Rheumatoid arthritis Flashcards
Presentation of rheumatoid arthritis
Symmetrical polyarthritis
- Pain (worse after rest, improves with activity)
- Swelling
- Stiffness (worse in morning)
Systemic symptoms:
- Fever
- Weight loss
- Flu like illness
- Muscle aches and weakness
Typically small joints of hands and feet, but can be larger joints e.g. knees, shoulders and elbows
Common joints affected by RA
PCP
MCP
Wrist and ankle
MTP joints in feet
Can also progress to large joints e.g. knee, hips and shoulders
C spine (rare but can be life threatening)
What can occur in RA affecting the C spine?
Atlantoaxial subluxation
This can cause spinal cord compression
Signs of RA in the hands
Z shaped deformity to the thumb
Swan neck deformity (hyperextended PIP with flexed DIP)
Boutonnieres deformity (hyperextended DIP with flexed PIP)
Ulnar deviation of the fingers at the knuckle (MCP joints)
Boggy feeling to the joints
Extra-articular manifestations of RA
Rheumatoid nodules
Secondary Sjogren’s syndrome (Sicca)
Anaemia of chronic disease
CV disease - at higher risk of this in RA
Episcleritis and scleritis
Pulmonary fibrosis with pulmonary nodules (Caplan’s syndrome)
Bronchiolitis obliterans (inflammation causing small airway destruction)
Systemic vasculitis
Felty’s syndrome (RA, neutropenia and splenomegaly)
Investigations in RA
FBC - for any anaemia
RF
- If RF negative check anti-CCP
CRP and ESR
X-ray hands and feet
Could consider doing a CXR as baseline/ to check for TB - if starting on something like methotrexate or a biologic
Testing for latent TB - Mantoux test
X-ray changes in RA
Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Bony erosions
Diagnosis of RA
Refer to rheumatology
- Any adult with persistent synovitis, even if they have negative rheumatoid factor, anti-CCP antibodies and inflammatory markers
- Urgent if involves small joints of hands/feet or symptoms present >3m
American College of Rheumatology (ACR) / European League Against Rheumatism (ELAR)
- 6 points or more = RA diagnosis
What can monitor disease and response to treatment?
DAS28 score
What is the prognosis of RA?
Varies
Worse if: Younger onset Male More joints and organs affected Presence of RF and anti-CCP Erosions seen on x-ray
Management of RA
First presentation and flares:
- Short course steroids
Maintenance therapy - DMARDs
What DMARD therapy is used in RA?
1st line - methotrexate, leflunomide or sulfasalazine
2nd line - 2 of above in combination
3rd line - methotrexate with a biologic (usually TNF inhibitor e.g. adalimumab, infliximab, etanercept)
4th line - methotrexate plus rituximab (Anti-CD20)
Important things to remember for methotrexate
Folate antagonist - need OW folic acid 5mg on different day to methotrexate
Side effects:
- Infection
- Mouth ulcers and mucositis
- Liver toxicity
- Bone marrow suppression and leukopenia (low white blood cells)
- Pulmonary fibrosis? - recent evidence suggests not
It is teratogenic - need effective contraception during and 6m after treatment in both men and women
Methotrexate counselling
Taken once weekly
Ask if they have ever had TB or hepatitis
Takes 4-6 months for full effects seen
Bloods - FBC, LFTs and U&Es:
- Before starting
- Then every 2W until therapy stabilised
- Then every 2-3m
Important side effects:
- Bone marrow suppression - go to A&E if you have fever or other signs of infection (can also cause unexplained bruising, bleeding and anaemia)
- Liver toxicity can occur - little or no alcohol intake
- Pulmonary toxicity - see doctor if SOB
- May also cause headaches, GI disturbance
Teratogenic:
- Effective contraception in males and females for duration of treatment and 6m after
- Ask if they or partner are currently trying to get pregnant or if they are currently pregnant
- Also contraindicated in breastfeeding
Leflunomide - important side effects
Hypertension
Peripheral neuropathy
Mouth ulcers and mucositis
Liver toxicity
Bone marrow suppression and leukopenia
It is also teratogenic - needs to be avoided prior to conception in mothers and fathers
