Rheumatoid Arthritis

Question 1

Define rheumatoid arthritis

Answer 1

Chronic inflammatory condition characterised by symmetrical deforming polyarthritis and extra-articular manifestations

Question 2

Aetiology and risk factors of rheumatoid arthritis

Answer 2

Autoimmune disease of unknown cause
Associated with LA-DR1 and DR4

Hx autoimmune e.g. Raynaud’s
Smoking (increases citrullination)
Female
Age 50-55
FHx

Question 3

Symptoms of rheumatoid arthritis

Answer 3

Symmetrical arthritis > 6 weeks (gradual | small joints | relieved with use/exercise | >1 hour)
- Proximal IPJs, knee, ankle, wrist, MTPj
Morning stiffness
Weight loss
Fever
Pleuritic chest pain

Extra-articular manifestations
Derm: Subcutaneous nodules, vasculitis rashes
Neuro: peripheral neuropathy, mononeuritis multiplex
Pulmonary: ILD, pleural effusion, serositis
Cardiac: pericarditis, myocarditis, endocarditis, increased CVD risk
Haem: Neutropenia, Felty’s syndrome, anaemia
MSK: osteoporosis
Ocular: keratoconjunctivitis sicca, episscleritis, scleritis

Question 4

Signs of rheumatoid arthritis on examination

Answer 4

Early: swelling, tenderness, warmth of PIPs/MCP, reduced range of movement, positive squeeze test

Late/poorly controlled
- Symmetrical deforming arthropathy
- Ulnar deviation at MCP
- Radial deviation at wrist
- Rheumatoid nodules (firm, painless, elbows, palms, extensor tendons)
- Vasculitic rash
- Swan neck (flexed MCP/DIP, extended PIPj)
- Boutonniere (Extended MCP/DIP, flexed PIP)
- Z deformity of thumb (CMC flexion, MP extensions, IP flexion)
- Trigger finger (Unable to straigten finger)
- Wasting of small muscles of hand
- Ulnar styloid
- Joint effusions

Question 5

Investigations for rheumatoid arthritis

Answer 5

Diagnostic criteria (American College of Rheumatology Criteria; NICE however, recommend clinical diagnosis is more important than criteria for diagnosis)

Rheumatoid factor: positive (70%)
Anti-CCP: positive (more specific)
ANA: positive (30%)
FBC: ?Felty’s - leucocytopenia, anaemia, thrombocytosis
CRP: raised
ESR: raised

X-ray joint: Narrowed joint space (more proximal) | Osteopenia, periarticular (earliest sign)| Soft tissue swelling | Erosive damage | joint deformity (latest sign)
Joint US: synovitis
MRI
CXR

Question 6

Management for rheumatoid arthritis

Answer 6

MDT

1. DMARD monotherapy
   - Methotrexate
   - Sulfasalazine (CI if allergic/hypersensitive to aspirin or sulfa-drugs)
   - Mycophenelate mofetil
   - hydroxychloroquine, cyclophosphamide, ciclosporin, azathioprine, tacrolimus, IM gold, tofacitinib, apremilast, penicillamine, Janus kinase inhibitors
   ± Glucocorticoid bridging treatment
2. DMARD combination therapy
3. Biological DMARD + conventional
   - Etanercept (TNF-alpha)
   - Infliximab (TNF-alpha)
   - Adalimumab
   - Rituximab (CD20)

Surgery: ulna stylectomy, joint prosthesis

Step up therapy when DAS (>5.1)/CRP is raised

Small joints affected, polyarthritis or S/S >3 months → refer urgently to rheum

Question 7

Management for flare ups of rheumatoid arthritis

Answer 7

Temporary steroids
1. Intra-articular (methylprednisolone/traimcinolone acetonide)
2. Intramuscular
3. PO 2-4 wks (prednisolone)

Question 8

How is rheumatoid arthritis monitored

Answer 8

CRP
Disease activity score (DAS) 28
TJC/SJC

Methotrexate → regular FBC and LFTs (risk of myelosuppression & liver cirrhosis)
Hydroxychloroquine → annual visual acuity testing, okay in pregnancy

Question 9

Complications of treatment for rheumatoid arthritis

Answer 9

Methotrexate: myelosuppression, liver cirrhosis
Hydroxychloroquine: eye
Glucocorticoid: osteoporosis, immunosuppression
TNF-alpha inhibitos: skin malignancy
NSAID: GI ulcers

Question 10

Complications of rheumatoid arthritis

Answer 10

Vasculitis, vasculitic ulcers
Anaemia
Eye: Ocular inflammation e.g. episcleritis | Keratoconjunctivits sicca (dry eye syndrome)
Neuro: Neuropathies | Carpal tunnel syndrome
Amyloidosis
Lung disease – nodules, fibrosing alveolitis, pleuritis, pleural effusion
Felty’s syndrome (triad of splenomegaly, neutropenia and rheumatoid arthritis)
Co-morbidities: CVD, depression, lymphoma (2x risk), serious infections
Cervical myelopathy or nerve root compression

Question 11

Prognosis for rheumatoid arthritis

Answer 11

Good prognosis if treated aggressively and early
Most patients achieve good disease control
Delay or untreated - disabled within 10 years, increased mortality from coronary artery disease
Flares are common even if well controlled but can be well treated with corticosteroids