Rheumatoid Arthritis

Question 1

Rheumatoid arthritis (RA) is an autoimmune condition that causes?

Answer 1

Chronic inflammation of the synovial lining of the joints, tendon sheaths and bursae.

Question 2

RA distribution?

Answer 2

Symmetrical and affects multiple joints (polyarthritis)

Question 3

Risk factors in RA?

Answer 3

3 times more likely in women than men
Middle age (can present at any age)
Family History
(HLA DR4 gene)

Question 4

Antibodies in RA?

Answer 4

Rheumatoid factor (RF)
Anti-citrullinated cyclic peptide antibodies (anti-CCP)

Question 5

Which antibody is more specific to RA?

Answer 5

Anti-CCP antibodies (presence often pre-dates onset of RA)

Question 6

RA presentation?

Answer 6

Symmetrical distal polyarthropathy
Pain
Swelling
Stiffness
Often of small joints of hands and feet

Question 7

RA systemic symptoms?

Answer 7

Fatigue
Weight loss
Flu like symptoms
Muscle aches and weakness

Question 8

Does pain/stiffness get better with activity?

Answer 8

Yes, unlike osteoarthritis

Pain often worse after rest

Question 9

Signs of RA in hands?

Answer 9

'Boggy' feeling when palpating synovium around joints
Z shaped deformity of thumb
Swan neck deformity (hyperextended PIP, flexed DIP)
Boutonniere deformity (hyperextended DIP, flexed PIP)
Ulnar deviation of the fingers at the knuckle (MCP joint)

Question 10

Extra-articular manifestations in RA?

Answer 10

Pulmonary fibrosis
Bronchiolitis obliterans
Felty's syndrome
Secondary Sjogren's
Anaemia of chronic disease
Cardiovascular disease
Carpal tunnel syndrome

Question 11

Investigations in RA?

Answer 11

Check RF
If RF negative, then check CCP
Inflammatory markers such as CRP and ESR
X-ray of hands and feet
Ultrasound scan can be used to evaluate synovitis

Question 12

X-ray changes in RA?

Answer 12

Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Bony erosions

Question 13

Referral in suspected RA?

Answer 13

Any adult with persistent synovitis, regardless of RF, CCP and inflammatory markers
Urgent if small joints of hands/feet involved for more than 3 months

Question 14

Diagnosis of RA?

Answer 14

Scoring based on:

• joints involved (more and smaller joints score higher)
• serology
• Inflammatory markers
• duration of symptoms (more or less than 6 wks)

Question 15

Monitoring disease activity in RA?

Answer 15

DAS28 Score
Disease activity score of 28 joints, points give for:
- Swollen joints
- Tender joints
- ESR/CRP result

Question 16

Health Assessment Questionnaire in RA?

Answer 16

Measures functional ability, NICE recommended to check response to treatment

Question 17

Prognosis in RA?

Answer 17

Varies
Worse if: 
- Male
- Younger onset
- More joints affected
- Presence of RF and anti-CCP
- Erosions seen on x-ray

Question 18

Management of RA?

Answer 18

Start treatment early!
Full involvement of multidisciplinary team
Short course of steroids can be used to settle flare ups
Aim is to induce remission

Question 19

What is a DMARD? 3 examples?

Answer 19

Disease Modifying Antirheumatic Drug
Methotrexate
Leflunomide
Sulfasalazine