Rheumatoid Arthritis Flashcards
1
Q
What is rheumatoid arthritis?
A
- A chronic systemic inflammatory disease characterised by a symmetrical, deforming, peripheral polyarthritis.
- It increases the risk of cardiovascular disease by 2-3 fold
- The prevalance is higher in smokers
2
Q
How does rheumatoid arthritis present?
A
- Morning stiffness (>30 mins)
- Swelling
- Joint pain typically of the small joints (except DIPJs) in a symmetrical manner
- Normally a polyarticular condition (affects a great number of joints)
- Can get rheumatoid nodules (often on elbows or knuckles and sometimes lungs) which are prognostic for bad outcomes as often develop extra articular pathologies and are RF +ve
- Can get extra-articular presentations with:
- Weight loss
- Fever
- Fatigue
- Pericarditis
- Lung fibrosis
- Lymphadenopathy
- Episcleritis
- Scleritis
- Felty’s syndrome (RA + splenomegaly + neutropenia)
- Peripheral neuropathy
- Vasculitis
- Carpal tunnel syndrome
3
Q
Extra-articular manifestations affect 40% of RA patients.
What are the extra-articular presentations of rheumatoid arthritis?
A
- Weight loss
- Fever
- Fatigue
- Cardiac
- Pericarditis
- IHD
- Pericardial effusion
- Lungs
- Lung fibrosis
- Lymphadenopathy
- Eye
- Episcleritis
- Scleritis
- Scleromalacia
- Felty’s syndrome (RA + splenomegaly + neutropenia)
- Peripheral neuropathy
- Vasculitis
- Carpal tunnel syndrome
- Osteoporosis
- Amyloidosis (rare)
4
Q
What are the early signs of rheumatoid arthritis?
A
- Inflammation, no joint damage
- Swollen MCP, PIP, wrist or MTP joints
- often symmetrical
5
Q
What are the later signs of rheumatoid arthritis?
A
- Joint damage and deformity
- Ulnar deviation
- Swan neck deformity
- Boutonneires deformity
- Z deformity of hands
- Dorsal wrist subluxation
- Hand extensor tendons may rupture
- Foot changes are similar
- Larger joints may be involved
- Altanto-axial joint subluxation may threaten the spinal cord
6
Q
What are investigations for rheumatoid arthritis?
A
- Rheumatoid factor is postive in 70%
- High titres are associated with severe disease, erosions and extra-articular disease
- Anticyclic-citrillinated peptide antibodies
- These are more specific for RA and sensitive too
- They may also predict disease progression
- Anaemia of chronic disease
- Raised platelets
- Raised ESR
- Raised CRP
- X rays
- Soft tissue swelling
- Juxta-articular osteopenia
- Decreased joint space
- Most changes are seen later
- Ultrasound and MRI
- Both can identify synovitis more accurately and have greater sensitivity in detecting bone erosins than conventional X-rays
7
Q
How is rheumatoid arthritis managed?
A
- Conservatively
- Refer to rheumatologist before irreversible destruction
- Physiotherapy/Occupational therapy
- Medically
- DMARDS - early use improves long term outcomes
- Methotrexate
- Sulfasalazine
- Hydroxychloroquine
- Steroids - reduce symptoms and inflammation rapidly
- Oral prednisolone
- IM depot methylprednisolone
- NSAIDs - symptoms relief, no effect on long term outcomes
- DMARDS - early use improves long term outcomes
- Surgically
- relieves pain
- improves function
- prevents deformity
8
Q
RA increases the risk of some diseases. What are they?
A
Cardiovascular and cerebrovascular diseases as atherosclerosis is accelerated in RA
9
Q
What modifiable factor increases the symptoms of RA?
A
Smoking
10
Q
How does RA affect quality of life?
A
- Depression, disability and pain are all important quality of life predictors
- RA affects all three of these so be mindful about the impact of the disease on their relationships, work and hobbes
- Consider therapies and support groups for patients - holistic care
11
Q
What is the diagnostic criteria for RA?
A
12
Q
What changes can be seen on X ray of someone with RA?
A
- Soft tissue swelling
- Extra-articular osteopenia
- Marginal atrophic erosions
- Joint space narrowing (no osteophytes or sclerosis so looks dark)
- LESS
- Loss of joint space
- Erosions
- Soft tissue swelling
- Soft bones (osteopenia)
13
Q
Where are rheumatoid nodules found?
What are they a sign of?
A
- Elbows or knuckles
- Lungs
- Cardiac
- They are prognostic for bad outcomes as often develop extra articular pathologies and are RF +ve
14
Q
What are the side effects of methotrexate?
A
- Nausea
- Hepatotoxicity (monitor LFTs)
- Hair thinning
- Reduce appetite
- Insomnia
- Pneumonitis
- Lung fibrosis
15
Q
What is the mode of action of methotrexate?
A
- It inhibits DHFR (dihydrofolate reductase)
- This leads to reduced tetrahydrofolate production which is needed as a co-factor for thymidylate synthase
- Therefore there is reduced thymidine production which leads to thymidine less cell death
