Rheumatoid arthritis Flashcards by Hannah Falconer

What are general symptoms and signs for arthritis/?

Symptoms:
Pain
Stiffness
Swelling 
Functional impairment
Systemic symptoms

Signs:
Tenderness
Swelling
Restriction of movement
Heat
Redness
Systemic features

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What is included in rheumatic disease?

RA
Seronegative arthritis
Crystal arthritis
Connective tissue diseases
Systemic vasculitis
Bone disease

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What is the functions of the synovium?

Maintenance of intact tissue surface
Lubrication of cartilage
Control of synovial fluid volume and composition
Nutrition of chondrocytes within joints

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What happens in a joint affected by rheumatoid arthritis?

Erosion into corner of bone
Thinning of cartilage
Inflamed synovium spreading across joint surface
Inflamed tendon sheath

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What is the definition of rheumatoid arthritis?

Chronic symmetric polyarticular inflammatory joint disease, primarily affects small joints of hands and feet

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Where does RA primarily affect?

Small joints of hands and feet

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What is the rheumatoid synovitis characterised by pathologically?

Inflammatory cell infiltration
Synoviocyte proliferation
Neoangiogenesis

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What does the synovial fluid in the joint cavity contain in RA?

Neutrophils

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What does the synovial pannus in RA cause?

Bone and cartilage destruction

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What is RA linked to etiologically?

Autoimmunity

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What do the autoantibodies in RA recognise?

Joint antigens e.g. type II colagen

Systemic antigens e.g. glucose phosphate isomerase

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How do the autoantibodies in RA contribute to inflammation?

Activation of complement

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What is the autoimmune reaction mediated by in seropositive RA?

Rheumatoid factor

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What are cases of RA where rheumatoid factor is not present, referred as?

Seronegative RA

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What is rheumatoid factor an an antibody against?

IgG Fc

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What is the aetiology of RA?

Genetic factors
Environmental factors: smoking, infectious agents, stress
Chronic infection

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What are examples of infectious agents associated with RA?

Viruses (EBV, CMV)
E.coli
Mycoplasma

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What are bone and cartilage destruction mediated by in RA?

Osteoclasts

Fibroblast-like synviocytes

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What is RA and what is it characterised by?

Chronic, auto immune, systemic illness

Symmetrical peripheral arthritis and other systemic features

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What is the criteria for classifying RA?

1987 ARA criteria
or
2010 ACR classification

What is the ACR classification for clinically diagnosing RA?

Morning stiffness >1 hour
> 3 joints involved
Hands and wrist involvement
Symmetrical
Nodules
Positive RF
Radiological changes
Symptoms present for > 6 weeks

Which sex is more affected by RA?

Female

What is the typical age of onset of RA?

4/5th decade

Any age from 16

What is the main pathological sign of RA?

Synovitis

What are the immunology investigations for RA?

Rheumatoid factor | Anti cyclic citrullinated antibodies (Anti CCP, ACPA)

What are investigations for RA?

Serology/immunology XR MRI Joint aspiration

What is the main differential for RA?

SLE

What are the main symptoms of RA?

``` Pain Stiffness Immobility Poor function Systemic symptoms ```

What are clinical signs of RA?

Swelling e.g. elbows, wrists, MCP joints, ankles, knee effusions Tenderness Limitation of movement e.g. unable to lift arms (Heat) (Redness)

What are the non-specific systemic features of RA?

Fatigue Weight loss Anaemia

What are the specific systemic features of RA?

``` Eyes Lungs Nerves Skin Kidneys ```

What are the long term systemic features of RA?

CVS | Malignancy

What are specific clinical features that can be described in the hands of a patient with RA?

``` Swan-necking Z-thumb Subluxation of the MCP Muscle wasting 'guttering' Ulnar deviation Fixed flexion deformity ```

What is the scoring system for disease activity/treatment in RA?

Disease activity score (DAS)

What does a DAS score of <2.4 mean in RA?

Clinical remission

What does a DAS score of >5.1 mean in RA?

Eligibility for biologic therapy

What bloods may be raised with RA?

Inflammatory markers = ESR, CRP

What is the rheumatology review for RA?

Check for positive RF and positive anti-CCP antibody Baseline hand and foot XR Glucocorticoids Initiation of DMARD therapy (sulfasalazine)

What is the rheumatology follow up for RA?

Early arthritis clinic: | monitoring appointments, monitoring disease activity, monitoring blood tests, patient education, MDT

What are the main DMARD's used in RA?

Methotrexate | Sulfasalazine

What is a DMARD?

Disease modifying anti-rheumatic drug

What MDT are involved in RA?

``` Rheumatology specialist nurse Rheumatology OT Rheumatology physio Pharmacist Clinical psychologist Podiatrist Orthotics Rheumatology Consultant ```

Apart from DMARDs what other medications can be used for RA?

Steroids | Symptomatic relief - analgesics

What treatment is used in RA for patients who fail to respond to DMARDs?

Anti-TNF-alpha

What are other treatment options available for RA?

Anti B cell: rituximab Anti IL-6 receptor JAK inhibitors

What are complications of RA which might require orthopaedic intervention?

``` Chronic synovitis Mechanical deformities Secondary OA Poor function Pain ```

What are complications of RA which would have extra-articular involvement?

Rheumatoid nodules Interstitial lung disease Vasculitis

What can be done to help functional impairment in RA?

``` Special adaptive cutlery Special footwear Walking aids Use of wheelchair Supportive family Care package ```