Rheumatoid Arthritis

Question 1

What is rheumatoid arthritis?

Answer 1

Seropositive inflammatory condition where the synovial membrane becomes inflamed. HLA DR4 mediated.

Question 2

Causes of rheumatoid arthritis?

Answer 2

Unknown. Triggers are thought to be stress, infection and cigarette smoking.

Question 3

Pathogenesis of RA

Answer 3

Trigger causes inflammation of the synovial membrane. An inflammatory pannus (inflamed synovium) forms which attacks and denudes articular cartilage leading to joint destruction. Tendon ruptures and joint instability and subluxation may occur as a result.

Question 4

How does RA present?

Answer 4

Symmetrical synovitis
Morning stiffness
Pain
Serum Rheumatoid factor
Rheumatoid nodules on extensor surfaces (in about 25% of patients)
Hand and foot involvement is early- larger joints become affected in advanced disease.
Positive pressure tests of MCP and MTP joints

Question 5

Long term rheumatic arthritis

Answer 5

Involvement of larger joints e.g. atlas and axial cervical spine.
E.g. atlanto-axial subluxation which can compress the cervical spine

Question 6

Joints in the hands unaffected by RA

Answer 6

Distal interphalangeal.

Question 7

Tenosynovitis

Answer 7

Inflammation of tendon sheath due to synovial inflammation. Can cause trigger finger- jerky movement of finger.

Question 8

Carpal tunnel syndrome

Answer 8

Compression of the median nerve.

Question 9

Diagnosis of RA using serological testing

Answer 9

Rheumatoid remains a clinical diagnosis but these tests are used to support it-
Rheumatoid factor- 70-80% specificity.
Anti CCP antibodies-90-99% specific.

Question 10

Anti-CCP antibodies

Answer 10

Far more specific Can be present for several years without articular symptoms. Related to smoking. Absence of these does not mean absence of disease.

Question 11

Extra-articular manifestations of RA

Answer 11

Lung involvement-
Pleural effusions, interstitial fibrosis and pulmonary nodules
Cardiovascular morbidity and mortality are increased in patients with RA.

Ocular involvement is common in individuals with RA and includes keratoconjunctivitis sicca, episcleritis, uveitis, and nodular scleritis that may lead to scleromalacia.

Question 12

X-ray findings of RA

Answer 12

At the start of the disease- X-ray will probably be normal

They may show peri-articular osteopenia (bone thinning) and periarticular erosions (late in disease)

Question 13

What may MRI’s show in RA?

Answer 13

Soft tissue inflammation
Bone marrow oedema- a forerunner for erosions.
Can distinguish synovitis from effusions.
Can detect erosions earlier.

Question 14

Ultrasound scans and RA

Answer 14

Increased sensitivity for synovitis in early disease

Very good at detecting erosions (over Xray)

Question 15

How is the disease activity measured in RA?

Answer 15

Das 28 score. 
>5.1  Active disease.
3.2- 5.1 Moderate disease.
2.6-3.2-Low disease activity.
Less than 2.6 Remission

Question 16

Management of RA

Answer 16

Early recognition and diagnosis
Early treatment with disease modifying anti-rheumatic drugs- suppress the immune system.
NSAIDs and steroids as adjuncts.
patient education and multidisciplinary team involvement.

Question 17

Treatment pyramid for RA

Answer 17

Aspirin + NSAIDs + DMARD #1
if this doesnt work add DMARD #2
If this doesnt work add DMARD #3

Question 18

Why use steroids in the treatment of RA?

Answer 18

Improve symptoms and reduce radiological damage.
Not to be used as sole therapy.
IM steroid- 3 injections of 120mg of methylprednisolone every 4 weeks. (if fewer than 5 joints involved)
Could also be given orally.

Question 19

Name some DMARDs

Answer 19

Methotrexate
Sulfasalazine
Hydroxychloroquine-DOES NOT PREVENT EROSIONS.
Combination therapy with MTX,SASP and HCQ.
Leflunomide.
Gold injections,Penicillamine,Azathioprine.

Question 20

Methotrexate

Answer 20

initial drug of choice in rheumatic arthritis
Start at 15mg a week with rapid escalation.
Maximun dose is 25mg a week
Folic acid 24 hours after MTX dose.
Parenteral MTX has better bioavailability and is better tolerated.
Anchor drug for patients on biologics

Question 21

Monitoring whilst on DMARDs

Answer 21

Regular monitoring of LFTS,FBC.
Risk of pneumonitis with Methotrexate-Baseline CXR.
Important to discuss with patients regarding teratogenic effects of these drugs.Advise effective contraception.

Question 22

DMARDs can cause

Answer 22

Regular monitoring needed.
Bone marrow suppression.
Infection.
Liver function derangement.
Pneumonitis in case of methotrexate.
Avoid Sulfasalzine in septrin allergy and G6PD deficiency