Rheumatoid arthritis

Question 1

Which joints are affected in RA?

Answer 1

Usually peripheral joints:

MCPs and PIPs

Wrists

Ankles

Elbows

Question 2

Does RA present in a symmetrical or asymmetrical pattern?

Answer 2

Symetrical

Question 3

Which gender is more commonly affected by RA?

Answer 3

Women - 3x more likely than men

Question 4

What gene marker increases likelyhood of developing RA?

Answer 4

HLA-DR4

Question 5

What are the potential triggers of RA?

Answer 5

Infections
Stress
Cigarette Smoking

Question 6

What joint structure is typically affected in RA?

Answer 6

Synovium - lines the inside of synovial joint capsules and tendon sheaths

Question 7

What is the pathophysiology of the altered immune response in RA?

Answer 7

The triggering event causes T cells to migrate to the synovium/joint where they are activated

B-cell activation and the production of autoantibodies (anti-cyclic-citrullinated peptide antibodies)

Formation of immune complexes and subsequent activation of the complement system and further recruitment of macrophages and other inflammatory cells

Further inflammation is proposed to cause further citrullation and further reaction

Question 8

What are the symptoms of RA?

Answer 8

Prolonged morning stiffness

Swollen, hot joints

Symmetrical distribution

Pain is worst at rest and improves with activity

profound fatigue

mild fever

sweats

weight loss

Question 9

What are the signs on examination in RA?

Answer 9

Reduced range of movement

Hand deformities

Rheumatoid nodules

Question 10

What are the hand deformities seen in RA?

Answer 10

Ulnar deviation

Boutonnieres

Swan neck deformity

Z shaped thumb

Piano key deformity (depression of ulnar head)

Question 11

What is the difference between Boutonnieres and Swan neck deformity?

Answer 11

Swan neck (hyperextension of PIP and flexion of DIP caused by flexor synovitis that increases the flexor pull on the MCP joint)

Boutonniere’s (flexion of PIP and hyperextension of DIP caused by chronic synovitis in which the PIP is forced into flexion, raising tension in the extensors of the DIP)

Question 12

What auto-antibodies are usually present in RA?

Answer 12

Rheumatoid factor

Anti-CCP antibody

Question 13

What are some of the clinical features of anti-CCP antibody?

Answer 13

Can be present for several years prior to articular symptoms.

Co-relates with disease activity.

Associated with current or previous smoking history.

More likely to be associated with erosive damage.

Anti-CCP ab patients remain positive despite treatment.

Low sensitivity –absence does not exclude disease

Question 14

What modalities of imaging are avaliable for RA?

Answer 14

Plain Xray

Ultrasound

MRI

Question 15

Why would ultrasound imaging be used in RA?

Answer 15

Good for detecting synovitis in early RA

Question 16

Why would MRI scans be used in RA?

Answer 16

Bone marrow oedema on MRI is associated with inflammatory joint disease and maybe a forerunner of erosion

Integrity of tendons can be assessed

Can distinguish synovitis from effusions

Can detect erosions earlier

Can be used to monitor disease activity

Question 17

What scoring system is used to assess disease activity?

Answer 17

Disease activity score 28 (DAS 28)

Question 18

What score on DAS 28 for RA indicates active disease and what score indicates remission?

Answer 18

>5.1 is active disease

<2.6 is remission

Question 19

How is RA managed in a new diagnosis?

Answer 19

DMARDs started within 3 months

Co-treatment with NSAIDs for symptomatic relief

Corticosteroids short term for symptomatic relief