Rheumatoid Arthritis

Question 1

Define RA

Answer 1

Chronic systemic inflammatory disease that is characterised by symmetrical, deforming, peripheral polyarthritis

Question 2

Describe the presentation of RA

Answer 2

symmetrically swollen, sore joints - distal so it is the hands and feet that are usually first affected .
Distal sparing
Pain, erythema. Pain is worst in the morning

Question 3

give the signs of RA

Answer 3

Early: 
swollen MCP, PIP, wrist or MTP joints 
tenosynovitis 
bursitis
Later: 
ulnar deveiation
subluxation of the wrist and ankle 
boutonniere deformity 
Z thumb 
radial deviation of the wrist 
piano key ulnar head

Question 4

give some extra-articular features of RA

Answer 4

•	Respiratory
o	Effusions
o	Fibrosis 
o	Nodules 
•	Cardiac
o	Pericardial effusions 
o	IHD
o	Pericarditis 
o	
•	Dermatological
o	Thinning 
o	Ulceration 
•	Ophthalmic
o	Scleritis 
•	Neurological
o	Peripheral neuropathy 
•	Haematological
o	Anaemia 
o	Thrombocytosis 
•	Gut 
o	Amyloidosis

Question 5

which antibodies would you test for in RA?

Answer 5

o RF
• Autoantibody against Fc portion of IgG
• Usually IgM against IgG, though can be any isotype.
• 60% sens, 80% spec
• Other conditions: SLE, SBE, SScl, SjS, TB, EBV, healthy controls (especially elderly) etc.
• Part of assessment, not diagnostic
o Anti-CCP/ACPA
• Don’t get bogged down in details re this
• Sens 60% spec 80-90%
• Picks up those who may be RF negative
• Predictor of worse prognosis, more erosions, resistant disease
• Linked with smoking (increases citrullination)

Question 6

Describe the x-ray features of RA

Answer 6

Soft tissue swelling, joint space narrowing, erosions, juxta-articular osteopaenia

Question 7

what would you differential include in a patient with likely RA?

Answer 7

o	OA
o	SLE/other connective tissue disease
o	PMR – polymyalgia rheumatica 
o	Psoriatic arthropathy
o	Spondyloarthropathies
o	Reactive arthritis
o	Sarcoid
o	CPPD (calcium pyrophosphate)
o	Lyme’s

Question 8

which criteria are used to measure disease severity?

Answer 8

DAS28

Question 9

How would you manage a patient with RA, non-pharmacologically?

Answer 9

• Non-pharmacological
o OT/PT (mobility Ax + preservation, work Ax, walking aids…), Podiatrists (foot clinics, specialty foot assessment, footwear adjustments), other AHPs, e.g. dieticians
• Manage risk factors
o Increased risk of cardiovascular and cerebrovascular disease in these patients
o Smoking increases the symptoms of RA – encourage cessation

Question 10

What drugs can be used to treat these patients?

Answer 10

o	Symptomatic
•	NSAIDs, Analgesia etc
•	No effect on disease progression 
o	Disease Modifying (DMARDs)
•	Glucocorticoids (oral, IA, IM)
•	MTX/SASP/LEF/Gold/HCQ
•	Biologics (anti-TNF, anti-CD20, anti-IL6, etc)
•	Steroids can be used for acute exacerbations e.g. IM methylprednisolone depot injection

Question 11

describe methotrexate and how you would administer it

• MOA
• Side effects

Answer 11

o Anchor drug in multiple Rheum conditions
o Dihydrofolate reductase inhibitor
o Other actions - anti-inflammatory
o 7.5mg – 25mg per week orally or s/c
o Common side effects: GI, hair, skin, rashes
o Serious side effects: lungs/liver/BM suppression
o Concomitant folic acid
o Pregnancy – total contraindication
o Withhold during infection and if on abx