Rheumatoid Arthritis

Question 1

What is Rheumatoid Arthritis?

Answer 1

An autoimmune condition leading to inflammation of joint synovium (the joint capsule) which in time can progress to underlying bone/cartilage being affected

Question 2

What will you find on a history taking of Rheumatoid Arthritis?

Answer 2

Symptoms:
Pain and stiffness - Normally symmetrical e.g. both hands or both feet
Normally affects hands and feet small joints
Joint swelling
DIP hand joint is never affected! So, if this affected not RA
Morning stiffness lasting >30 mins common
Extra Articular manifestaiotjn - keratoconjuctivitis sicca, episcleritis, pulmonary nodules, pleural effusions, pericarditis and subcutaneous rheumatoid nodules occur in around 20% of cases

Risk Factors:
Most patients present in their 50s
More commonly affects women

Specific Questions to ask:
How is the patient dealing with chronic disease
Work out the DAS28 score (disease activity score). Assesses severity and prognosis based off of inflammatory markers, joints affected etc
Use diagnostic criteria for Rheumatoid Arthiritis

Differentials:
Osteoarthritis - joint pain and stiffness that is typically worse with activity and stiffness < 30 mins in the morning
SLE - May have similar joints affected but will see no RA deformity like ulnar deviation
Gout -Tophi and high levels of uric acid are specific for gout and very rare in RA, very few cases of gout are polyarticular
Psoriatic arthritis - less often symmetric. Fewer than 5 joints are commonly affected and DIP joints may be involved. Patient may have psoriasis

Question 3

What will you find on examination of Rheumatoid Arthritis?

Answer 3

Hands:
Ulnar Deviation
Boutonniere deformity of the thumb
Swan neck deformity
Z shaped thumb
MCP subluxation 
Piano Key deformity 
Palmar Erythema 
Rheumatoid Nodules - Specially on the elbox/hands 
Splinter Haemorhages 

Legs:
Hammer Toe
Hallux Valgus

Question 4

What investigations will you order in Rheumatoid Arthritis?

Answer 4

Bloods:
FBC - Anaemia o f chornic disease, GI blood loss secondary to use of NSAID
CRP/ESR – Assess inflammation, so will be raised
LFT’s - Raised ALP can be raised
Antinuclear Antibodies – Exclude SLE
Rheumatoid Factor – positive in 70%
Anti CCP - Positive in about 98% of RA patients
UnE

Imaging:
Xray of affected joint - Tissue swelling, Juxta-articular osteopenia, Loss of joint space, Erosions, Deformity

Question 5

What is the treatment of Rheumatoid Arthritis?

Answer 5

Refer to Rheumatologist

Lifestyle:
Diet and exercise
Physiotherapy
Reduce strain on affected joints 
Walking aids
Joint supports

Medical:
1st Line - Methotrexate + another DMARD (Sulfasalazine/Hydroxychloroquine) + Oral Corticosteroids + NSAID for pain relief (May take 12 weeks to show improvement)
2nd Line - Methotrexate + TNF-Alpha inhibitor + NSAID for pain relief
3rd line - Methotrexate + Rituximab + NSAID for pain relief
During Flare Ups can use intraarticular corticosteroids

Question 6

What conditions are associated with rheumatoid arthritis?

Answer 6

Raynaud’s syndrome
Sjögren’s syndrome
Felty’s syndrome
Vasculitis 
Osteoporosis
Heart - Myocarditis, Pericarditis, Valvular incompetence 
Glomerulonephritis
Pleuritis, pulmonary fibrosis