Rheumatoid arthritis

Question 1

What is the aetiology of rheumatoid arthritis?

Answer 1

• It is an autoimmune disease of unkonw aetiology
• It is characterised by persistent joint synovial tissue inflammation
• Most common autoimmune disease in Australia and second most common arthritis
• Genetic predisposition and smoking are considered triggers

Question 2

What are the symptoms of rheumatoid arthritis?

Answer 2

Symptoms-

• Insidious onset of stiffness and pain of the small joints of the hands and feet
• Joint involvement is symmetrical
• Morning stiffness, rest stiffness and pain relieved with activity
• MAlaise, weakness, weight loss and fatigue can be features
• Bimodal peak is noted, more common in females
• Pain is persistent and most commonly affects MCP and PIP in the hands, wrist and elbows, shoulder, C spine, TMJ, hips, knees, ankle,MTP and tarsal joints

Question 3

What is the revised criteria for diagnosis of RA?

Answer 3

• Symptom duration of >6 weeks
• Early morning stiffness of > 1 hour
• Arthritis in 3 or more regions
• B/L compression tenderness of MTP
• Symmetry of the affected areas
• RF positivity
• Anti CCP positivity
• Bony erosions evident on radiographs of the hands or feet in advanced disease

Question 4

What are the common deformities in RA?

Answer 4

• Deformity, sublucation, instability or ankylosis
• Swan neck deformity, buotonnieres, z deformity and ulnar deviation

Question 5

What are the extra-articular manifestations of RA?

Answer 5

• Anaemia
• Eye inflammation
• Sjogrens syndrome
• Pericarditis and myocarditis
• Lymphadenopathy
• Pleural effusion, fibrosing alveolitis and nodules in lung
• Splenomegaly
• Amyloidosis in the kidneys
• Vasculitis
• Raynauds and bursitis

Question 6

What are the investigations for diagnosis of RA?

Answer 6

• Raised ESR or CRP
• RF positivity and anti-CCP positivity

Question 7

What are the differential diagnosis of RA?

Answer 7

• Infective arthritis (fever and rash)
• Reactive arthritis (post throat, sexual and gut
• Other inflammatory arthritis such as psoriasis)
• Crystal arthropathies including gout
• Connective tissue diseases such as SLE and Raynauds
• Metabolic causes

Question 8

What are the Ix used in differentiating RA from other forms of arthritis?

Answer 8

• ESr and CRP
• RF and anti-CCP
• ANA
• Urate levels
• Syovial fluid analysis
• X Rays of affected parts

Question 9

What are the prognostic indicators for monitoring RA?

Answer 9

• Activity limitations and co-morbidities including ones for cardiovascular disease
• Number of swollen and tender joints
• Extra-articualr manifestations
• FBC/UEC/fadting lipids, glucose, LFT, X Ra chest and joints and urinalysis

Question 10

What are the general principles of management?

Answer 10

• Diagnosis is generally distressful; patient and the family need need careful explanation on the treatment, monitoring and follow-up
• DMARDS from outset is recommended and hence needs early referral to the specialist and team arrangements
• Fully assess the functionsl impairment
• Review patient regularly, monitor progress and impairments
• Rest and splints in acute flare-ups, regular exercise like walking, smoking cessation, physio referral and diet low in animal fats are beneficial

Question 11

What is the role of DMARDs in the management of RA?

Answer 11

• Early and aggressive therapy with DMARDS is indicated
• Commonly used DMARDS include immunosuppressants such as azathioprine, cyclosporin and methotrexate; biological DMARDs such as etanercept, infliximab, rituximab and abatacept
• Biological DMARDS are used if conventional ones are ineffective

Question 12

What are the monitoring guidelines and side-effects when managing with DMARDS?

Answer 12

• Methotreaxate is first line; sulfasalazine or leflunamide used when methotrexate contraindicated
• Methotrexate is a weekly dose (5-10mg weekly) and given with folic acid daily; FBC and LFTs atleast monthly
• Hydroxychloroquine and sulfasalazine safely used in pregnancy; potential fathers and females intending to get pregnant should stop using methotrextae at least 3 months before planning pregnancy
• Alcohol rises the risk of cirrhosis when used with methotrexate
• Adverse effects of DMARDS in general include anaemia, liver damage, lung disease and death

Question 13

What are the other pharmacological options?

Answer 13

• NSAIDS are effective but side effects are issues
• Fish oil has been shown to reduce symptoms and need for NSAIDs
• Oral glucocorticosteroids should be considered in severe disease as a temporary adjunct to NSAIDs