Rheumatoid Arthritis

Question 1

At what age is the peak onset of RA?

Answer 1

30-50 years.

It can occur in all age groups

Question 2

What is the prevalence?

Answer 2

1%

Question 3

What is the ratio of females to males that get it?

Answer 3

3:1

Question 4

What ethnicity is it high in?

Answer 4

Native Americans

Question 5

What human leucocyte antigen is it associated with?

Answer 5

HLA-DR4

Question 6

What condition is RA associated with?

Answer 6

Felty’s syndrome

Characterized by the combination of rheumatoid arthritis, splenomegaly and neutropenia. The condition is more common in those aged 50-70 years, and is more prevalent in females than males and more in Caucasians than blacks.

Question 7

If a patient has newly diagnosed active RA, what does the NICE 2009 guidance recommend?

Answer 7

Start a combination of 2 x DMARDS (1 being Methotrexate) + Short Term glucocorticoids.

Question 8

What are some side effects of methotrexate?

Answer 8

• Myelosuppression
• Liver cirrhosis
• Pneumonitis

Question 9

Name 3 other DMARDs apart from methotrexate.

Answer 9

• Sulfasalazine
• Leflunomide
• Hydroxychlroquine

Question 10

When are TNF-inhibitors indicated?

Answer 10

There is inadequate response to at least two DMARDs including methotrexate.

Question 11

Name 3 DMARDs

Answer 11

1. Etanercept - can cause demyelination.
2. Infliximab
3. Adalimumab.

Question 12

What are some common extra-articular side effects of RA?

Answer 12

• Respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy
• Ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, chloroquine retinopathy
• Osteoporosis
• Ischaemic heart disease: RA carries a similar risk to type 2 diabetes mellitus
• Increased risk of infections
• Depression

Question 13

What are 2 less common extra-articular complications of RA?

Answer 13

• Felty’s syndrome ( RA + Splenomegaly + low white cell count)
• Amyloidosis

Question 14

What is associated with a poor prognosis?

Answer 14

• Female Gender
• RF positive
• Poor functional status at presentation
• HLA DR4
• X-ray: early erosions (e.g. after < 2 years)
• Extra articular features e.g. nodules
• Insidious onset
• Anti-CCP antibodies

Question 15

NICE recommends, that if you think someone has RA, but they are RF negative. What further auto-antibody should you do?

Answer 15

Anti-CCP

Question 16

How long before RA develops, can anti-cyclic citrullinated peptide antibody be detected?

Answer 16

Anti-cyclic citrullinated peptide antibody may be detectable up to 10 years before the development of rheumatoid arthritis.

Question 17

How does Anti-CCP antibodies compared to RF in terms of specificity and sensitivity?

Answer 17

It has a sensitivity similar to rheumatoid factor (70-80%, see below) with a much higher specificity of 90-95%.