Rheumatoid arthritis

Question 1

presentation of RA

Answer 1

early morning stiffness lasts >30 mins
typically improves with exercise and as day goes on
typically symmetrical pain
onset often more acute than OA - few weeks
it is a systemic inflammatory condition - fever, weight loss, reduced appetite, fatigue can all occur

can be triggered by viral illness - recent illness

Question 2

joints affected in RA

Answer 2

typically: symmetrical swollen, painful, stiff small joints of hands, wrists, and feet
MCP and PIP joints predominantly
larger joints can become involved

Question 3

presentation of RA on hand examination

Answer 3

Early in disease:
swollen MCP, PIP, wrist or MTP joints, often symmetrical
look for tenosynovitis, or bursitis
swelling = boggy swelling

Later:
joint damage, deformity
ulnar deviation of the fingers
guttering of interossi muscles
Doral wrist sublaxation (incomplete or partial dislocation)
boutonniere - flexion of PIP and hyperextension of DIP swan neck deformities - hyperextension of PIP and flexion of DIP
Z deformity of thumbs

Question 4

extra-articular manifestations of RA

Answer 4

respiratory: pulmonary fibrosis, interstitial lung disease, lung nodules, pleural effusions, pleuritis
nodules on elbows
lympahdenopathy
vasculitis - typically small vessel
pleural effusion, pericarditis
palmar ertythema; nail fold infarcts, ulceration
neurology: carpal tunnel syndrome, peripheral neuropathy, mononeuritis multiplex, atlant-axial sublaxation
splenomegaly
felty’s syndrome - RA + splenomegaly +neutropenia
episcleritis, scleritis, scleramalacia perforans - ‘corneal melt’
keratoconjunctivitis - dry eyes and dry motuh
anaemia (normocytic), leukopenia, pancytopenia
amyloidosis
fatigue, low grade fever, weight loss
raynauds
haemolytic anaemia

Question 5

investigations for RA

Answer 5

rheumatoid factor
Anti CCP
FBC - often anaemia of chronic disease (normal MCV) baseline and infection
ESR/CPR - inflammation
U and Es, LFTs - potential to start medications
TFTs - if abnormal can present with joint pain
X-ray
if uncertainty about synovitis do US, can identify synovitis and joint effusion more accurately

Question 6

RA antibodies

Answer 6

rheumatoid factor - can be positive or negative. NOT DIAGNOSTIC. May be present in normal population, in sjorgens, other rheumatic conditions, certain malignancies and chronic infections

Anti CCP - specific for RA

Question 7

diagnosis of RA

Answer 7

clinical diagnosis
scores >= to 6/10 are diagnostic
test those with one or more joints with definite clinical synovitis/swelling which isn’t best explained by another disease

A = joint involvment (1 large joint = 0, 2-10 large joints = 1, 1-2 small joints =2, 4-10 small joints = 3, >10 joints (At least one small) = 5)
B = serology - anti CCP and RF. both neg = 0, one low = 1, one high = 3
C = acute phase reactants - ESR or CRP needed (normal = 0, abnormal = 1)
duration of symptoms (>or = 6 weeks gets a point)

Question 8

management of RA

Answer 8

refer to rheumatologist
analgesia for symptomatic relief - NSAIDs
rapid and aggressive suppression of inflammation improves LT outcome by reducing joint damage, maintain function and QoL and preventing disability

combination DMARD therapy (2) and corticosteroids offer ideally within 3 months of onset of persistent symptoms
often methotrexate and either hydroxychloroquine, sulfalasine, leflunomide

Question 9

how to measure disease activity score

Answer 9

DAS28
joint tenderness
number of swollen joints
patient global assessment of disease activity
measure of acute phase response (mainly ESR can be CRP)
provides a score 0-10
aim to reduce score <3
remission <2.6
low <3.2
moderate< 5.1
severe >5.1-10