Rheumatoid Arthritis

Question 1

what is rheumatoid arthritis?

Answer 1

symmetrical inflammatory arthritis affecting mainly the peripheral joints

Question 2

what can happen if rheumatoid arthritis isn’t treated?

Answer 2

can lead to joint damage and irreversible deformities leading to loss of function and increased morbidity and mortality

Question 3

what does rheumatoid arthritis affect?

Answer 3

articular and extra-articular structures

Question 4

who gets rheumatoid arthritis?

Answer 4

can affect men and women but more common in women
any age
1% of population

Question 5

what causes rheumatoid arthritis (RA)?

Answer 5

can be triggered by infection, stress, smoking

Question 6

what mediates RA?

Answer 6

HLA-DR4

Question 7

is RA always the same?

Answer 7

no
severity and course can vary
possible depend on genetic factors and presence of autoantibodies (worse prognosis)

Question 8

what is the main structure involved in RA?

Answer 8

synovium
C1 and C2
hand
wrists
elbows
shoulders
TMJ
knees
hips
ankels
feet

Question 9

what is synovium?

Answer 9

lines inside of of synovial joint capsules and tendon sheaths (tenosynovium)
makes direct contact with synovial fluid which acts as a joint lubricant?

Question 10

what happens to the synovium?

Answer 10

synovium becomes inflamed > spongy mass of inflammation > increased blood flow > more inflammatory cells
inflammatory cascade activates osteoclasts which erode the bone (early osteoarthritis)

Question 11

what is the end result?

Answer 11

pannus

highly vascular swollen inflamed synovium

Question 12

describe the psthogenesis of RA?

Answer 12

unknown antigen presented to T cell > T cell activated > stimulates B cells and macrophages > macrophages release cytokines (TNF alpha, IL6 and IL1), B cell produce antibodies (rheumatoid factor) > icreased osteoclast proliferation, inflammation and joint destruction etc

Question 13

definition of early RA?

Answer 13

< 2 years from symptoms onset

Question 14

when is the windown of opportunity where disease can be modified?

Answer 14

first 3 months

Question 15

features of RA?

Answer 15

short history
early morning stiffness (>30 mins/1hr)
swelling
pain in synovial joints
>6 weeks duration

Question 16

how is RA diagnosed?

Answer 16

history/clinical examination (mainly)
Blood test
inflammatory markers (CRP,ESR)
Autoantibodies (rheumatoid factor - only in 70%)
Imaging (hand, feet, chest)

Question 17

what causes early morning stiffness?

Answer 17

thick protein synovial fluid build up during sleep

Question 18

clinical examination of RA?

Answer 18

swelling in joint
symmetrical
tenderness in joint
loss of function (cant make a fist)
positive compression test of MCP and MTP joints

Question 19

what blood tests are done for RA?

Answer 19

FBC (anaemia, raised platelets)

Question 20

describe synovium in RA?

Answer 20

hypervascular
inflamed
attracting lots of inflammatory cells

Question 21

RA X ray?

Answer 21

normal in early stages

changes only seen late on

Question 22

what is the compression test?

Answer 22

if a gentle squeeze on the joint causes pain

Question 23

give some possible clinical presentations of RA

Answer 23

PIP, MCP, MTP , wrist synovitis
mono/teno synovitis
trigger finger (bent and straightens with a click)
carpal tunnel
polymyalgia rheumatica
palindromic rheumatism
systemic symptoms
poor grip strength

Question 24

is gout continuous? what are the implications of this?

Answer 24

no
comes and goes so can be confused with palindromic rheumatism
however doesn’t occur in women before menopause

Question 25

what does extensor tenosynovitis vs synovitis look like?

Answer 25

tenosynovitis = swelling not over the joint, but over the tendons (e.g back of hand)
synovitis = over the joints

Question 26

what can tenosynovitis cause?

Answer 26

fraying and destruction of the tendon

Question 27

what are the 2 types of auto-antibodies produced in RA?

Answer 27

rheumatoid factor (Rheumatoid IgM) - only 70% specific
Anti CCP antibody - 90-99% specific so more used

Question 28

what are anti CCP antibodies?

Answer 28

against cyclic citrullinated peptide
present for many years before symptoms
associated with smoking history and erosive damage
stays positive even after treatment

Question 29

how is imaging used in RA?

Answer 29

plain X rays of hands, feet and chest
US
MRI
can show soft tissue swelling, erosions and periarticular osteopaenia?
normal in early stages

Question 30

which imaging is more sensitive for RA?

Answer 30

US and MRI
more sensitive in early stages
can show synovitis and erosions earlier

Question 31

what is DAS 28?

Answer 31

scoring of joint disease severity
lower DAS (<2.6) = less damage to joint

Question 32

when are biological treatments used for joint disease?

Answer 32

DAS28 > 5.1 after 2 DMARDs

Question 33

how is RA managed?

Answer 33

early disease modifying anti-rheumatic drugs (DMARDs) for all RA patients
NSAIDs and steroids as adjuncts
patient education
immunosuppresants

Question 34

definition of remission?

Answer 34

DAS28<2.6

Question 35

treatment pathway for RA?

Answer 35

aspirin/NSAIDs + steroids + DMARD 1

2. add DMARD 2
3. add DMARD 3
4. gradually withdraw treatment

Question 36

name some DMARDs

Answer 36

methotrexate
sulfasalazine
hydroxyxhloroquine
combination of first 3
leflunomide
gold injection, penicillamine, azathioprine

Question 37

methotrexate?

Answer 37

first line

escalated from 15-25mg/week

Question 38

how are DMARDs used?

Answer 38

methotrexate first line

combination of 3 often used

Question 39

what are biological agents?

Answer 39

inhibit parts of immune pathway
anti TNF (infliximab)
certolizumab, golimumab
T cell receptor blocker (abatacept)
B cell depletory (rituximab)
IL6 blocker (tocilizumab)
JAK 2 inhibitor - tacitinib

Question 40

complications of untreated RA?

Answer 40

deformation of the joint

Question 41

how are steroids used?

Answer 41

only to bridge between therapy

for flares only