rheumatoid arthritis

Question 1

What should I know about RA epidemiology? gender, race, geography, incidence and severity

Answer 1

relatively rare (o.4/1000 in women; 0.2/1000 in men)
more in women than men
more in northern America and Europe than southern europe
high incidence in some native american pops
incidence and deverity have been declining

Question 2

What should I know about RA age?

Answer 2

the pop in peak productive yrs are most affected
ppl with RA miss lots more work than ppl without.
early treatment is important for adding quality yrs to life

Question 3

RA: risk factors (genetics and modifiable)

Answer 3

genetics: 2-4 ofld incr. risk in siblings
may be genetics or background
association with HLA-DR4
12% concordance in monozygotic twins
smoking increases the risk

Question 4

What are some key features of RA in hx and PE

Answer 4

morning stiffness, arthritis of 3 or more joint areas, arthritis in hand joints, esp. wrist, MCP, or PIP, symmetric arthritis, rheumatoid nodules (over bony prominences or extensor surfaces like fingers and elbows). may see painful, red, tender, warm joints

Question 5

What are some key features of RA in labs?

Answer 5

increase in RF, or anti-CCP (also see high ESR and CRP). must make sure they are hepatitis negative- hep positivity can cause false positive RF and can cause problems with current RA treatments

Question 6

What can MRI do for RA?

Answer 6

show synovitis, tenosynovitis, bony erosions, bone marrow edema. rarely used due to high costs.

Question 7

Changes that might be seen in chronic RA

Answer 7

boutonniere deformity, swan neck deformity, severe ulnar deviation, bilateral hammer toe formation that puts a lot of pressure on metatarsal heads and causes callous formation/foot pain

Question 8

What are some systemic manifestations of RA?

Answer 8

pericarditis, pleuritis, secondary sjogren’s, pulmonary fibrosis, tenosynovitis, Baker’s cyst (swelling of bursa behind knees), LAD, anemia of chronic disease, secondary amyloidosis

Question 9

What is the pathogenesis of RA?

Answer 9

there is a proliferation of synovial lining tissue and neoangiogenesis. this causes invasion of the subchondral bone, degradation of cartilage,a nd narrowing of the joint spaces. the granulation tissue/invasive synovial lining = pannus
involves TNF-alpha, IL-1, IL6
considered type III or IV hypersensitivity

Question 10

radiographic findings in RA

Answer 10

radiographic changes like erosions or bony decalcifaction, joint space narrowing, periarticular ospteopenia. no new bone formation or bone spurs.

Question 11

Ultrasound imaging in RA

Answer 11

can show prolif of synovial lining cells; can show synovial hyperemia (extra blood flow)

Question 12

what are the goals of tx for RA?

Answer 12

restore function, prevent joint damage, prevent extra-articular complications; decr local and systemic inflammation, decr. swelling and stiffness of jts; improve fatigue

Question 13

tx for RA: non-specific

Answer 13

non-specifics: NSAIDs and corticosteroids

Question 14

tx for RA: disease modifying meds

Answer 14

methotrexate, sulfasalazine, hydroxychloroquine

Question 15

tx for RA: biologics

Answer 15

TNF-alpha inhibitors (mainstay), IL-1 receptor antagonist, IL-6 antagonist, B cell antagonist, antagonists of co-stimulatory signals.