Rheumatoid Arthritis

Question 1

what is RA

Answer 1

symmetrical inflammatory arthritis affecting mainly the peripheral joints

Question 2

if untreated what can RA lead to

Answer 2

joint damage, irreverisble deformities, loss of function, increased morbidity and mortality

Question 3

who is more likely to get it men or women

Answer 3

women (x3)

Question 4

what age group can be affected by RA

Answer 4

any

Question 5

what part of spine can be affected

Answer 5

just C1 and C2

Question 6

what gene mediates RA

Answer 6

HLA-DR4

Question 7

what are the potential triggers for RA

Answer 7

smoking, infections, stress

Question 8

what do the severity and course of RA depend on

Answer 8

genetic factors and presence of auto antibodies

Question 9

what is the link to smoking

Answer 9

smoking cause proteins in the lungs to become citrullinated (irreversible) and antobodies are created against these which also target the joints

Question 10

what is the main structure involved in RA and how is it affected

Answer 10

synovium- gets thickened and inflammed

Question 11

what is the synovium

Answer 11

lines the inside of joint capsules and tendon sheaths

Question 12

what joints are synovial

Answer 12

C1,C2, hand, wrists, elbows, shoulders, TMJs, knees, ankles, feet, hips

Question 13

what is a pannus and how is it formed in RA

Answer 13

an abnormal layer of fibrovascular tissue or granulation tissue

Inflammation and exuberant proliferation of the synovium leads to formation of pannus and destruction of cartilage, bone, tendons, ligaments, and blood vessels. Pannus= the hypertrophied (enlarged) synovium

Question 14

how is the inflammatory cascade perpetuated

Answer 14

inflamed synovium caused increased blood flow- more antibodies and inflammatory cells

Question 15

how does bone erosion occur in RA

Answer 15

as osteoclasts activated by proinflammatory cytokines

cartilage cells are prevented from being regenerated

Question 16

describe the immune pathogenesis of RA

Answer 16

antigen (unknown) presented to niave T cells which is activated and stimulates B cells to produce rheumatoid factor and IL-6 and macrophages to produces IL-1 and 6 and TNF alpha

net result is osteoclast stimulation, hypervascular pannus and destruction of cartilage and joint

Question 17

what is the theraputic window for rheumatoid arthritis

Answer 17

when it is in early stages (first three months)

Question 18

what defines early RA

Answer 18

less than two years since symptom onset

Question 19

what is tendonsynovium

Answer 19

the synovium surrounding a tendon, can be affected by RA

Question 20

the involvement of larger or smaller joints produces a higher ECR/EULAR score

Answer 20

smaller joints

Question 21

what are the symptoms of RA

Answer 21

will be fit and well then joints will start to be sore

early morning stiffness lasting 30-hour or even until lunchtime

swelling of the joints that is symmetrical and tender

involvement of small joints of hands and feet

positive compression tests of metacarpophalangeal (MCP) and metatarsalangeal (MTP) joints

Question 22

why do you get early morning stiffness

Answer 22

as synovial fluid gets thicker overnight due to lack of movement

Question 23

what diagnostic tests can be done

Answer 23

mostly history and clinical exam

blood tests- anaemia of chronic disease, raised platelets

inflammatory markers (CRP, ESR, plasma viscosity)

autoantibodies (seen in 70% of cases)

imaging (x rays of hands, feet and chest as a baseline)

systemic exam- listen for involvement of the lungs, test reflexes and sensations

Question 24

what does RA in the feet feel like

Answer 24

walking on pebbles

Question 25

what is monoarthritis

Answer 25

rare- when one joint in inflamed

Question 26

what is tenosynovitis

Answer 26

inflammation of tendons (rare)

Question 27

what is trigger finger

Answer 27

clinical presentation of RA, when finger gets stuck in flexed position then extends with a click

Question 28

how many patients with RA have bilateral carpal tunnel syndrome

Answer 28

15%

Question 29

what is polymyalgia pheumatica

Answer 29

muscle pain, stiffness and inflammation in the muscles surrounding the neck, shoulder and hips

