Rheumatoid arthritis Flashcards
Give three presenting features of joint synovitis in rheumatoid arthritis
-
Symmetrical peripheral polyarthritis
- Warm, erythematous joints
- ‘Boggy’ swelling around joints
- Inability to make a fist/flex fingers
- Typically involving the small joints of the hands and feet
- Most commonly affecting MCP, PIP, wrist, and MTP joints
- DIPJ are spared
- Early morning stiffness >1hr
- Joint pain worse at rest and in the morning
Outline the ACR/EULAR 2010 criteria for rheumatoid arthritis
Provide three hand signs in rheumatoid arthritis
- Inability to make a fist or flex fingers
- +ve MCP squeeze test
- Sparring of DIPJ
- Ulnar deviation of MCPJ
- Dorsal subluxation
- Boutonniere and swan-neck deformity of fingers
- Z-deformity of thumb
- Involvement of large joints
List three risk factors for rheumatoid arthritis
- Female (pre-menopause 3:1)
- Peak age 30-50
- Hereditary link in 1o relatives
- HLA-DR4 associated
- Smoking
What antibody is highly specific for rheumatoid arthritis?
Anti-cyclic citrullinated peptide (Anti-CCP) antibody
98% specificity
Associated with more severe RA and smokers
List 4 radiological findings seen with rheumatoid arthritis
- Symmetrical
- DIPJ sparring
- Soft tissue swelling
- Juxta-articular osteoporosis
- Erosions of periarticular bare areas
- Osteopenia (early)
- Narrow joint space (late)
- Dorsal subluxation
List six extra-articular features of rheumatoid arthritis
- Rheumatoid nodules: typically elbows, fingers
- Muscle wasting around joints
- Peripheral neuropathy, carpal tunnel syndrome; trigger finger
- Atlantoaxial subluxation
- Pericarditis; pericardial effusion; atherosclerosis
- Pulmonary fibrosis, pleural effusion
- Amyloidosis
- Vasculitis
- Sjogren’s syndrome, scleritis and episcleritis
- Achilles tenosynovitis
Request four investigations for rheumatoid arthritis
- RF; anti-CCP: prognostic markers
- FBC - normocytic anaemia and reactive thrombocytosis
- U+Es; LFTs
- CRP; ESR: usually elevated, treatment markers
- X-ray of hands and feet
- USS or MRI - early soft tissue swelling, synovitis
- CXR: exclude lung manifestations of RA
- Health Assessment Questionnaire (HAQ): determine baseline
When is a rheumatoid arthritis flare suspected?
Worsening:
- Stiffness, pain, joint swelling; or general fatigue
- Signs of joint synovitis; tenderness; or loss of function
- Inflammatory markers raised from baseline
Describe the management of a flare of rheumatoid arthritis
Must exclude septic arthritis
- Short-term glucocorticoids:
- Intra-articular glucocorticoid injection
- IM glucocorticoid
- PO prednisolone
- Consider NSAIDs ± PPI
- Refer to rheumatologist if recurs
- Refer for physiotherapy
What is the medical management of rheumatoid arthritis?
-
cDMARD monotherapy: ideally within 3 months of symptoms
- eg. MTX; leflunomide; sulfasalazine
- Can take up to 2-3 months to have effect
- Consider steroid ‘bridging’ treatment
- Step-up strategy: additional cDMARD
- Early combination treatment slows disease progression
- Consider biological DMARDs
- eg. Sarilumab (IL-6); adalimumab, infliximab (TNF)
- DMARDs require regular blood monitoring*
- Women of childbearing age (and men if trying to conceive) should be given contraceptives whilst on MTX and for 3/12 after stopping*
Name two cDMARDs are available for rheumatoid arthritis
- Methotrexate
- Sulfasalazine
- Leflunomide
- Hydroxychloroquine: consider if mild or palindromic disease
What is the dosing regimen of methotrexate?
- Methotrexate once weekly (Monday)
- Folic acid once weekly (Friday)
MTX inhibits folic acid reductase
List three side effects of methotrexate
- Hair loss
- Immunosuppression
- Liver dysfunction
- Lung fibrosis
- Neural tube defects (teratogenic)
What monitoring is required whilst taking methotrexate?
- Baseline CXR - check for pulmonary fibrosis
- FBC: neutropenia and thrombocytopenia
- U+Es: renal impairment
- LFTs: hepatitis and cirrhosis
Repeat bloods at 2/4/8 wks, then 8-weekly
Can methotrexate be taken during pregnancy?
No, as it is highly teratogenic and abortifacient
Women of childbearing age (and men if trying to conceive) should be given contraceptives whilst on MTX and for 3/12 after stopping
How long do DMARDs typically take to provide a beneficial effect?
2-3 months
Name three side-effects of NSAIDs
- Dyspepsia
- Rash
- Peptic ulcers
- Gastric erosions: offer longterm PPIs
- Perforation and bleeding
- Asthma exacerbation
Name three side-effects of corticosteroids
- Short-term:
- Insomnia; psychosis; mania; depression
- Gastritis; peptic ulceration; acute pancreatitis
- Thrush
- Impaired glucose regulation; Cushing’s syndrome
- Long-term:
- Osteoporosis; AVN of femoral head
- Adrenal insufficiency: do not stop abruptly
- Immunosuppression
- Cataracts
What is the DAS28 score?
A measure of disease activity in rheumatoid arthritis, based on:
- Number of tender joints
- Number of swollen joints
- CRP/ESR level
- Visual analogue scale of pain and discomfort (0-100)
DAS28 score greater than 5.1 (inadequate response) on 2+ DMARDs is the indication for commencing biological therapies
Name two biological therapies available for RA?
- Anti-TNF: Infliximab, adalimumab, etanercept, golimumab
- Anti-CD20: Rituximab
- IL-6 antagonist: Sarilumab
What is the indication for biological therapies in RA?
DAS28 score greater than 5.1 (inadequate response) to at least 2 DMARDs
What investigation should be done prior to starting anti-TNF therapy for RA?
QuantiFERON Gold for latent and active TB, and CMV
Anti-TNF therapy can reactivate any latent TB and other infections, so this must be treated if present prior to starting anti-TNF.
What pre-operative screening should be done in patients with rheumatoid arthritis and why?
Anteroposterior and lateral cervical spine radiographs
- Atlantoaxial subluxation is a rare complication of rheumatoid arthritis
- Can lead to cervical cord compression
- Ensure the patient goes to surgery in a C-spine collar and the neck is not hyperextended on intubation
