Rheumatoid arthritis Flashcards
How does RA typically present?
Symmetrical swollen, painful snd stiff small joints in the hands and feet.
It is worse in the morning.
Can fluctuate and larger joints may become involved.
What are the less common presentations of RA?
- Sudden onset, widespread arthritis
- Recurring mono/polyarthritis of various joints (palindromic RA)
- Persistent monoarthritis (often hip, shoulder or knee)
- Systemic illness with extra-articular symptoms e.g. fatigue, fever, weight loss, pericarditis, pleurisy but initially few joint problems (more common in men)
- Polymyaligic onset - vague limb girdle aches
- Recurrent soft-tissue symptoms e.g. frozen shoulder, carpal-tunnel syndrome, de Quervain’s tenosynovitis
What is the epidemiology of RA?
Prevalence roughly 1% - increased in smokers
M 1:2 F
Peak onset in 50s 60s
Increased severity linked with HLA DR4/1
What are the early signs in RA?
These are due mostly to inflammation without joint damage
- swollen MCP, PIP, wrist or MTP joints. Symmetrical.
- Tenosynovitis and bursitis
What are the late signs of RA?
Joint damage and deformity
- ulnar deviation of fingers
- dorsal subluxation of wrist
- Boutonierre and swan-neck deformities of fingers
- Z deformity of the thumb
- hand extensor tendons may rupture
- foot changes are similar
- large joints can be involved
- atlanto-axial subluxation may compromise the spinal cord (rare)
What are the extra-articular signs of RA?
- nodules on elbows and in lungs
- lymphadenopathy
- vasculitis
- fibrosing alveolitis
- obliterative bronchiolitis
- pleural and pericardial effusion
- Reynaud’s syndrome
- carpal tunnel syndrome
- peripheral neuropathy
- splenomegally (5%)
- episcleritis
- sceritis
- scleromalacia
- keratoconjunctivitis sicca
- osteoporosis
- amyloidosis
What investigations should be undertaken in a case of suspected RA?
- Rheumatoid factor (present in about 70%), a high titre is associated with severe disease, erosions and extra-articular disease
- Anticyclic citrullinated peptide anti bodies antiCCP are 98% specific
- Often anaemia of chronic disease
- Increased platelets, ESR and CRP due to inflammation
- X-ray
- ultrasound +MRI
What would you see on x-ray?
Show soft tissue swelling, juxta-articular osteopenia and decreased joint space. Later may see bony erosions, subluxation and complete carpal destruction
What is at the advantage of US and MRI?
Can identify synovitis more accurately and have greater sensitivity in detecting bone erosions than X-ray
Who should be tested for RA?
Those with 1 or more joints with definite swelling which is not better explained by another disease…
What are the diagnostic criteria for RA?
Total A-D score, 6 or more out of 10 are diagnostic
A) Joint involvement: swelling or tenderness with imaging evidence
B) Serology: RF and antiCCP
C) Acute phase reactants: CRP and ESR
D) Duration of symptoms: Less or more than 6 weeks
What are DMARDs and how are they used in RA?
Disease-Modifying Antirheumatic Drugs
They are the first line treatment. Ideally started within 3 months of persistent symptoms.
Can take 6-12 weeks for symptomatic benefit
Best results are often achieved with a combination:
Methotrexate + Sulfasalazine + Hydroxychloroquine (others include leflunomide and IM gold)
What is a major side-effect of DMARDs?
Immunosuppression
Can be potentially fatal, resulting in pancytopenia, increased risk of infection and neutropenic sepsis
What are the side-effects of the DMARDs?
1) Methotrexate - penumonitis, oral ulcers, hepatotoxicity
2) Sulfasalazine - rash, reduced sperm count, oral ulcers
3) Leflunomide - teratogenicity, oral ulcer, increased BP, hepatotoxicity
4) Hydroxychloroquine - irreversible retinopathy
What are the other biological agents used and their nice guidance?
1) TNF-alpha inhibitors
- Infliximab, etanercept, adalimulab, certolizumabpegol, golimumab.
- All approved by NICE, usually in combination with methotrexate, as 1st line agents for active RA after FAILURE to respond to 2 DMARDs.
- Clinical response can be striking
2) B-cell depletion
- e.g. rituximab
- Used in conjunction with Methotrexate in severe active RA
- Indicated when DMARDs and TNF-alpha blockers have failed
3) IL-1 and IL-6 inhibition
- e.g. Toclizumab (IL-6)
- Used in conjunction with methotrexate for patients where both TNF-alpha and rituximab have failed
- Less clinical improvement that other agents
4) Disruption of T-cell function
- e.g. Abatacept
- Used infrequently for patients who haven’t responded to DMARDs, TNF-alpha blockers and rituximab
