Rheumatoid Arthritis

Question 1

What are the normal functions of the synovium?

Answer 1

• Maintenance of intact tissue surface
• Lubrication of cartilage
• Control of synovial fluid volume and composition (lubricin)
• Nutrition of chondrocytes within joints

Question 2

What is RA?

Answer 2

Autoimmune condition causing chronic inflammation of the synovial lining (synovitis)

Question 3

Is RA inflammatory or mechanical?

Answer 3

Inflammatory

Question 4

Is RA symmetrical or assymetrical?

Answer 4

Symmetrical polyarthritis- Symmetrical and multiple joints

Question 5

Is RA more common in men or women?

Answer 5

3 times more common in women

Question 6

What is the pathology of RA?

Answer 6

• Thickened synovial lining which spreads across joint surface
• More production of synovial fluid
• Thinning of cartilage
• Erosion into corner of bone via activated osteoclasts
• Inflamed tendon sheath

Question 7

What is Rheumatoid Factor?

Answer 7

RF is an autoantibody that detects the Fc portion of the IgG antibody

Question 8

What are anti-CCP antibodies?

Answer 8

Autoantibodies that are more specific to RA than RF.
Often predate the development of RA

Question 9

What are the features of RA?

Answer 9

Pain worse on rest and better on movement
Morning stiffness >30 minutes
Soft, boggy swelling

Question 10

What are the systemic symptoms of RA?

Answer 10

Fatigue
Weight loss
Flu like illness
Muscle aches and weakness

Question 11

What joints are commonly affected?

Answer 11

PIP joints
MCP joints
Wrist
Ankle
MTP joints
Cervical spine

Question 12

What joints are never affected in RA?

Answer 12

DIP joints
- These are affected by OA (Heberden’s nodes)

Question 13

What are the hand signs of RA?

Answer 13

Z shaped deformity in thumb
Swan neck deformity
Boutonnieres deformity
Ulnar deviation of fingers at MCP joints

Question 14

What is swan neck deformity?

Answer 14

Hyperextended PIP with flexed DIP

Question 15

What is Boutonnieres deformity?

Answer 15

Hyperextended DIP with flexed PIP
Due to a tear in the central slip of the extensor components of the fingers

Question 16

What are some extra articular manifestations of RA?

Answer 16

Caplan’s syndrome- pulmonary fibrosis
Bronchiolitis obliterans
Anaemia of chronic disease
Secondary Sjogren’s syndrome
Rheumatoid nodules
Carpel tunnel syndrome
Amyloidosis
CVD

Question 17

What investigations are done for RA?

Answer 17

Clinical signs
RF
Anti- CCP (if RF negative)
CRP, ESR, WCC
X ray of hands and feet
US - confirms synovitis

Question 18

What X ray changes are seen in RA?

Answer 18

Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Bony erosions

Question 19

What is the management of RA?

Answer 19

Steroids
NSAIDs (with PPI)
DMARDs
Biologics
Physiotherapy
Surgery

Question 20

What are DMARDs?

Answer 20

Disease modifying anti-rheumatic drugs
- Methotrexate
- Sulfalazine
- Leflunomide
- Hydroxychloroquine

Question 21

What are biologics?

Answer 21

Most advanced therapy available:
- Anti TNF: adalimumab, infliximab
- Anti CD20: rituximab

Question 22

What is NICE guidance for medical treatment?

Answer 22

1. Monotherapy- methotrexate, leflunomide or sulfasalazine
2. Combination therapy- 2 DMARDs
3. Methotrexate + biologic (TNF inhibitor)
4. Methotrexate + rituximab