Rheumatoid Arthritis

Question 1

What is Rheumatoid arthritis

Answer 1

RA is a chronic, progressive, systemic inflammatory disease characterized by:

Destruction of synovial joints with loss of cartilage and bone
Damage to ligaments and tendons
Loss of physical function and decreased quality of life
Disability and underemployment

Question 2

Targeted population for the New RA Diagnostic Criteria August 2010

Answer 2

Patients who

1) have at least 1 joint with definite clinical 	synovitis (swelling)
2) with the synovitis not better explained by 	another disease

Question 3

Classification of RA

Answer 3

score-based algorithm: a score of 6/10 is needed for classification of a patient as having definite RA
4 domains: number and location of synovitis, serologic abnormality, elevated acute phase reactants, symptom duration (now 6 weeks)

Question 4

4 domains that are assessed in diagnostic tree for RA

Answer 4

Number and location of joints
Presence or absence of serological markers, RF anti-CCP
Duration of symptoms now cut down to six weeks from 3 months
Presence of elevated acute phase reactants

Question 5

Locations of RA

Answer 5

In RA the DIPJs are not affected and in contrast the MCPJs are affected. An area that is frequently affected are the wrists and shortening of the intercarpal space is common.
MCP and PIP of the index and the long finger are mc in RA
Foot the 4th and 5th MTPJ

Question 6

RA risk factors

Answer 6

Current Smoking

Genetics: Family history confers risk (accurate)
HLA-DRB4 (we do not measure)
Other genetic markers (clinically we do not measure)

Female sex

Age

Question 7

Erythrocyte Sedimentation Rate (ERS) Lab value for RA

Answer 7

Male = age / 2
Female = (age + 10) / 2

		  Causes of elevated ESR
			Infection
			CTD
			Malignancy
			Pregnancy
			Anemia
			Obesity
			Other
**non specific

Question 8

C-Reactive Protein Quantative Lab value

Answer 8

Male = age / 50
Female = age / 50 + 0.6
Rises and falls more quickly than ESR

can be elevated in obesity, diabetes, malignancy, and cigarette smoking and heart disease.

Rises in about 4-6 hours in response to tissue injury and will normalize within the week once the inflammation has abated

Question 9

Rheumatoid Factor

Answer 9

RF not used to measure RA disease activity, but higher titers can be associated with disease severity, erosions, extra-articular manifestations, disability

Not diagnostic
5% have false positive

Question 10

Anti-Cyclic Citrullinated Peptide Antibodiesanti-CCP

Answer 10

RA sensitivity—47-76%
specificity—90-96%

Can occur in active TB, SLE, Sjogren’s, Polymyositis, Dermatomyositis, Scleroderma

If (+) CCP progressive radiographic joint damage

Question 11

Radiographic studies with RA

Answer 11

X-rays– standard of care

Ultrasound

Magnetic Resonance Imaging

Question 12

Findings with X-rays

Answer 12

ulnar drift in hands
Symmetrical narrowing
Wrists/MCP/PIP
Mouse bite erosions
Soft and squishy
Pseudocystic
Can be present
Osteopenia

Question 13

Early radiographic progression in RA

Answer 13

Joint-space narrowing and erosion are seen in 67% of patients within the first 2 to 5 years of disease

Question 14

DMARD Pharmacologic Therapy

Answer 14

Corticosteroids– prednisone, methylprednisilone
Hydroxychloroquine– Plaquenil™
Sulfasalazine – Azulfidine™
Methotrexate Journal of Rheumatology July 18, 2010 “anchor drug”
Leflunomide – Arava™
Azathioprine – Imuran™

Question 15

Biologic Response Modifiers Targets

Answer 15

TNF inhibitors
	Etanercept (Enbrel™)
	Infliximab (Remicade ™)
	Adalimumab (Humira™)
	Golimumab (Simponi™)
	Certolizumab pegol (Cimzia™)
B cells
	Rituximab (Rituxan™)
T cells
	Abatacept (Orencia ™)
IL-6	
	Tocilizumab (Actemra™)

Question 16

Biologic Response Modifiers Pre drug screening

Answer 16

CXR
	PPD
	Pneumovax
	Influenza vaccine
	Hepatitis serologies B and C

Question 17

Biologics BRMs Side effect profile

Answer 17

Injection site/infusion reaction
Infection risk (bacterial, TB/other granulomatous, opportunistic, i.e. fungal)
?Malignancy risk
Demyelinating Ds, MS or Family Hx
Heart failure
Drug induced syndromes (ANA, dsDNA)
Cytopenias

Question 18

When to refer to a rheumatologist

Answer 18

Uncertain diagnosis refer early

Confusing lab results

Uncomfortable with DMARD use

Considering use of a biologic

Patient not responding

Erosions or other radiographic changes

Question 19

Take home points for RA

Answer 19

A careful history and physical can help you separate the difference between inflammatory and non-inflammatory arthritis.

• Appropriately selected laboratory tests, joint arthrocentesis, and selected imaging studiescan significantly aid in diagnosing persons with joint pain.
• Early treatment and/or referral for those with inflammatory arthritis is essential.
• Pts with RA and likely AS and PsA have higher risks for CVS disease and should be monitored annually.