Rheumatoid Arthritis Flashcards
What is Rheumatoid arthritis and its epidemiology
Chronic inflammatory autoimmune disease. It has a gradual onset over days to weeks. More common in females and smokers. The peak onset of 40-60.
What are the articular features of rheumatoid arthritis
- Symmetrical polyarticular inflammaotry arthritis involving the small joints of hands, weists and feet. Other joints affected as disease porgresses
- Inflammatory pain which is better with movement and associated with EMS > 30mins
- Distal interphalangeal joints spared (different from psoriatic arthritis)
- Joints are warm, tender and swollen
What are the specific articular deformities in Rheumatoid arthritis?
- Wrist subluxation,
- MCP subluxation
- Swan neck finger deformity (MCP felxtion, PIP hyperextension and DIP hyperflexion)
- Boutonniere finger deformity (PIP hyperflexion and DIP hyperextension)
- Ulnar deviation of proximal phalanges
- Z-shaped thumb.
- Feet deformities (hammer toes)
What is the presentation of C-spine involvement in rheumatoid arthritis?
- RA typically spares lumbar and thoracic spine.
- Neck pain readiating to the occiput but can also cause myelopathy resulting in weakness in upper limbs
- Minor neck trauma can therefore cause serious complications such as migration of the odentoid peg through the foramen magnum so do C-spine imaging
What are the peri-articular features in Rheumatoid arthritis?
- Carpal tunnel syndrome (pain, weakness and paraesthesia in median nerve distribution)
- Tenosynovitis (usually of flexor tendons of the hand)
- Bursitis (typically of olecranon and sub-acromial)
What are the general systemic features of Rheumatoid arthritis?
RA is a multisystem inflammatory disease which can affect most organs.
Patients feel generaly unwell with fevers, weight loss and fatigue.
What are the haematological fatures of rheumatoid arthritis
- Anaemia of chronic disease (common)
- Splenomegaly
- Amyloidosis
- Generalised lymphadenopathy
What is Felty’s syndrome?
Triad of Rheumatoid arthritis, splenomegaly and neutropenia
What are the dermatological features of Rheumatoid arthitis?
- Rhumatoid nodules (firm, dark nodules usually around inflammation)
- Small vessel vasculitis
- Raynauds syndrome
What are the ophthalmic features of Rheumatoid arthritis?
- Keratoconjunctivitis sicca (dry eyes)
- Episcleritis and scleritis
- Steroid induced cataracts
- Chloroquine retinopathy
What are the respiratory features of Rheumatoid features?
- Pleural effusions containing rheumatoid factor
- Pulmonary rheumatoid nodules
- Pneumonitis leading to pulmonary fibrosis (can be due to methotrexate)
What are the orthopaedic features of Rheumatoid arthritis?
Osteoporosis
What are the cardiac factures of rheumatoid arthritis?
- IHD (RA has similar risks to T2DM)
- Pericardial effusions containing rheumatoid factor
What are the neurological features of rheumatoid arthritis?
Peripheral neuropathy
What are the antibodies seen in Rheumatoid arthritis?
Rheumatod factor (IgM antibody which feacts with the Fc region of patients own IgG. Type III hypersensitivity) - first line
Anti-CCP is more specific than RF
What are the radiological features of Rheumaotid arthritis?
- Soft tissue swelling
- Periarticular osteoporosis,
- Juxta-articular erosion
- Narrowing of joint space
SPADES: Soft tissue swelling, periarticular osteoporosis, abscent joint space, defromity, erosions, subluxation
What is the socrring system used in rhumatoid arthritis?
DAs28
What is the treatment for symptomatic relief in RA?
- Regular paracetamol and NSAIDs,
- During flares - intra-articular, IM or oral course of steroids
What is the indication for DMARD treatment in RA?
If DAS28 score is over 5.1?? or as soon as possible
Initial therapy for RA?
DMARD monotherapy +/- short course of prednisolone. DMARds should be started as soon as possible Possible options are:
Mthotrexate but must monitor FBC and LFTs for myelosuppresion and liver cirrhosis.
Sulfasalazine,
Leflunomide,
Hydroxychloroquine (only if disease is mild or palindromic disease)
What biologic drugs can be used in RA and when?
TNF alpha agents eg, infliximab, etanercept, adalimumab.
Offered when inadequate response to at least two DMARDs including methotrexate.
Can also use Rituximab
What DMARD drugs can be used in pregnancy?
Hydroxychloroquine or sulfasalazine
What are poor prognostic features of rheumatoid arthritis?
- Rheumatoid factor postitive
- Anti-CCP antibodies
- Early erosions on X rays
- Extra-articular features
- HLA DR4
Explain the diagnosis of rheumatoid arthritis
- Rheumatoid factor
- Anti-CCP antibodies
- X-rays of hands and feet
