Rheumatoid Arthritis

Question 1

What is rheumatoid arthritis?

Answer 1

Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints.

Question 2

at what age patients with rheumatoid arthritis are normally diagnosed?

Answer 2

Most patients present in their 50s, the mean age typically being 50-55 years.

Question 3

what is a typical presentation of rheumatoid arthritis?

Answer 3

Patients usually present with a history of bilateral, symmetrical pain and swelling of the small joints of the hands and feet that has lasted for >6 weeks. Morning stiffness lasting over 1 hour is commonly reported but can also be seen in other inflammatory conditions

Question 4

what is the most common cause of swan-neck deformity?

Answer 4

Swan neck deformity is seen in advanced RA with damage to the ligaments and joints.

Question 5

what are the clinical tests to confirm the diagnosis of rheumatoid arthritis?

Answer 5

Rheumatoid factor (RF) , Anti-cyclic citrullinated peptide antibody (anti-CCP), Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)

Question 6

what is rheumatoid factor?

Answer 6

Rheumatoid factor is positive in about 60% to 70% of patients with RA.It is not required for diagnosis but is helpful if present. It should be tested at presentation and does not need to be repeated if positive. The higher the values, the worse the prognosis and the greater the need for aggressive treatment.

Question 7

what is anti-CCP?

Answer 7

Anti-cyclic citrullinated peptide antibody, a prognostic marker, is reported in about 70% of patients with RA.Anti-CCP can be positive when RF is negative, and it seems to play more of a pathogenic role in the development of RA. Anti-CCP does not need to be serially measured, even though it tends to decrease with better disease control.

Question 8

what is erythrocyte sedimentation rate?

Answer 8

Erythrocyte sedimentation rate (ESR) levels are also usually obtained because they reflect the level of inflammation. However, up to 40% of patients with RA may have normal levels.

Question 9

what are the key diagnostic symptoms/personal factors for RA?

Answer 9

active symmetrical arthritis lasting >6 weeks (common)
age 50 to 55 years (common)
female sex (common)
joint pain and swelling (common)
morning stiffness (common)

Question 10

what checks need to be done before starting treatment?

Answer 10

Hepatitis B and C status, purified protein derivative (PPD), full blood count (FBC), and liver function tests (LFTs) need to be checked before starting treatment.

Question 11

which parameters of RA should be monitored during treatment?

Answer 11

FBC and LFTs should be monitored regularly during treatment.

Question 12

what are the investigations for diagnosis of RA?

Answer 12

Offer to carry out a blood test for rheumatoid factor in adults with suspected rheumatoid arthritis who are found to have synovitis on clinical examination.

Consider measuring anti-CCP antibodies in adults with suspected RA if they are negative for rheumatoid factor.

X-ray the hands and feet in adults with suspected RA and persistent synovitis.

Question 13

what is the drug treatment for adults with newly diagnosed active RA?

Answer 13

Offer first-line treatment with cDMARD monotherapy using oral methotrexate, leflunomide or sulfasalazine as soon as possible and ideally within 3 months of onset of persistent symptoms.

Consider hydroxychloroquine for first-line treatment as an alternative to oral methotrexate, leflunomide or sulfasalazine for mild or palindromic disease.

Question 14

what is the role of steroids in RA at the start of RA treatment?

Answer 14

Consider short-term bridging treatment with glucocorticoids (oral, intramuscular or intra-articular) when starting a new cDMARD

Question 15

what can be used for managing flares in adults in RA?

Answer 15

Offer short-term treatment with glucocorticoids for managing flares in adults with recent-onset or established disease to rapidly decrease inflammation.

Question 16

what factors need to consider when treating symptoms of RA with oral NSAIDs?

Answer 16

offer the lowest effective dose for the shortest possible time

offer a proton pump inhibitor (PPI), and

review risk factors for adverse events regularly.

Question 17

what classes of drugs can be prescribed when control of pain or stiffness is inadequate?

Answer 17

Consider oral non-steroidal anti-inflammatory drugs (NSAIDs, including traditional NSAIDs and cox II selective inhibitors), when control of pain or stiffness is inadequate.

Question 18

what does non-pharmacological management of RA involve?

Answer 18

Physiotherapy

Occupational therapy

Hand exercise programmes

Podiatry

Psychological interventions

Diet and complementary therapies

Question 19

what is the bridging therapy used in RA?

Answer 19

Glucocorticoids used for a short period of time when a person is starting a new DMARD, intended to improve symptoms while waiting for the new DMARD to take effect (which can take 2 to 3 months).

Question 20

what are the Conventional disease-modifying anti-rheumatic drugs (cDMARDs)?

Answer 20

Conventional disease-modifying anti-rheumatic drugs are synthetic drugs that modify disease rather than just alleviating symptoms. They include methotrexate, sulfasalazine, leflunomide and hydroxychloroquine, but do not include biological DMARDs and targeted synthetic DMARDs.

Question 21

what is Palindromic rheumatism?

Answer 21

Palindromic rheumatism is a rare form of inflammatory arthritis which causes attacks of joint pain and swelling similar to rheumatoid arthritis, but the joints return to normal in between attacks. Patients with palindromic rheumatism may later develop rheumatoid arthritis.

