Rheumatoid arthritis

Question 1

What are the typical features in the history and examination in RA?

Answer 1

Polyarticular
Symmetrical joint involvement
Better with exercise and worse with rest
Signs of inflammation swelling, pain, erythema, limited ROM
MCP, PIP hand involvement (OA usually involves the CMC, DIP and assymetrical)
pain worse with rest and better with exercise
stiffness lasting more than 1 hour
smoking
Recent infection gastronenteritis, genitourinary symptoms
Dry mouth, dry eyes, raynauds phenomenon, mouth ulcers.
Systemic symptoms ie weight loss, fever, night sweats.

Question 2

List out 10 causes of inflammatory polyarticular arthritis?

Answer 2

RA 
Sjorgrens
Psoariatic arthrits 
Viral reactive arthritis ross river, hep B/C, parvovirus. barmah forest virus. 
Reactive arthritis 
Crystal arthropathy gout and pseudogout
sarcoid, paraneoplastic syndrome.

Question 3

What investigations are useful in suspected RA?

Answer 3

FBC for WCC
EUC, LFT 
ESR/CRP for active inflammation. 
RF - poor specificity
Anti CCP - predictive for erosive disease. more specific.
Xrays of affected joints 

Consider the following in additional symptoms
ANA if suspect other auto immune causes ie sjorgrens disease.
ACE if suspect sarcoid
Hepb/C and parvovirus serology if symptoms for less than 6 weeks.
CXR if suspect sarcoid
Serum uric acid level if suspect gout
Synovial fluid analysis.

Question 4

How can GP monitor disease activity for a patient diagnosed with RA?

Answer 4

Duration of morning stiffness
number of tender and swollen joints
visual analogue scale
ESR and CRP
Functional scale

Question 5

What side effects of methotrexate as a GP do you need to be aware of?

Answer 5

Hepatotoxity
Alcohol consumption needs to be minimised or avoided.
Photosensitivity
compliance with medication - due to dosing errors.
contraception and teratogens.
avoid use with trimethoprim - as it is a folate antagonist.
careful with live vaccines - discuss with rheaumatologist
discuss cardiovascular risk.