Rheumatoid Arthritis

Question 1

What is the typical clinical picture of a patient with RA?

Answer 1

Pain and stiffness in synovial joints
Inflammation of tendon sheaths in symmetrical distribution

Reduction in grip strength due to inability to make fists

Rapid onset
Swelling of affected joints
Prolonged early morning stiffness (the more they move, it gets better)

In terms of the spine, only C1/C2 can be affected by RA

Question 2

What are typical features of both early and advanced RA?

Answer 2

Synovium thickening due to inflammation –> secondary: cartilage degradation

Question 3

What are the extra-articular manifestations of RA?

Answer 3

Interstitial Lung Fibrosis
Caplan Syndrome (lung nodules)
Episcleritis

Increased risk of CVS mortality and morbidity
Osteoporosis

Question 4

How is RA diagnosed? How to interpret relevant special investigations?

Answer 4

• Thorough history and clinical examination (S factors)
  *Prolonged morning stiffness
  *Small joints of hands and feet
  *Symmetric distribution
  *Positive compression test of metacarpophalangeal & metatarsophalangeal joints
• Inflammatory markers (CRP, plasma viscosity/ESR)
• Autoantibodies
  *Rheumatoid factor (moderate sensitivity/specificity)
  *Anti-CCP antibodies (higly specific - if you are positive you almost certainly have the disease; but 30% do not have these antibodies - low sensitivity)
  - does not go away with treatment, so not a
  recovery indicator
• Imaging (X-ray; Ultrasound - better than X-ray, especially with early disease; MRI - gold standard)

Question 5

How to manage RA?

Answer 5

• Early recognition, diagnosis and treatment (opportunity window: first 12 weeks after diagnosis)
• Disease modifying anti-rheumatic drugs (DMARDS) + short-term glucocorticoid
  eg. Methotrexate (first choice) - orally/subcutaneously, used in combination, teratogenic
  *Side effects: bone marrow suppression, infection, lung function derangement, pneumonitis, nausea
• “Tight control”: monthly visit, measure DAS28 (aim for a low score), modify drugs correspondingly

Question 6

What is RA and what is the pathogenesis of RA?

Answer 6

Symmetrical peripheral joint polyarthritis, affecting synovial joints and tendon sheaths

Genetically-related condition

Primary trigger: citrullation (arginine converted to citrulline –> protein unfolding due to loss of charge –> form antigen) leading to activation of anti-CCP antibodies –> inflamed synovium
RF: cigarette smoking some point during life (promote citrullation), infection

Question 7

What is an assessment for RA disease activity?

Answer 7

DAS28 score
28 joints, excluding distal interphalangeal joints

Question 8

What are some biologics available for RA and who gets them in UK?

Answer 8

Anti-TNF agents and JAK inhibitors

Criteria: tried to DMARDs and DAS28 > 3.2

Question 9

Why might RA patients have anemia?

Answer 9

60% of RA patients have anemia, the most common form is anemia of chronic disease

ACD pathogenesis - low iron level in blood, high in storage; affected erythropoietin

Another form is iron-deficiency anemia, due to loss of blood. This might be a complication of NSAIDs.