Question 22

what does involve Step-up strategy in RA?

Answer 22

Additional DMARDs are added to DMARD monotherapy when disease is not adequately controlled.

Question 23

what does involve Step-down strategy in RA?

Answer 23

During treatment with 2 or more DMARDs, tapering and stopping at least 1 drug once disease is adequately controlled.

Question 24

what is synovitis?

Answer 24

Soft tissue joint swelling.

Question 25

What is the clinical and cost effectiveness of subcutaneous methotrexate compared with oral methotrexate for adults with early onset RA starting a new DMARD?

Answer 25

Methotrexate is an important drug in the treatment of RA. Subcutaneous administration is an alternative option for people who have side effects with oral treatment. Evidence on the effectiveness of subcutaneous methotrexate is lacking, but its effects may be superior, due to increased bioavailability, and fewer side effects than with oral drugs.

Question 26

what are the other symptoms of RA?

Answer 26

Other symptoms of rheumatoid arthritis include rheumatoid nodules and non-specific symptoms such as malaise, fatigue, fever, and weight loss.

Question 27

what are the aims of treatment for RA?

Answer 27

The aims of treatment are to relieve the symptoms of rheumatoid arthritis, achieve disease remission or low disease activity if remission cannot be achieved, and to improve the patient’s ability to perform daily activities.

Question 28

when should treatment for RA ideally start?

Answer 28

Treatment should be started as soon as possible, ideally within 3 months of onset of persistent symptoms, and the dose should be titrated to the maximum tolerated effective dose.

Question 29

what to do If symptoms of rheumatoid arthritis are inadequately controlled despite dose escalation on DMARD monotherapy?

Answer 29

If symptoms of rheumatoid arthritis are inadequately controlled despite dose escalation on DMARD monotherapy, combination therapy with another conventional DMARD (either oral methotrexate, leflunomide, sulfasalazine, or hydroxychloroquine sulfate) should be given.

Question 30

what to do if there has been an inadequate response to combination therapy with conventional DMARDS?

Answer 30

Treatment with a tumour necrosis factor (TNF) alpha inhibitor (either adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab), other biological DMARD (either abatacept, sarilumab, or tocilizumab), or targeted synthetic DMARD (either baricitinib or tofacitinib) is recommended if there has been an inadequate response to combination therapy with conventional DMARDS.

Question 31

what are the monitoring requirements for RA?

Answer 31

Patients with active rheumatoid arthritis should be monitored monthly until the treatment target (either remission or low disease activity) has been achieved, and all patients with rheumatoid arthritis should be reviewed annually. In patients who have maintained the treatment target for at least 1 year without corticosteroids, cautiously reducing drug doses to the lowest that are clinically effective, or tapering and stopping at least one drug if the patient is being treated with two or more DMARDs should be considered.

Question 32

can steroids be used long-term for RA?

Answer 32

In patients with established rheumatoid arthritis, the long-term use of corticosteroids should only be continued if all other treatments options (including biological and targeted synthetic DMARDs) have been offered.

Question 33

how to manage pregnant patients with RA?

Answer 33

Most medicines used to treat RA cannot be used while a patient is pregnant or planning a pregnancy; however, symptoms of RA usually diminish during pregnancy.

Corticosteroids are considered the safest option for patients planning pregnancy or who are pregnant, although sulfasalazine or hydroxychloroquine can also be used.

Biological agents and JAK inhibitors are generally not recommended in pregnancy due to a lack of safety data

Question 34

what should be prescribed alongside steroids? except PPI

Answer 34

If corticosteroids are given daily, calcium and vitamin D supplementation and yearly to biannual bone density assessment are recommended

Question 35

what is the drug regimen for methotrexate?

Answer 35

methotrexate: 7.5 mg orally once weekly (on the same day each week) initially, increase gradually according to response, maximum 20 mg/week

Question 36

what are TNF-alpha inhibitors approved for? give examples

Answer 36

TNF-alpha inhibitors approved for the treatment of moderately to severely active RA include etanercept, infliximab, adalimumab, certolizumab pegol, and golimumab

Question 37

what are the long term complications in RA?

Answer 37

work disability

increased joint replacement surgery

increased coronary artery disease

increased mortality

increased interstitial lung disease

Question 38

what the drug specific complications in RA?

Answer 38

methotrexate-related liver toxicity and lung involvement
Dose is adjusted or treatment discontinued.

TNF-alpha inhibitor-related infections
Treatment should be stopped while the infection is being treated. If serious, discontinuation of the TNF-alpha inhibitor should be considered. Repeated episodes should also lead to consideration of discontinuation.

Question 39

what is the overall prognosis for RA?

Answer 39

RA patients treated aggressively and early have a good prognosis with most patients achieving good disease control.

If there is a delay in treatment initiation or the disease remains untreated, many patients are disabled within 10 years.

Untreated, RA is also associated with increased premature mortality, most commonly from coronary artery disease.
Flares of disease are common, even in patients well controlled with disease-modifying anti-rheumatic drugs. Temporary measures, such as oral corticosteroids, are usually adequate.