Rheumatoid arthritis

Question 1

symptoms

Answer 1

of inflammation
- Pain, swelling, early morning stiffness lasting longer than an hour ; as day goes on gets better
rapid onset
Cant make fists

Question 2

who might get it

Answer 2

anyone
men and women both affected however 3;1 ratio of women

Question 3

main structure involved

Answer 3

synovium

Question 4

triggers

Answer 4

infections and smoking

Question 5

what type of arthritis is it

Answer 5

chronic symmetrical poly arthritis; affects more than 5 joints

Question 6

can it affect systems outwith joints

Answer 6

yes

Question 7

triggers

Answer 7

infections and cigarette smooking

Question 8

what does the severity depend on

Answer 8

genetic factors and presence of auto antibodies

Question 9

what is raised in the blood

Answer 9

inflammatory markers, autoantibodies such as rheumatoid factor

Question 10

what can be used for short term sympomatic relief

Answer 10

Analgesics, NSAIDs and steriods can be used short term for symptomatic relief

Question 11

DMARDS

Answer 11

disease modifiying anti - rheumatic drugs

Question 12

when do give dmards

Answer 12

within 3 months of symptom onset

Question 13

what is first line drug

Answer 13

oral methotrexate

Question 14

examples of DMARDS

Answer 14

Methotrexate
hydroxycholorquine
sulfasalazine
leflunomide

Question 15

second line drugs

Answer 15

Biological disease modifying anti-rheumatic drugs (bDMARDs

Question 16

examples of bdmards

Answer 16

anti-tnf agents and t cell receptor blockers

Question 17

when to give bdmards

Answer 17

if have tried 2 DMARDs and patient still has DAS28 score > 5.1

Question 18

DAS28

Answer 18

a measure of disease activity in rheumatoid arthritis (RA). DAS stands for ‘disease activity score’, and the number 28 refers to the 28 joints that are examined in this assessment

Question 19

what additional med do patients with rheumatoid arthritis require

Answer 19

• Patients on DMARDs should receive theannual influenza vaccineand thepneumococcal vaccine every 5 yearsas per the schedule (neither vaccine is live)
• Patients aged over 50 years should receive thezoster vaccinationbefore starting bDMARDs or tsDMARDs

Question 20

clinical features

Answer 20

polyarhralgia; pain in many joints
- Early morning stiffness > 30 mins that usually improves with activity
- Reduction in grip strength
- Joint deformities (‘rheumatoid hand’)
- Swan neck deformity: PIP hyperextension and DIP flexion
- Boutonniere deformity: PIP flexion and DIP hyperextension
- Atlanto-axial subluxation

Question 21

extra articular manifestations

Answer 21

• Constitutional symptoms: low-grade fever, myalgia, malaise, fatigue, weight loss, night sweats
• Lungs: interstitial fibrosis, pneuomconiosis (Caplan syndrome), rheumatoid lung nodules, pleuritis, pleural effusions
  
  • Fibrosis in RA has a predominance for the lower lobes
• Heart: pericarditis, myocarditis, increased risk of CVD
• Skin: pyoderma gangrenosum, Raynaud’s phenomenon, rheumatoid skin nodules
• Eye: keratoconjunctivitis
• Other MSK: osteopenia/osteoporosis, Sjogren syndrome

Question 22

how might rheumatoid arthritis begin

Answer 22

Those with hla dr1 and dr4 may interact with smoke from cigarette/ pathogen causing modification of own anitgen such as IgG and type 2 collagen

Question 23

hwo might type 2 collagen be modified

Answer 23

via citrullination when arginine is converted to citrulline
immune cells get confused and no longer recognise as self antigens

Question 24

how does inflammation in the joint space occur

Answer 24

helper cells and antibodies enter circulation and reach joints where they recruit more cells

Question 25

what happens once synovial cells are activated

Answer 25

activated via cytokines etc
create a pannus; thick synovial membrane made of aggressive macrophage- and fibroblast-like mesenchymal cells, macrophage-like cells and other inflammatory cells that release collagenolytic enzymes

Question 26

what does chronic inflamamtion cause

Answer 26

angiogenesis; formation of new blood vessels around the joint causing more inflammation

Question 27

what does the pannus produce

Answer 27

proteases whcih wear down the protein in cartilage

Question 28

is methotrexate safe in pregnancy

Answer 28

no