Rheumatoid Arthritis Flashcards by Georgia Leggett

What is RA?

Chronic systemic inflammatory AI disorder primarily affecting joints

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Describe epidemiology of RA

Common, ~1% of UK
Peak onset 30-50y
F > M

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List 3 risk factors for RA

Genetic disposition: HLA-DR4 + HLA-DR1
FH
Smoking

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What are the typical presenting symptoms of RA?

Symmetrical pain + swelling of joints in hands + feet
Morning stiffness >30 mins

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Which joints are most commonly affected in RA?

Metacarpophalangeal (MCP)
Proximal interphalangeal (PIP)
Metotarsophalangeal (MTP)

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Describe the pain in RA

Worse at rest + or during periods of inactivity

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Describe the swelling in RA

Around joint (not bone swelling) giving a ‘boggy’ feel on palpation

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List 4 hand deformities that may be seen in advanced RA

Swan neck deformity: PIP hyperextension + DIP flexion
Boutonniere deformity: PIP flexion + DIP hyperextension
Z-deformity of the thumb: hyperextension of IPJ with fixed flexion of MCP
Ulnar deviation of fingers

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What deformity of the cervical spine may occur in RA?

Atlantoaxial subluxation

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What test can be performed on examination in RA?

Metacarpophalaneal squeeze test
Pain on squeezing metacarpophalangeal / metatarsophalangeal joints together

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Describe onset of RA

Variable
Most: insidious onset
Some: rapid or relapsing-remitting course

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List 3 ways RA may present in addition to joint synovitis

Rheumatoid nodules
Extra-articular features
Systemic features

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What are rheumatoid nodules?

Hard, firm non-tender swellings over extensor surfaces

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List 4 systemic symptoms of RA

Malaise + Fatigue
Fever
Night sweats
Weight loss

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List 4 extra-articular systems of RA

Vasculitis
Lungs
Eyes
Heart

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List 3 ocular manifestations of RA

Keratoconjunctivitis sicca (most common)
Scleritis (erythema + pain)
Episcleritis (erythema)

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Name 3 lung manifestations of RA

Pulmonary nodules
Pleuritis
Interstitial lung disease

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Name 2 vasculitic manifestations of RA

Raynauds
Peripheral vasculitis manifests as lived reticularis

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Name 3 cardiac manifestations of RA

Pericarditis
Myocarditis
Increased risk MI, stroke, CHF

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Describe diagnosis of RA

Clinical diagnosis supported by bloods + imaging

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What investigations are performed for RA?

Bloods
X-rays of hands + feet

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Which bloods are performed for RA?

FBC, U+Es, LFTs
Rheumatoid factor
Anti-CCP
Anti-nuclear antibodies
CRP + ESR: usually raised

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What is the first line antibody test for RA?

Rheumatoid factor (RF)
Usually IgM that reacts with Fc portion of own IgG
+ve in 60-70% of RA

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What are high titres of RF associated with in RA?

Severe progressive disease
(NOT a marker of disease activity)

List 5 conditions with positive RF other than RA

Felty's syndrome Sjogren's syndrome Infective endocarditis SLE Systemic sclerosis

Which antibody can be detected up to 10y before development of RA?

Anti-cyclic citrullinated peptide antibody

Describe the sensitivity and specificity of anti-CCP

Sensitivity ~70% Specificity 90-95%

What are 2 early x-ray features seen in rheumatoid?

Juxta-articular osteoporosis/ osteopenia Soft-tissue swelling

List 3 late x-ray changes in RA

Loss of joint space Periarticular erosions Subluxation

Which imaging modalities may be more informative in early RA?

US or MRI Higher sensitivity for detecting early signs of inflammation Typical RA findings on XR may be subtle/ absent

Describe management of acute flares of RA

Intra-articular methylprednisolone acetate or IM methylprednisolone or PO Prednisolone

Describe initial long term management of RA

DMARD mono therapy +/- short term bridging Prednisolone

What is the most common first line DMARD used in RA? What monitoring is required?

Methotrexate once weekly Monitoring FBC + LFTs essential due to risk of myelosuppression + liver cirrhosis + Folic acid supplementation to minimise adverse effects

What monitoring is required when using methotrexate?

1. 2 weekly 2. Once on stable dose for 6w: once monthly for 3/12 3 monthly + Baseline CXR + Lung function tests

Name an important side effect of methotrexate

Pneumonitis

What is the treatment for Methotrexate toxicity?

Folinic acid

Which drugs should be avoided concurrently whilst taking methotrexate? Why?

Trimethoprim + co-trimoxazole (anti-folate abx) Risk of bone marrow aplasia due to additive folate depletion -> Fatal pancytopenia + megaloblastic anaemia

Name 3 alternative DMARDs to methotrexate for RA

Sulfasalazine Leflunomide Hydroxychloroquine (mild or palindromic disease)

How is response to treatment monitored?

CRP + disease activity score (DAS28)

When is TNF-inhibitor therapy indicated for RA?

Inadequate response to at least 3 DMARDs inc. methotrexate

List 3 TNF inhibitors used in RA

Etanercept (SC) Infliximab (IV) Adalimumab (SC)

Other than TNF inhibitors, which biological DMARDs can be used in RA

Rituximab (Abatacept; not currently recommended by NICE)

What is Felty's syndrome?

RA Splenomegaly Low WCC

List 3 side effects of methotrexate

Myelosuppression Liver cirrhosis Pneumonitis

List 4 side effects of sulfasalazine

Rashes Oligospermia Heinz body anaemia Interstitial lung disease

List 3 side effects of Leflunomide

Liver impairment Interstitial lung disease HTN

List 2 side effects of hydroxychloroquine

Retinopathy Corneal deposits

List 5 side effects of Prednisolone

Cushingoid features Osteoporosis Impaired glucose tolerance HTN Cataracts

Give 1 side effect of Gold

Proteinuria

Name 2 side effects of Penicillamine

Proteinuria Exacerbation of myasthenia gravis

Name 2 side effects of Etanercept

Demyelination Reactivation of TB

Name a side effect of Infliximab

Reactivation of TB

Name a side effect of Adalimumab

Reactivation of TB

Name a side effect of Rituximab

Infusion reactions are common

Name 2 side effects of NSAIDs

Bronchospasm in asthmatics Dyspepsia/ peptic ulceration

Which drugs for RA are safe during pregnancy?

Prednisolone Hydroxychloroquine Sulfasalazine

List 8 poor prognostic factors in RA

RF +ve Anti-CCP antibodies Poor functional status at presentation X-ray: early erosions (e.g. after < 2y) Extra articular features e.g. nodules HLA DR4 Insidious onset Female

What classification is used for research purposes (not diagnostically) in RA?

ACR/ EULAR classification criteria High specificity but low sensitivity Does not account for early disease/ predominant extra-articular manifestations Can diagnose RA w/o fulfilling