Rheumatoid arthritis Flashcards
What are the features of RA?
Symmetrical distal polyarthritis
Swollen, painful joints in hand and feet Systemic symptoms: Fatigue Weight loss Flu-like illness Muscle aches Weakness
Stiffness worse in morning
Presentation insidious and develops over a few months
Gradually gets worse with larger joints becoming involved
+ve squeeze test over MCTP and MTP joints
What deformities in the hand may be present in RA?
Swan neck Boutonniere Guttering - muscle wasting over dorsum of hand Z-thumb Ulnar deviation Subluxation of MCP joints
What is palindromic rheumatism?
Short episodes (1-2 days) of inflammatory arthritis with joint pain, stiffness and swelling, usually only affecting a few joints
+ve RF and CCP may suggest it will progress to full RA
What is atlantoaxial subluxation?
This is when the axis (C2) and its dens shift within the atlas (C1)
Caused by local synovitis and damage to the ligaments and bursa around the dens of the axis and atlas
Occurs in 50% of RA
Subluxation can cause spinal cord compression and is an emergency
What extra-articular conditions can also occur in RA?
Pulmonary fibrosis with pulmonary nodules (in presence of RA it's called Caplan's syndrome) Bronchiolitis obliterans Felty's syndrome (mnemonic SANTA) Secondary Sjorgen's syndrome (aka sicca syndrome) Anaemia of chronic disease Cardiovascular disease Episcleritis and scleritis Rheumatoid nodules Lymphadenopathy Carpal tunnel syndrome Amyloidosis
SANTA: Splenomegaly Anaemia Neutropenia/leukopenia Thrombocytopenia rheumatoid Arthritis
What investigation are used to diagnose RA?
Antibodies:
RF - not diagnostic as also present in other conditions e.g. Sjorgen’s, but still useful
Anti-CCP - more sensitive and specific to RA than RF
Bloods:
FBC - Hb may be low due to anaemia of chronic disease, iron deficiency from use of NSAIDs, or due to menorrhagia, Felty’s syndrome, pernicious anaemia, autoimmune haemolytic anaemia
LFTs
U&Es
Inflammatory markers - CRP and ESR
TFTs - hyper/hypothyroidism can cause joint pain
X-ray of hands and feet:
Early disease - may see soft tissue swelling
Chronic disease - may see periarticular erosions, osteopenia, joint space narrowing and deformity
US of joints:
Confirms synovitis and joint effusion
More sensitive at identifying bone erosion
How is RA diagnosed?
American college of rheumatology (ACR) 2010 criteria that scores patients on: Joints involved Serology Inflammatory markers Duration of symptoms
A total score >=6 indicates diagnosis of RA
How is disease activity monitored in RA?
DAS28 score:
Based on assessing 28 joints and points given for swollen joints, tender joints and ESR/CRP result
What is the management for RA?
Involve MDT e.g. physio, OT, specialist nurse, psychology, podiatry
On 1st presentation:
steroids or NSAIDs (co-prescribed with PPI)
Initial therapy:
DMARDs +/- bridging prednisolone
During flare ups:
Prednisolone - oral or IM
DMARDs:
1st line = mono therapy with methotrexate, leflunomide or sulfasalazine. Hydroxychloroquine can be given in mild disease
2nd line = x2 DMARDs used in combination
3rd line = methotrexate PLUS biological therapy (usually TNF inhibitor)
4th line = methotrexate PLUS rituximab
What DMARDs are safe to use in pregnancy?
Sulfasalazine and hydroxychloroquine
RA symptoms improve in pregnancy due to higher natural production of steroid hormones
