Rheumatoid Arthritis Flashcards
What type of arthritis is rheumatoid?
Symmetrical inflammatory seropositive
Which group of joints does RA mostly affect?
Peripheral
Are the deformities of RA reversible?
No
Can RA affect extra-articular structures?
Yes
What is the sex distribution of RA?
3 times more common in women than men
What age group can RA affect? What is the age range of peak prevalence?
Can affect any age group
Highest prevalence 35-50
What is RA known as when it occurs in under 16s?
Juvenile idiopathic arthritis
RA is what type of disease?
Autoimmune
What mediates RA in a genetically susceptible individual?
HLA-DR4
Genetic factors are responsible for what percentage of the risk of developing RA?
50%
First degree relatives of a person with RA are how many times more likely to develop the condition themselves?
2-3 times
What are some potential triggers of RA?
Infections, stress and smoking
The presence of autoantibodies has what effect on the prognosis?
Worse prognosis
What is the main structure involved in RA? Where is this found?
Synovium- inside synovial joint capsules and tendon sheaths
Which joints can RA affect?
Only those which contain synovium
Which joints in the spine can RA affect? Why is this? What can happen if these joints are badly affected?
C1 and C2- they are the only ones containing synovium
They can subluxate and cause spinal cord compression
What happens to the synovial membrane in RA?
Becomes very hypertrophic and inflamed
What gets released which leads to joint destruction?
Inflammatory cytokines
What can damage to the tendons and soft tissues cause?
Subluxation and joint instability
What do B cells in RA release?
Rheumatoid factor and IL-6
What do T cells in RA release?
TNF alpha, IL-1 and IL-6
Erosions on imaging are a result of what?
Osteoclast activity
Which joints in the hand are spared in RA? Why is this?
DIP joints due to a lack of synovium
What defines early rheumatoid arthritis?
Less than 2 years since symptom onset
What is the therapeutic window of better outcomes in RA?
First 3 months
Morning stiffness in RA should last how long?
> 30 mins
RA usually affects how many joint areas?
3 or more
What is the most common place to get RA?
Hands
What is a less common feature that occurs in around 25% of patients? Where are these most likely to occur?
Rheumatoid nodules- on the extensor surfaces or sites of frequent mechanical irradiation
What are three different types of lung involvement?
Pleural effusions, interstitial fibrosis or pulmonary nodules
Morbidity and mortality due to what is increased in RA?
Cardiovascular disease
What are some examples of ocular involvement?
Keratoconjunctivitis sicca, episcleritis, uveitis, nodular scleritis
What is the end point of ocular involvement in RA?
Scleromalacia
Routine blood tests should be taken to look for what?
Anaemia, raised platelets and inflammatory markers
What 3 imaging types can be used for RA diagnosis?
X-ray, US, MRI
Which imaging test can be useful for detecting synovial inflammation to confirm a diagnosis?
US
What may be some early signs of RA on x-ray?
Peri-articular osteopenia, soft tissue swelling
What is a late sign of RA on x-ray?
Erosions and deformities
Compression of which joints will be extremely painful in RA?
MTP and MCP
What is the best antibody test for RA? What other antibody may show up?
Anti-CCP- best
Rheumatoid factor- may also show
What type of antibody is rheumatoid factor?
IgM
Rheumatoid factor can also come up positive in patients with what else?
Infections or cancer
Can a patient still have RA without antibodies?
Yes
What imaging should always be done in a possible case of RA, even if there are no symptoms there?
X-ray of hands and feet
What, when seen on MRI is associated with inflammatory joint disease and may be a forerunner of erosions?
Bone marrow oedema
What test is gold standard for joint disease?
MRI
What gets missed out of DAS28 scoring?
Feet and ankles
What DAS28 score indicates active disease?
> 5.1
What DAS28 score indicates moderate disease?
3.2-5.1
What DAS28 score indicates low disease activity?
2.6-3.2
What DAS28 score indicates remission?
< 2.6
What medications can be used as adjuncts in RA therapy?
Simple analgesia, NSAIDs and steroids
Can you take patients off drugs in RA?
Yes, if they improve
When should steroids be used in RA?
In combination with DMARDs
How can steroids be given?
Oral, IM, IA
How should patients be taken off steroids?
Gradually
What is the first line DMARD drug?
Methotrexate
What are some other DMARD drugs?
Sulphasalazine, hydroxychloroquine, leflunomide
What does hydroxychloroquine not do which other DMARDs do?
Prevent erosions
Why should you always give steroids and DMARDs?
Because DMARDs take a while to work so steroids calm inflammation in the meantime
What adverse effect can DMARDs cause? How can this be monitored?
Bone marrow suppression- monitor with regular blood tests
What lung problem can methotrexate cause? What should patients be told about this when they begin therapy?
Pneumonitis- report any dyspnoea or dry coughs
Can you get pregnant on DMARDs? What do you need to tell patients?
No, they are teratogenic (except sulphasalazine)- tell patients about contraception
When can biologics be used for RA?
If there has been failure to respond to at least two DMARDs (including methotrexate) and the DAS28 score > 5.1
Which biologic agents are best for RA? Give examples.
Anti-TNF e.g. infliximab, adalimumab
What is the risk of biologics?
Immunosuppression and severe infection
What should all patients be screened for before starting biologics?
TB
