Rheumatoid Arthritis Flashcards
What type of arthritis is rheumatoid arthritis?
Inflammatory arthritis
What are the associations with rheumatoid arthritis?
~1% population F:M = 3:1 HLA DR4, DR1 association 30-50yrs Smokers
What is the pathogenesis of rheumatoid arthritis?
Inflammatory milieu –> synovial inflammation –> periarticular osteoporosis, bone & cartilage erosion –> progressive joint damage and destruction
What are the key players in rheumatoid arthritis and what is their relevance?
CD4+ T cells, Plasma cells, synoviocytes, macrophages, osteoclasts, IL-1, IL-6, IL-17, TNF alpha, IgG, IgM, RANK L
They are the targets for many treatments
What is the relevance of synoviocytes?
They can migrate between joints –> symmetrical presentation
What is the typical presentation of RA?
Symmetrical joint pain and swelling
Onset of pain over weeks - months
Early morning stiffness
Fatigue
What joints are commonly affected in RA?
Wrists, PIP, MCPs, MTPs
What may be seen on examination in RA?
Symmetric polyarthritis affecting small joints of the hand +/- deformity +/- extra-articular features
Joint swelling, tenderness
What signs may be present in RA?
Ulnar deviation
Swan neck deformity
Boutonniere deformity
Nodules
What systems may show extra-articular features in RA?
Neuro Haem Eyes Mouth Lungs Heart Renal Skin Other
What is an important neurological extra-articular features of RA?
Cervical myopathy
What are the haematological extra articular features of RA?
Anaemia of chronic disease Neutropenia Splenomegaly Felty's syndrome Large granular lymphocyte leukaemia Lymphoma
What are the ocular extra-articular features of RA?
Keratoconjuncitivitis sicca
Episcleritis
Scleritis
What are the oral manifestations of RA?
Xerostomia
Peridontitis
What are the pulmonary manifestations of RA?
Pleural effusions Pulmonary nodules Interstitial lung disease Pulmonary vasculitis Organising pneumonia
What are the cardiac manifestations of RA?
Pericarditis Ischaemic heart disease Myocarditis Cardiomyopathy Arrhythmia Mitral regurgitation
What are the renal manifestations of RA?
Membranous nephropathy
Secondary amyloidosis
What are the dermatological manifestations of RA?
Rheumatoid nodules
Purpura
Pyoderma gangrenosum
What are some other extra-articular manifestations of RA?
Vasculitis
Osteoporosis
Hypoandrogenism
What investigations are done for suspected RA?
Bloods: serology, FBC, inflammatory markers, U&Es, LFTs
What serology is done in suspected RA?
Rheumatoid factor: antibody (IgM mostly) against Fc portion of IgG
Anti-CCP antibodies
What may also raise rheumatoid factor?
Chronic infections - HCV, infective endocarditis
CTD - Sjogren’s, scleroderma, SLE
What imaging is done for RA?
Xray
USS
MRI
What may be seen in RA Xray?
Soft tissue swelling
Periarticular osteopenia
Joint space narrowing
Marginal erosion
When might specialist tests be needed in RA?
To monitor extra-articular features e.g. Lung function tests
Why might joint aspiration be useful?
To rule out septic arthritis or crystal arthropathy
What does joint aspirate look like in RA?
Sterile cloudy fluid with raised polymorphs
What classification is used for RA?
ACR/EULAR
>= 6 - definite RA
What is the monitoring score for RA?
DAS28 (disease activity score)
What DAS score indicates remission?
<= 2.6
What DAS score indicates high disease activity?
> 5.1
What DMARDs are used in RA?
Methotrexate
Leflunomide
Sulfasalazine
Hydroxychloroquine
What are the management options in RA?
Symptom relief: NSAIDs, PT
Acute flare: corticosteroids
Long term: DMARDs, biologics
When are biologics used in RA?
If failed 2x DMARD
DAS28 > 5.1
What RA drugs are considered safe in pregnancy?
Sulfasalazine and hydroxychloroquine
