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B Disease Database > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

How is Rheumatoid Arthritis defined?

A

Rheumatoid arthritis is an autoimmune disease associated with autoantibodies to the Fc portion of immunoglobulin G (rheumatoid factor) and to citrullinated cyclic peptide.

There is persistent synovitis, causing chronic symmetrical polyarthritis and systemic inflammation in the joints.

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2
Q

What is the gender bias in Rheumatoid Arthritis?

A

Female:male –> 3:1

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3
Q

What is the common age of onset for rheumatoid arthritis

A

30-50

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4
Q

What causes rheumatoid arthritis?

A

The cause is multifactorial and genetic and environmental factors play a part:

  1. Gender –> only postmenopausal women have the same risk as men
  2. Familial
  3. Genetic factors account for 60% of disease susceptibility
    HLA-DR4
    HLA DRB1
  4. Smoking
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5
Q

What sort of tissue does rheumatoid arthritis affect?

A

RA is primarily a synovial disease which invades local tissues and rheumatoid synovitis results when chemoattractants produced in the joint recruit circulating inflammatory cells.

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6
Q

What is the key inflammatory element in rheumatoid arthritis?

A

Overproduction and overexpression of tumour necrosis factors (TNF) is a key inflammatory element in RA

  • Driven by macrophages, T and B lymphocytes
  • Leads to synovitis and joint destruction
  • TNF-α stimulates overproduction of interleukin-6 and other cytokines
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7
Q

What are the three progressive phases of rheumatoid arthritis?

A
  1. Initiation phase due to non-specific inflammation. Increased levels of cytokines, chemokines and CRP
  2. Amplification phase due to T cell activation
  3. Chroinc inflammatory phase with tissue injury resulting from cytokines, IL–1, TNF-alpha, and IL–6.
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8
Q

What are two detectable serum factors found in rheumatoid arthritis patients?

A

Rheumatoid factors (RFs) and anti-citrullinated peptide antibodies (ACPAs)

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9
Q

What is rheumatoid factors?

A

RFs are circulating autoantibodies that have the Fc portion of IgG as their antigen

In RA they show a much higher affinity and their production is persistent and occurs in the joints

They are of any immunoglobulin class (IgM, IgG or IgA), but the most common tests employed clinically detect IgM rheumatoid factor

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10
Q

What are seronegative RA patients?

A

The term ‘seronegative RA’ is used for patients in whom the standard tests for IgM rheumatoid factor are persistently negative. They tend to have a more limited pattern of synovitis.

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11
Q

What is the most typical presentation of a rheumatoid arthritis patient?

A

A slowly progressive, symmetrical, peripheral polyarthritis, evolving over a period of a few weeks or months.

The patient is usually between 30 and 50 years of age, but the disease can occur at any age

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12
Q

What are the typical symptoms of rheumatoid arthritis?

A
  • Tender, warm, swollen joints
  • Joint stiffness that is usually worse in the mornings and after inactivity
  • Fatigue, fever and loss of appetite
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13
Q

What are the first joints that are often affected in rheumatoid arthritis?

A

In early RA, the majority of patients complain of pain and stiffness of the small joints of the hands (metacarpophalangeal, MCP; proximal and distal interphalangeal, PIP, DIP) and feet (metatarsophalangeal, MTP)

  • The wrists, elbows, shoulders, knees and ankles are also affected
  • Fatigue is a common complaint. The pain and stiffness are significantly worse in the morning. Sleep is disturbed
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14
Q

What are the symptoms and prognosis for seronegative RA?

A

In Seronegative RA, it initially affects the wrists more often than the fingers and has a less symmetrical joint involvement. It has a better long-term prognosis, but some cases progress to severe disability. This form can be confused with psoriatic arthropathy, which has a similar distribution

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15
Q

What are common deformities in the hand in RA?

A

Ulnar deviation
Boutonniere’s deformity
Swan neck deformity

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16
Q

What are common deformities in the shoulder in RA?

A

Initially, the symptoms mimic rotator cuff tendonosis with a painful arc syndrome and pain in the upper arms at night

As the joints become more damaged, global stiffening occurs. Late in the disease rotator cuff tears are common and interfere with dressing, feeding and personal toilet.

17
Q

What are common deformities in the elbow in RA?

A

Synovitis of the elbows causes swelling and a painful fixed flexion deformity

In late disease, flexion may be lost and severe difficulties with feeding result, especially combined with shoulder, hand and wrist deformities.

18
Q

What are common deformities in the feet in RA?

A

One of the earliest manifestations of RA is painful swelling of the MTP joints:

  • The foot becomes broader and a hammer-toe deformity develops
  • Exposure of the metatarsal heads to pressure by the forward migration of the protective fibrofatty pad causes pain
  • Ulcers or calluses may develop under the metatarsal heads and over the dorsum of the toes
19
Q

What are common deformities in the knees in RA?

A

Ulcers or calluses may develop under the metatarsal heads and over the dorsum of the toes

In later disease, erosion of cartilage and bone causes loss of joint space on X-ray and damage to the medial and/or lateral and/or retropatellar compartments of the knees

20
Q

What are common deformities in the hips in RA?

A

The hips are occasionally affected in early RA but are less commonly affected than the knees at all stages of the disease.

21
Q

What are complications in rheumatoid arthritis?

A
  1. Septic arthritis
  2. Ruptured tendons
  3. Joint infections
  4. Osteoporosis
22
Q

How is rheumatoid arthritis diagnosed?

A

The diagnosis relies on clinical features

Investigations include:

  1. Blood count → Normochromic, normocytic anaemia may be present.
  2. CRP → raised
  3. Serology → ACPA is present earlier in the disease. Rheumatoid factor is present in approximately 70%
  4. X-rays → show soft tissue swelling in early disease but MRI demonstrates synovitis and early erosions
  5. Aspiration of joint → if an effusion is present. The aspirate looks cloudy owing to white cells
23
Q

How is rheumatoid arthritis managed?

A

Symptoms are controlled with analgesia and NSAIDs

Disease-modifying anti-rheumatic drugs (DMARDs)

24
Q

How would you try induce remission in rheumatoid arthritis?

A

Depot methylprednisolone 80-120 mg

25
Q

What are the remission criteria in rheumatoid arthritis?

A

morning stiffness < 15 min
No fatigue, joint pain, joint tenderness or soft tissue swelling
ESR < 30 women; ESR < 20 in men

26
Q

What dose inflixmab would you normally give?

A

3-10 mg/kg every 4-8 weeks SC

27
Q

What dose adalimumab would you normally give?

A

40 mg alternate weeks SC

28
Q

What are poor prognostic factors in rheumatoid arthritis?

A 
Age
Female sex
Symmetrical small joint involvemeent
Morning stiffness > 30 minutes
> 4 swollen joints 
CRP > 20
Positive RF and ACPA
29
Q

How would you distinguish rheumatoid arthritis from osteoarthritis?

A

RA: swollen inflamed synovial membrane
OA: loss of articular cartilage

RA: erosion of bone
OA: ends of bones rub together

RA: autoimmune
OA: degenerative

RA: symmetrical
OA: asymmetrical

RA: morning stiffness > 30 min
OA: morning stiffness < 30 min

B Disease Database (21 decks)

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