogenesis (formation of new blood vessels) meaning more inflammatory proteins can reach and destroy the joint. The cytokines dont only stay at the joint, they move through the blood stream and attack other organs.

Question 28

which joints are affected in the hands?

Answer 28

PIP and MCP

Question 29

why are DIP joints not affected by RA?

Answer 29

RA affects joints containing synovium so the joint must be 1. large enough to contain enough synovium 2. be a synovial joint DIP is a synovial joint but it is too small

Question 30

how many patients experience rheumatoid nodules?

Answer 30

25%

Question 31

what lung involvement may occur to a patient with RA?

Answer 31

pleural effusion interstitial fibrosis pulmonary nodules

Question 32

what DAS 28 score suggests high level of disease?

Answer 32

>5.1

Question 33

what DAS28 score means a patient is eligible for biological therapy ?

Answer 33

>5.1

Question 34

what investigation does NICE always recommend for someone with suspected RA?

Answer 34

Xray

Question 35

what are some common side effects of hydroxychloroquine?

Answer 35

- retinotherapy | - corneal deposits