Rheumatoid Arthritis

Question 1

Define Rheumatoid Arthritis

Answer 1

Chronic inflammatory autoimmune disease characterised by inflammation of synovial joints

• Leads to joint & periarticular destruction
• Also causes extra-articulate features

Question 2

What is the epidemiology of RA?

Answer 2

• 1% Prevalence
• Peak = 30-50 yrs
• Native americans ++
• F:M = 3:1

Question 3

What are the risk factors to RA?

Answer 3

Rheumatoid factor
Diabetes mellitus
Smoking
Obesity

High birth weight
Onset more common in winter
Silica exposure

Question 4

What is the pathology of RA?

Answer 4

SYNOVITIS
1. Inflammatory cells infiltrate synovium ==> proliferation
2.Chronic inflamed tissue extends form joint margins
3. Erosion of articulate cartilage ==> bone erosion
=JOINT DESTRUCTION

Question 5

What are symptoms of articular features of RA?

Answer 5

• Joint pain
• Morning stiffness >45mins (or after gelling)
• Swelling - Boggy, erythema, warmth, movement limitation
• Joint involvement = symmetrical

Question 6

How do articular features of RA usually progress?

Answer 6

• Onset = weeks to months

- Progress = most rapid in 1st 6 years, 80% have permanent joint abnormality in 10 yrs

Question 7

Which joints are commonly affected in RA?

Answer 7

MOST: 2nd + 3rd metacarpophalengeal joints (MCP) + wrists + feet MTP joints

OTHER: PIP joints, shoulders, elbows, hips, knees, ankles

Question 8

What type of irreversible deformities can occur if RA is left untreated?

Answer 8

1. Ulnar deviation of fingers
2. Boutonnaiere deformity (hyperextension DIP + flexion PIP)
3. Swan neck deformity (flexion DIP, hyperextension DIP)
4. Subluxation of wrist
5. Radial wrist deviation
6. Hammer toe
7. Claw toe
8. Atlantoaxial subluxation between C1 and C2

Question 9

What are the periarticular features of RA?

Answer 9

1. Rheumatoid nodules (fingers, elbows, achilles tendons)
2. Tenosynovitis/bursitis
3. Carpal tunnel syndrome

Question 10

What are common systemic features of RA?

Answer 10

• Fever
• Malaise
• Arthralgia
• Weakness
• Fatigue

Question 11

What blood tests can be run by RA?

Answer 11

BLOODS
-RF+ve (60-70%)
-Anti-CCP*
-ESR, CRP
-FBC - normochormic, normocytic anaemia + reactive thrombocytosis
-Antinuclear antibodies - up to 30% in RA
(Uric acid to exclude gout)

Question 12

What can X ray findings show?

Answer 12

1. Soft tissue swelling
2. Periarticular osteoporosis
3. Juxta-articular erosions
4. Narrowing of joint spaces

Question 13

How is RA managed?

Answer 13

1. Start DMARDs ASAP
   - Methotrexate, sulfasalazine, leflunomide, hydroxychloroquine
   - Analgesics
   - Steroids
2. TNF-alpha inhibitors (no response to two DMARDs)
   - Etanercept, infliximab, adalimumab
3. Others
   - Rituximab, abatacept