rheumatoid arthritis

Question 1

what is it?

Answer 1

inflammatory autoimmune disorder characterised by symmetrical joint pain, swelling and synovial destruction

Question 2

what is the pathophysiology?

Answer 2

synovium becomes inflamed and invasive; inflammatory mediators eats away into articular cartilage and bone

Question 3

what type of hypersensitivity reaction is it driven by?

Answer 3

4

Question 4

what are the markers for it and what one is more sensitive?

Answer 4

rheumatoid factor and anti-CCP

Question 5

what is rheumatoid factor?

Answer 5

IgM or IgA binds to Fc region of IgG

Question 6

what does anti-CCP correlate with?

Answer 6

disease activity anf levels remain positive despite treatment

Question 7

how does it clinically present?

Answer 7

pain
swelling
loss of mobility

Question 8

what are characteristics of it?

Answer 8

symmetrical pain
most commonly affects PIPs/MCPs and MTPs
early morning stiffness >30min -> improves with activity

Question 9

what are the joint deformities?

Answer 9

swan neck deformity
boutonniere deformity

Question 10

what is swan neck deformity?

Answer 10

PIP hyperextension and DIP flexion

Question 11

what is boutonniere deformity?

Answer 11

PIP flexion and DIP hyperextension

Question 12

only affects vertebrae at which level?

Answer 12

C1-C2

Question 13

why does it only affect vertebral level C1-C2?

Answer 13

only joint in spine with synovium

Question 14

what are the clinical signs?

Answer 14

swelling of affected joints
positive compression test of MCP and MTP
bouchards nodes
cysts
synovitis

Question 15

what investigations are used?

Answer 15

bloods
x-ray
USS
MRI

Question 16

what will bloods show?

Answer 16

raised inflammatory markers (CRP, plasma viscosity, ESR)
presence of rheumatoid factor and anti-CCP

Question 17

what will x-ray show in early disease?

Answer 17

can be normal
may show soft tissue swelling and periarticular disease

Question 18

what will x-ray show in late disease?

Answer 18

erosions
subluxation

Question 19

what is USS useful for?

Answer 19

detecting synovial inflammation if clinical uncertainty
useful in making treatment changes

Question 20

when would you use MRI?

Answer 20

if diagnostic doubt

Question 21

what score do you need to have on diagnostic criteria to diagnose?

Answer 21

6/10 or more

Question 22

what is 1st line treatment?

Answer 22

1 DMARD +/- corticosteroid

Question 23

when should DMARDs start?

Answer 23

within 3 months of symptom onset

Question 24

what is the preferred DMARD?

Answer 24

methotrexate

Question 25

what is an alternative if methotrexate not working or can’t use?

Answer 25

hydroxychloroquine

Question 26

what is 2nd line treatment?

Answer 26

2 DMARDs

Question 27

what DMARDs are used in combination therapy?

Answer 27

methotrexate + hydroxychloroquine

Question 28

what is the rule for methotrexate in someone trying to get pregnant?

Answer 28

stop 1 month before pregnancy

Question 29

what should be given in a pregnant woman with RA?

Answer 29

folic acid and aspirin

Question 30

what is 3rd line treatment?

Answer 30

biologics

Question 31

which biologics can be used?

Answer 31

TNF-inhibitors - infliximab
B-cell depletor - rituximab

Question 32

what are complications?

Answer 32

longstanding in spine -> atlanto-axial subluxation = cervical cord compression
Felty’s syndrome
Caplan’s syndrome

Question 33

what is felty’s syndrome triad?

Answer 33

RA
neutropenia
splenomegaly