Rheumatoid Arthritis

Question 1

Define/describe Rheumatoid Arthritis

Answer 1

Chronic multi-system disorder
Unknown etiology
Most common symptoms being persistent inflammatory synovitis,
Usually involving peripheral joints in a symmetrical pattern.

Question 2

Epidemiology of RA

Answer 2

Affects 2.1 million Americans, or about 1% of the adult US population.
The female to male ratio is 2.5-3:1; the difference diminishes in older patients.
Affects people between ages 20-50 years old

Question 3

What is the definitive lab finding for RA?

Answer 3

No single clinical or laboratory finding is pathognomic for rheumatoid arthritis.

Question 4

What are the ACR 1987 Classification Criteria for RA?

Answer 4

4/7 criteria

• morning stiffness lasting at least 1 hour
• swelling in 3 or more joints
• swelling in hand joints
• symmetric joint swelling
• erosions or decalcification on xray of hand
• Rheumatoid nodules
• abnormal serum rheumatoid factor

Question 5

What may be seen on XR in a pt with RA?

Answer 5

Chronic joint swelling leads to joint deformity radiographically represented by
joint erosions,
periarticular osteopenia
joint space narrowing.

Question 6

What are concerns when a pt has chronic neck pain with RA? What should you do?

Answer 6

Atlantoaxial instability needs to be suspected when patients complain of chronic neck pain and flexion films should be performed.
If general anesthesia is considered pre-operative cervical spine flexion films need to be performed.

Question 7

Discuss the significance of rheumatiod factor in diagnosing RA

Answer 7

Rheumatoid factor while part of the classification criteria does not establish the diagnosis.

Question 8

What are other rheumatic conditions that test positive for RF?

Answer 8

RA 80%
juvenile chronic arthritis 20%
ankylosing spondylitis <15%
SLE 40%
Sjogren's syndrome 90%
cryoglobulinemia >90%

Question 9

What are rheumatic diseases that always test negative for RF?

Answer 9

Reiter’s syndrome

psoriatic arthritis

Question 10

RF + causes in non-rheumatic diseases

Answer 10

1. infections
   - endocarditis
   - hepatitis
   - acute viral infection
   - parasitic infection
   - TB
2. Lung diseases
   - interstitial fibrosis
   - chronic bronchitis
   - silicosis
3. miscellaneous
   - cirrhosis
   - sarcoidosis
   - MI
   - chronic active hepatitis
   - malignancies
   - post vaccination
   - aging

Question 11

Discuss common lab findings in RA, especially in relation to acute flares.

Answer 11

Acute phase reactants may be elevated when the disease is active.
Anemia of chronic disease is common.
Thrombocytosis often parallels the elevation of the acute phase reactants.

Question 12

What is the significance of anticyclic citrllinated peptide antibodies (Ant-CCP)?

Answer 12

Anticyclic citrullinated peptide antibodies (anti-CCP) present in 50-70% of patients.
Their specificity is 96% .
Significant predictive value for rheumatoid arthritis.
Detected several years prior to the development of rheumatoid arthritis.
Anti-CCP predicts more significant erosive joint changes.
Smoking adds further to the severity of the disease.

Question 13

What are extraarticular manifestations of RA?

Answer 13

Increase risk of a myocardial infarction.
Pericardial and pleural effusions.
Interstitial lung disease, more commonly usual interstitial pneumonia (UIP) form.
Secondary amyloidosis.

Question 14

What are nonbiological DMARDs for RA and how long does it take to see benefits?

Answer 14

1. azathioprine (2-3 mos)
2. D-penicillamine (3-6 mos)
3. gold PO or IM (3-6 mos)
4. hydroxychloroquine (2-6 mos)
5. leflunomide (4-12 wks)
6. Methotrexate (1-2 mos)
7. Sulfasalazine (1-3 mos)

Question 15

RA biologic agents

Answer 15

TNF-a blockers (Enbrel, HUkira, REmicade, Cimzia, Simponi)
IL-1 blockers (kineret)
T-cell constimulation modulator (Orencia)
Monoclonal antibodies (Rituxan, Actemra)
JAK inhibitor (Xeljanz)