rheumatoid arthritis

Question 1

what

Answer 1

autoimune condition, chronic synovitis of joints, tendon sheaths and bursa

symmetrical polyarthriris

Question 2

genetic associations

Answer 2

HLA DR4

HLA DR1

Question 3

antibodies

Answer 3

rheumatoid factor

cyclic citrullinated peptide antibodies (anti-CCP antibodies)

Question 4

RF

Answer 4

autoantibody that targets Fc portion of IgG –> activation of immune system against patients own IgG causing systemic inflammation

Question 5

presentation

Answer 5

symmetrical distal polyarthropathy - joint pain, swelling + stiffnesss (worse after rest, improves w activity)

systemic symptoms - fatigue, weight loss, muscle aches

Question 6

palindromic rheumatism

Answer 6

self-limiting short episodes of inflammatory arthritis

1-2 days then completely resolves

positive antibodies indicates it may progress to full RA

Question 7

commonly affected joints

Answer 7

PIPJ
MCPJ
MTPJ
wrist 
ankle 
cerival spine

Question 8

which joints are almost never effected by RA

Answer 8

distal IP joints

enlarged, painful DIPJ most likely heberden’s nodes due to OA

Question 9

atlantoaxial subluxation

Answer 9

axis (C2) and odontoid peg shift within atlas (c1)

can cause spinal cord compression

Question 10

signs in hand

Answer 10

boggy feeling synovium 
Z shaped deformity thumb 
swan neck deformity 
boutonniers deformity 
ulnar deviation at MCP joints

Question 11

extra-articular manifestations

Answer 11

rheumatic nodules
pulmonary fibrosis
bronchiolitis obliterans
IHD
pericarditis
pericardial effusion
carpal tunnel syndrome 
felty's syndrome 
episcleritis + scleritis
amyloidosis
anemia of chronic disease

Question 12

felty’s synrdome

Answer 12

RA
neutropenia
splenomegaly

Question 13

Ix

Answer 13

RF
anti-CCP antibodies 
CRP, ESR
X-Ray of hands, feet
USS - synovitis

Question 14

x-ray changes

Answer 14

joint destruction + deformity 
soft tissue swelling 
periarticular osteopenia 
boney erosions 
subluxation 
reduced joint space

Question 15

when to suspect RA

Answer 15

those with swollen joint and a suggestive clinical history which is not better explained by another disease

Question 16

diagnosing RA

Answer 16

diagnostic criteria

score of 6+ is diagnostic

Question 17

diagnosis critera: pt scores based on

Answer 17

1. joints involved (more and smaller joints score higher)
2. serology (RF and anti-ccp)
3. inflammatory markers - CRP, ESR
   duration of symptoms (more or less than 6wks)

Question 18

DAS28 score

Answer 18

disease activity score - useful in monitoring disease and response to Rx

assessment of 28 joints - points given for swollen joints, tender joints, ESR/CRP

Question 19

worse prognosis with…

Answer 19

younger onset
male 
more joints + organs effected
RF and anti-CCP +ve
erosions seen on xray

Question 20

Mx optoins

Answer 20

referral
MDT - physio, OT, psychology, podiatry

steroids

Question 21

aim of management

Answer 21

induce remission - use CRP and DAS28 to monitor

reduce dose to minimal effective dose

Question 22

DMARD guidelines

Answer 22

1. monotherapy with methotrexate, leflunomide or sulfasalazine. Hydroxychroloquine if mild
2. use 2 of above drugs in combination
3. methotrexate + a biologic (usually a TNF inhibitor)
4. methotrexate + rituximab

Question 23

managing RA in pregnant women

Answer 23

pregnant women tend to have symptoms improvement

sulfasalazine or hydroxychloroquine

Question 24

anti-TNF examples

Answer 24

adalimumab
infliximab
etanercept

Question 25

anti-CD20 exable

Answer 25

rituximab

Question 26

methotrexate - how does it work

Answer 26

interferes with metabolism of folate and suppresses cetrian components of immune system

taken by injection o rtablet once a week

Question 27

what needs to be prescribes alongside of methotrexate

Answer 27

folic acid 5mg , once a week taken on a different day to methotrexate

Question 28

methotrexate side effects

Answer 28

mouth ulcers + mucosiitis
liver toxicity
pulmonary fibrosis
bone marrow suppression and leukopenia

teratogenic - needs to be avoided prior to conception in male and females

Question 29

Leflunomide

Answer 29

immunosuppresant

Question 30

Leflunomide side effect

Answer 30

peripheral neuropathy

teratogenic

Question 31

Sulfasalzine

Answer 31

immunosupressive and anitinflammatory

Question 32

Sulfasalzine side effects

Answer 32

reduced sperm count

bone marrow suppresoin

Question 33

Hydroxychloroquine side effects

Answer 33

nightmares
macular toxicity
liver toxicity
skin pigmentation

Question 34

rituximab

Answer 34

monoclonal antibody that targets CD20 protein on surface of B cells