What is rheumatoid arthritis?
- autoimmune disease associated with antibodies to Fc portion of IgG (rheumatoid actor) + anti-CCP (citrullinated cyclic peptide)
- causing chronic inflammation in synovial lining of joints
What is the pathogenesis of rheumatoid arthritis?
- citrullination of self antigens
- these are recognised by T+B cells > antibody production (RF + anti-CCP)
- stimulates macrophages + fibroblasts release TNFa
- proliferation of synoviocytes which grow over cartilage
- causing restriction of nutrients + damage to cartridge
- activated macrophages stimulates osteoclast differentiation > bone damage
Typical history of rheumatoid arthritis
- female
- 30-50 years old
- progressive, peripheral + symmetrical polyarthritis
- affecting MCPs/PIPs/MTPs + spares DIP
- history of >6 weeks for morning stiffness >30mins duration
- joint pain, stiffness + swelling
- fatigue
- improves with use
Risk factors for rheumatoid arthritis
- female
- smoking
- family history HLA DR4
- obesity
What is the pattern of rheumatoid arthritis?
Symmetrical polyarthritis
What joints does rheumatoid arthritis often affect?
MCP
PIP
MTP
What large joints can rheumatoid arthritis affect?
Ankle
Knee
Hips
Shoulders
C spine
What is found in examination of rheumatoid arthritis?
- Z shaped thumb deformity
- ulnar deviation/palmar subluxation of MCPs
- swan-neck + boutonnière deformity of digits
- rheumatoid nodules (often at elbow)
- positive squeeze test
- check median nerve - carpal tunnel association
What is swan neck deformity?
Hyperextended PIP
Flexed DIP
What is boutonnière deformity?
Hyperextended DIP
Flexed PIP
Investigations of rheumatoid arthritis
- X ray for established disease
- USS/MRI for early disease
- RF + anti-CCP
- FBC - normocytic anaemia (can cause ACD)
- inflammatory markers (CRP)
X ray features of rheumatoid arthritis
LESS
- Loss of joint space
- Erosions
- Soften tissue swelling
- Subluxation
- (see through bones - osteopenia)
Treatment of rheumatoid arthritis
- initially DMARD monotherapy - methotrexate + short course of bridging prednisolone
- consider combination DMARDs - hydroxycholorquine, sulfasalazine, leflunomide
- if still severe then consider biologics - anti-TNFs e.g. etanercept
- NSAIDs for symptoms control with PPI cover
- IM methyprednisolone for flares
- Physiotherapy + occupational therapy
What DMARDs are safe in pregnancy + which are teratogenic?
Hydroxychloroquine + sulfasalazine are SAFE
Methotrexate + leflunomide are TERATOGENIC
Who are extra-articular manifestations of rheumatoid arthritis mainly in?
RF+ patients with severe articular disease
What are extra-articular manifestations of rheumatoid arthritis?
CAPS
- Carpal tunnel syndrome
- Anaemia of chronic disease, Amyloidosis, Atlkantoaxial involvement
- Pulmonary fibrosis, Pulmonary nodules, Pleruisy, Pleural effusion, methotrexate Pneumonitis
- Sjogren’s syndrome, Splenomegaly (Felty’s syndrome)
How can rheumatoid arthritis cause spinal cord compression?
- Synovitis + damage to ligaments around odontoid peg of C2
- this allows C2 to shift within A1
- causes atlantoaxial subluxation
- this can cause spinal cord compression
What is Felty’s syndrome compromised of?
RA
Neutropenia
Splenomegaly
If a patient is allergic to sulfasalazine, what drug may they also be allergic to?
aspirin
Side effects of methotrexate
- nausea (most common)
- oral ulcers
- myelosuppression
- liver cirrhosis
- pneumonitis
- teratogenic
Side effects of sulfasalazine
- GI upset (most common)
- rashes
- orange urine
- oligospermia > male infertility
- Heinz body anaemia
- interstitial lung disease
Side effects of hydroxycloroquine
- GI distubrance (most common)
- retinopathy
- corneal deposits
- blue-grey skin pigmentation
Side effects of leflunomide
- GI upset
- liver impairment - hepatitis
- hypertension
- interstitial lung disease
- teratogenic
What monitoring is required when on methotrexate + why?
FBCs - risk of myelosuppression
LFTs - risk of liver cirrhosis
-
Drug treatment in rheumatology38
-
Rheumatoid Arthritis28
-
Systemic Lupus Erythematosus21
-
Spondyloarthropathies37
-
Gout, pseudogout + septic arthritis29
-
Oestoarthritis11
-
Raynaud’s Phenomenon12
-
Sjogren’s Syndrome15
-
Giant Cell Arteritis (temporal arteritis)10
-
Polymyalgia Rhuematica7
-
Fibromyalgia6
-
Systemic Sclerosis14
-
Vasculitis38
-
Ehlers Danlos Syndrome + Marfan’s Syndrome18
-
Antiphospholipid Syndrome8
-
Dermatomyositis + Polymyositis10
-
Osteomalacia + Osteogenesis Imperfecta12
