Rheumatoid Arthritis

Question 1

Rheumatoid Arthritis:

Cause, sex prevalence and main avoidable risk factor?

Answer 1

• Unknown cause
• *twice as many women affected than men
• *Dose response relationship with tobacco smoking

Question 2

Rheumatoid Arthritis:

Symptoms and variations?

Answer 2

• Symmetrical joint pain/swelling (typically wrist and MCP/MTP)
• Gradual or sudden onset
• Morning stiffness ≥ 1 hr
• Extensor surface nodules (30%)
• Flulike symptoms (fatigue, weakness, malaise)

Polymayalgic = >65yo and limb girdle (shoulder and/or hip pain)

Palindromic rheumatism = episodic joint symptoms lasting hours to days at variable intervals

*25% of cases present as a single joint

Question 3

Rheumatoid Arthritis:

How to clinically diagnose?

Answer 3

Clinically diagnosed IF
a)	≥3 persistently swollen or painful joints
OR
b)	Symmetrical MCP or MTP involvement
OR
c)	Morning stiffness lasting  >30 minutes
OR
d)	Positive MCP/MTP squeeze test

*Swelling in a joint for ≥6 weeks should be referred to a rheumatologist even if RA is not suspected

Question 4

Rheumatoid Arthritis:

RA specific investigations?

Answer 4

• ESR/CRP
• Rh Factor (60-70% of RA patients = more aggressive disease)
• Anti-CCP = more erosive disease

Question 5

Rheumatoid Arthritis:

Managment?

Answer 5

• RA carries a up to 50% increased CVD mortality = STATINS
• RA carries and up to 40% increased risk of osteoporotic fractures = OPTIMISE osteoporosis management
  1) REFERRAL (*DMARDS are most effective at preventing severity and disability associated with disease if initiated within 12 weeks of onset)

2)	Analgesia
•	Paracetamol
•	NSAIDs
•	Omega 3 (2.7 – 12g per day) 
OR
•	Gamma Linolenic Acid (GLA) 1400mg per day
OR
•	Evening primrose oil 3000mg

3) Disease Modifying AntiRheumatic Drugs (DMARDs)
• Methotrexate, azathioprine, leflunomide, hydroxychloroquine, cyclosporin
• Ant TNFa (abatacep, adalimumab, etanercept, infliximab, rituximab, golimumab)
• Anti interleukin 1 (anakinra, tocilizumab)

*prior to starting DMARDs
• Check influenza and pneumococcus vaccination
• BBV status
• Get a CXR and check CBE, EUC, LFTs as baseline

Question 6

Rheumatoid Arthritis:

What factors to look out for when RA patient is on DMARDs?

Answer 6

*Talk with a rheumatologist about considering cessation of DMARDs IF:
•	WCC <3.5
•	MCV >105
•	PLT <140
•	Neutrophils <1.6
•	Eosinophils >0.5
•	Creatinine maintains a rise of 30% over 12 months
•	ALT or AST >100
•	Albumin <30 and unexplained

Question 7

Rheumatoid Arthritis:

GPs role in monitoring needs to include?

Answer 7

• Complications of medications (compliance, toxicity, advise to temporarily cease when serious infection, increased risk of atypical infections)
• Nodules, rashes, joints
• Foot review (annually)
• BP
• Renal function
• Functional performance
• Mental health
• Promote physical activity