Rheumatoid Arthritis

Question 1

What is Rheumatoid Arthritis?

Answer 1

A long-term autoimmune disease that primarily affects the joints of the hand

Question 2

What is the pathophysiology of RA?

Answer 2

Citrullination of self-antigens which is recognised by immune cells that then produce antibodies (RF & anti-CCP). This leads to an inflammatory cascade that results in destruction of joints & bone.

Question 3

What are the risk factors for RA?

Answer 3

• Gender = Female
• Family Hx
• Smoking
• Obesity
• Environmental exposure (e.g. asbestos, silica,etc.)

Question 4

What are the signs?

Answer 4

• Soft tissue swelling
• Tenderness (MCPJ squeeze test positive)
• Ulnar deviation/Palmar sublaxation of MCPs
• Swan-neck & Boutonniere deformity
• Rheumatoid nodules (commonly at elbows)
• Median nerve (carpal tunnel association)
• Atlanto-axial sublaxation

Question 5

What are the symptoms?

Answer 5

• Progressive, peripheral, symmetrical polyarthritis
• Pain
• Joint swelling
• Mainly in hand joints (w sparing of DIPs)
• Can also affect hips/knees/shoulders/C-Spine
• Morning stiffness > 30 mins
• Fatigue/malaise

Question 6

Answer 6

Rheumatoid Nodules

(These are most frequently found at elbows)

Question 7

What sign is seen here?

Answer 7

Ulnar deviation

Question 8

What sign is seen here?

Answer 8

Palmar sublaxation

Question 9

What signs are seen here?

Answer 9

A = Boutonniere’s deformity

(PIP flexion & DIP hyperextension)

B = Swan-neck deformity

(PIP hyperextension & DIP flexion)

Question 10

What is atlanto-axial sublaxation?

Answer 10

Malalignment of the 1st & 2nd vertebrae

Question 11

What “routine tests” would aide a diagnosis of RA?

Answer 11

• FBC
• U&Es
• LFTs
• Inflammatory markers (CRP, ESR, Plasma visocity)
• XR (In established disease)
• USS/MRI (in early stages)

Question 12

What autoantibody tests are important to carry out?

Answer 12

• RF
• Anti-CCP
• ANA
• Anti-Ro & La Antibodies

Question 13

What changes may be seen on FBC?

Answer 13

Normocytic, Normochromic Anaemia

(Anaemia of Chronic Disease)

Question 14

What is the typical effect on inflammatory markers?

Answer 14

Inflammatory markers usually elevated

Question 15

What are the XR features of RA?

Answer 15

LESS

1. Loss of joint space
2. Erosions (Periarticular)
3. Soft tissue swelling
4. Sublaxation

Question 16

What is the pharmaceutical management of RA?

Answer 16

1. DMARD monotherapy
   
   • Methotrexate usually
   • Hydroxychloroquine
   • Sulfasalazine
   • Leflunomide
   • 2. Short course of steroids
   • Prednisolone / Methylprednisolone
   • 3. NSAIDs (w PPI coverage)

• For symptomatic relief

Question 17

What side-effects of methotrexate are worth monitoring for? What tests would you use to monitor for these?

Answer 17

Liver cirrhosis - LFTs

Myelosuppression - FBCs

Pneumonitis is another important complication to consider

Question 18

How is treatment response monitored?

Answer 18

Using a combo of CRP & disease activity.

Question 19

How are flare-ups managed?

Answer 19

Short course of glucocorticoids (e.g. prednisolone, methylprednisolone, etc.)

Question 20

What is the non-pharmalogical management?

Answer 20

• OT/PT
• Podiatry
• Psychological therapy

Question 21

What are the extra-articular features of RA?

Answer 21

• 3Cs = Carpal tunnel syndrome, CVD risk, Cord compression
• 3As = Anaemia, Amyloidosis (Rare), Arteritis (Rare)
• 3Ps = Pericarditis (uncommon), Pleural disease (common), Pulmonary disease (common)
• 3Ss = Sjogren’s (common), Sleritis (uncommon), Splenic enlargement

Question 22

Why does cord compression occur as a complication?

Answer 22

Due to atlanto-axial sublaxation

Question 23

What is the name for splenic enlargement paired with neutropenia?

Answer 23

Felty’s Syndrome

(Rare extra-articular manifestation)