Question 30

what is palindromic rheumatism

Answer 30

variant of RA that comes and goes- usually progresses to complete RA

Question 31

how is grip affected in RA patients

Answer 31

reduced- many unable to make a fist

Question 32

what is extensor tenosynovitis

Answer 32

swelling in the extensor tendons | tendons flare and tear

Question 33

what is synovitis

Answer 33

inflammation of the synovial membrane

Question 34

what happens to the muscles in synovitis

Answer 34

waste due to the inflammation

Question 35

what autoantibodies are associated with RA

Answer 35

rheumatoid factor (rheumatoid IgM) antibodies to cyclic citrullinated peptide (anti-ccp antibodies) anti-ccp antibodes have higher sensitivity and specificity

Question 36

describe the link between RA and anti-ccp antibodies and what they are associated with

Answer 36

can be present for several years prior to articular symptoms associated with erosive damage remain positive despite treatment associated with smoking

Question 37

what does the low sensitivity of antibodies mean

Answer 37

absence does not exclude the disease

Question 38

what imaging can be done for RA

Answer 38

x rays ultrasound MRI scans

Question 39

what do xrays show

Answer 39

soft tissue swelling periartiuclar osteopaenia erosions OR nothing in early stages

Question 40

what do ultrasound scans show

Answer 40

increased sensitivity for synovitis in early disease erosions increased blood flow to inflamed synovium

Question 41

what do MRI scans show

Answer 41

bone marrow oedema (associated with inflammatory joint disease and possible precursor to erosions) integrity of tendons can distinguish synovitis from effusions detects erosions earlier can monitor disease activity (most sensitive but limited by cost)

Question 42

what and how many joints are affected by RA

Answer 42

``` 28 in total 10 PIPs 10 MCPs 2 wrists 2 elbow 2 shoulders ```

Question 43

what are the DAS288 scoring parameters

Answer 43

>5.1 active disease 3. 2-5.1 moderate 2. 6-3.2 low disease activity <2.6 remission

Question 44

what is the treatment for RA

Answer 44

disease modifying anti rheumatic drugs NSAIDs and steriods only s adjuncts (steroids bridge until effect of DMARDs starts)

Question 45

what treatments when remission is achieved

Answer 45

gradually withdraw treatments

Question 46

what is the management pathway for RA

Answer 46

``` aspirin/ NSAIDs + steriods +DMARD 1 +DMARD 2 +DMARD 3 ```

Question 47

why is aggressive treatment of RA important

Answer 47

stops disease progression- why its essential to diagnose and treat early

Question 48

how can steroids be given in RA

Answer 48

orally, IA (intra articular) or IM

Question 49

when steroids be given IA

Answer 49

if fewer than 5 joints involved

Question 50

name three DMARDs

Answer 50

methotrexate (main one) sulfasalazine hydroxycholoquine (combo therapy with all three) also have leflunomide, gold injection, penicillamine, azathioprine

Question 51

what must be give 24 hours after methotrexate

Answer 51

folic acid

Question 52

what is the route of methotrexate

Answer 52

parenteral

Question 53

what dosage of methotrexate

Answer 53

start at 15mg/ week then increase | max dose 25mg/week

Question 54

what precautions should be made when on DMARDs

Answer 54

regularly monitor LFTs and FBCs teratogenic effects- advise contraception

Question 55

what are the risks of DMARDs

Answer 55

pneumonitis (methotrexate) bone marrow suppression live function derangement infection

Question 56

what are biologic agents and when are they used in RA

Answer 56

e.g. anti TNF agents (-mabs), t cell blocker, B cell depletor, IL-6 blocker, JAK 2 inhibitor dont give to patients already prone in to infection rationed as very expensive only when no response to DMARDs and DAS28 score greater that 5.1 on two occasions 4 weeks apart

Question 57

what is co prescribed by biological agents

Answer 57

methotrexate

Question 58

what should you screen for and avoid when using biological agents

Answer 58

latent/ active TB, hep B and C, HIV, varicella zoster avoid live attenuated vaccines

Question 59

what are the complications of untreated RA

Answer 59

joint damage and deformities

Question 60

how is cardiovascular disease risk affected by RA

Answer 60

accelerated (risk decreased with DMARDs)

Question 61

what should be screened for (bone wise) in RA patients

Answer 61

osteoporosis (osteoclasts, post menopausal)