Rheumatoid Arthritis

Question 1

What conditions come under inflammatory arthritis?

Answer 1

Rheumatoid 
Reactive 
Psoriatic 
SLE
Gout 
Ankylosing spondylitis

Question 2

What parts of the joints does RA target and which joints are generally effected?

Answer 2

Synovial lining
Tendon sheaths
Bursa

Affected multiple joints, tends to be small joints i.e. MCP and PIP
= SYMMETRICAL POLYARTHRITIS
NOTE: DIP never effected (differentiated from osteo)

Question 3

Which antibodies are associated with RA? Which are more specific?

Answer 3

Rheumatoid factor (RF)

• autoantibody which targets Fc portion of IgG to activate immune system
• NOT specific

Anti-CCP antibodies

• more specific for RA
• can pre-date presentation of RA so be used to indicate that patient likely to develop RA in future

Question 4

How might a patient with RA typically present?

Answer 4

Symptoms associated with SYNOVITIS

Pain stiffness and swelling in small joints of hands and feet
=symmetrical distal polyarthropathy
I.e. wrist, ankle, MCP, PIP

Boggy joints due to thickend synovium (due to dense immunological infiltrates in to the synovium)

Morning stiffness (>1 hr mins)

Pain and stiffness relieved with activity and worsens with rest

Question 5

Which joints are commonly affected in RA?

Answer 5

PIP
MCP
Wrist and ankle 
MTP (metatarsophalangeal joints)
Cervical spine 
Some large joints i.e. knee/hip/shoulders

Question 6

What medical emergency can occur in RA involving the spine?

Answer 6

Atlantoaxial subluxation

• shift of odontoid peg within atlas due to synovitis and ligament damage
• can lead to spinal cord compression

Question 7

What damage can synovial inflammation cause?

What signs in the hands is this associated with?

Answer 7

Damage:

• erosion of bones
• erosion of articular cartilage= loss of joint space

Boggy synovium
Z-shaped deformity of thumb
Swan-neck deformity (hyperextended PIP with flexed DIP)
Boutonnières deformity (hyperextended DIP with flexed PIP)
Ulnar deviation at MCP joints i.e. hand towards little finger side

Question 8

What other conditions might be found in association with RA?

Answer 8

Pulmonary fibrosis
Bronchiolitis obliterans (inflammation causes destruction of small airway)
Anaemia of chronic disease
Sicca syndrome= dry eyes/mouth etc

Question 9

How can RA be diagnosed?

Answer 9

NOTE: mainly a clincial diagnosis so can still make diagnosis even if all blood tests and plain radiographs are normal

+ve RF
+ve anti-CCP
CRP and ESR markers
Plain radiograph of hands + feet
-erosions and joint-space narrowing not usually present in early disease
-useful to establish a baseline
USS
-can be used to identify synovitis when clinical examinations not clear
I.e. Doppler signal can be used to show increased blood flow to joint due to increased vascularity

Question 10

What are the classical X-ray changes seen in RA?

Answer 10

Sparing of DIP
Peri-articular erosions/osteopenia 
Boney erosions
Sublaxation 
-ligament damage leads to being unable to hold joint inplace 
Deformities 
-Swans neck and Boutonniere 
Ulnar deviation 
Narrowing of joint space 
Soft tissue swelling

Question 11

How is RA managed conservatively?

Answer 11

Manage pain= analgesics/NSAIDs with PPI cover
(NOTE: best management of synovitis-associated pain is to treat the synovitis)

Education about disease + lifestyle advice i.e. smoking

Manage co-morbidities + CVS risk

Vaccinations i.e. pneumococcus
-to manage increased risk of infections when on immunosuppressive medication

Question 12

What are the key principles of pharmacological treatment?

How is RA managed pharmacologically?

Answer 12

Treat early i.e. w/i 3-4 months of symptoms to decrease long term joint damage
Treat-to-target
-improve function + reduce long term joint damage to prolong life expectancy

1st line DMARD monotherapy
-Methotrexate
Or leflunomide/sulfasalazine if px trying to conceive
-glucocorticoids up to 3 months

Question 13

What biological therapies can be used to treat RA?

Answer 13

DMD= disease modifiying drugs

Anti-TNF MAb

• Adalimumab
• Certolizumab
• golimumab
• infliximab

Anti-TNFR
-etanercept i.e. soluble TNF-R

Anti-IL6

• Tocilizumab
• Sarilumab

Anti-CD20
-Rituximab targets abundance of BC in synovium

Anti-CD80/86
-Abatacept blocks co-stimulatory molecules to prevent activation of TC

JAK inhibitors

• Tofacitinib
• Baricitinib
• block downstream signalling molecules of cytokines associated signalling pathways

Question 14

How would you summarise RA?

Answer 14

Inflammatory symmetrical polyarthritis affecting small joints (MCP and PIP)
Associated with swan-neck and boutonnière deformities

Question 15

What disease-related extra-articular features are associated with RA?

Answer 15

Fatigue 
Anaemia of chronic disease 
Skin nodules 
Interstitial lung disease 
Accelerated artherosclerosis 
Osteoporosis= due to systemic inflammation presentin RA

Question 16

What treatment-related extra-articular features of RA can occur?

Answer 16

Infection
Osteoporosis= steroid-induced
Anaemia= NSAIDs induced peptic ulcer leading to chronic GI bleed

Question 17

What are the 4 domains used as part of RA classification criteria?
What score would indicate RA was likely with this scoring system?

Answer 17

Joints (0-5)

• based on number and size of joints affected
• increased score for the number of joints and if they are small joints

Serology (0-3)
-higher the RF and CCF the higher the score

Symptom duration (0-1)

• <6 weeks
• > 6weeks

Acute phase response (0-1)
-whether CRP/ESR are normal or not

At least 6 points required for RA

Question 18

What is the purpose of DAS28 in RA treatment?

What are the 4 main elements?

Answer 18

Score used to measure the disease activity of RA to see whether treatment regime needs changing or whether disease has entered remission

1. Tender swollen joint
2. Swollen joint count
3. ESR/CRP
4. Global patient assessment

High DAS28 when on methotrexate is indication to add DMD (disease modifiying drug)

Question 19

What are the benefits of using biologic/targeted sythnetic DMARDs?

Answer 19

Improve efficacy of synthetic DMARD (methotrexate)

Reduce immunogeneicity

Question 20

What is the order of stepping down treatment in RA and why?

Answer 20

Glucocorticoids

Biological/targeted synthetic DMARDs

Conventional synthetic DMARD

Removal of drugs can lead risk of disease flare