Rheumatoid arthritis Flashcards
What is RA?
Autoimmune disease + aninflammatory arthritis
- causeschronic inflammationof thesynovial lining(synovitis) of thejoints,tendon sheathsandbursa
What genes increase risk of RA?
- HLA DR4(a gene often present in RF positive patients)
- HLA DR1(a gene occasionally present in RA patients)
Who is it more common in M/F, age group?
What other history suggests RA?
Females 3x more likely
Middle aged people most common- 30-50 yrs old
Family history of RA
Smoking history - implicated in aetiology and severity of RA
Symptoms common in RA
- symmetrical
- swollen, painful polyarthritis in small joints in hands and feet- (usually PIPs, MCPs, MTPs and usually spares DIPs but can affect any joint)
- stiffness worse in the morning lasting longer than 30 mins
- Resting pain, pain improves in day with movement
-Fatigue/ Malaise
How long must symptoms be present to diagnose RA?
6 weeks
What are the signs of RA?
- Soft tissue swelling and tenderness
- Ulnar deviation/palmar subluxation of MCP’s
- positive ‘squeeze test’ of MCPJ
- Rheumatoid nodules- common in elbows
- Swan neck and boutonnière deformities
- Carpal tunnel syndrome association- median nerve affected
Extra articular manifestations are present in what patients most commonly?
Most commonly in RF+ patient with severe articular disease
What are the extra-articular manifestations of RA? 3Cs
- 3 C’s
- Carpal tunnel syndrome
- Increased Cardiac risk (CVD)
- Cord compression (due to atlanto-axial subluxation)
What are the extra-articular manifestations of RA? 3As
- 3A’s
- Anaemia (normochromic normocytic)
- Amyloidosis (very rare)
- Caused nephrotic syndrome and CKD
- Arteritis (rare)
- nail fold infarcts, cutaneous vasculitis and mononeuritis multiplex
What are the extra-articular manifestations of RA? 3Ps
- Pericarditis
- Pleural disease (common)
- pulmonary disease (common)
- Bronchiectasis, fibrosis and bronchiolitis obliterans
What are the extra-articular manifestations of RA? 3Ss
- Sjorgen’s (common)
- Scleritis/episcleritis(uncommon)
- Splenic enlargement (together with neutropenia = Felty’s syndrome- rare)
How is RA diagnosed?
Clinically - symptoms, signs and bloods and Xray used to support diagnosis
What 2 autoantibodies are found in RA ? which one is more specific?
- Rheumatoid factor
-Anti- CCP (more specific )
What test do you do for RF?
RF can be detected by either:
- Rose-Waaler test: sheep red cell agglutination
- Latex agglutination test (less specific)
What other investigations would you do to support a RA diagnosis ?
-RF and Anti- CCP autoantibodies
-FBC- normocytic normochromic anaemia (chronic disease) and low WCC
- Inflammatory markers- CRP and complement proteins raised and ESR
- X ray
- Ultrasound/MRI
- May need PFTs and HRCT if chest involvement
X ray findings for RA
most commonly affected- MCP and PIP joints esp. 2nd and 3rd
Early x-ray findings (L.E.S.S acronym)
- Loss of joint space
- juxta-articular osteoporosis
- Soft-tissue swelling
Late x-ray findings
- Erosions (periarticular)
- Subluxation
When are Ultrasound and MRI used in RA?
- more sensitive in early disease
- To check for soft tissue swelling
Management of RA?
- Lifestyle modification- smoking cessation
- Acute- steroids IM/PO (bridging treatment to DMARDS)
- If one joint involvement- steroid injections
- Symptom control- NSAIDS with PPI cover
-Physiotherapy/OT, Podiatry, Psychological- counselling
Treatment: - First: DMARD monotherapy
- DMARD combination therapy
If disease still severe while using 2 DMARDs: Biologics such as TNF-inhibitors used
Biologics such as TNF-inhibitors: what checks or tests must be done ?
You need to check if they had TB or have TB- to prevent causing miliary TB
- risk of infection is high
- Mantoux test or quantiferon test
