Rheumatoid arthritis

Question 1

When is the pain worse?

Answer 1

In the morning.

Question 2

What is the pathophysiology of RA?

Answer 2

· Inflamed synovium is central to the pathogenesis.

· Synovium shows:

• Increased angiogenesis.
• Cellular hyperplasia.
• Influx of inflammatory cells.
• Cytokines.

· High levels of metalloproteinase.

Question 3

What is the aetiology of RA?

Answer 3

· Unknown, but thought to involve a type III hypersensitivity reaction.
· Associated with HLA DR4 and HLA DR1.

Question 4

What risk factors may contribute to a person developing RA?

Answer 4

· Genetic predisposition - FHx.

· Smoking.

Question 5

What hand signs and symptoms may occur?

Answer 5

·  Z deformity.
·  Boutonniere deformity.
·  Swan neck deformity.
·  Ulnar deviation.
·  Raynaud's.

Question 6

What wrist signs and symptoms may occur?

Answer 6

Carpal tunnel syndrome.

Question 7

What feet signs and symptoms may occur?

Answer 7

Subluxation of toes and hammer toe deformity.

Question 8

What skin signs and symptoms may occur?

Answer 8

Rheumatoid nodules and vasculitis.

Question 9

What cardiovascular signs and symptoms may occur?

Answer 9

Atherosclerosis is increased in RA.

Question 10

What respiratory signs and symptoms may occur?

Answer 10

Pulmonary fibrosis.

Question 11

What bone signs and symptoms may occur?

Answer 11

Osteoporosis.

Question 12

What other signs and symptoms may occur?

Answer 12

· Pain and swelling.

· Morning stiffness.

Question 13

What investigations would you request if you suspected a patient had RA?

Answer 13

· Bloods.

· X-ray.

Question 14

What are the typical blood results for RA?

Answer 14

· ESR and CRP - raised.

· RF and anti-CCP antibodies - positive.

Question 15

What would a typical RA x-ray show?

Answer 15

Bony erosion, subluxation, carpal instability, joint involvement and osteoporosis.

Question 16

List some differentials.

Answer 16

· Psoriatic arthritis. 
· Infectious arthritis. 
· Gout. 
· SLE.
· OA.

Question 17

What are the 3 management options?

Answer 17

1. Conservative.
2. Medical.
3. Surgery.

Question 18

What conservative management options are available?

Answer 18

Patient education - exercise, physio.

Question 19

What medical management options are available?

Answer 19

· Glucocorticoids.
· DMARDS - Disease modifying anti-rheumatic drugs - such as methotrexate.
· NSAIDs.

Question 20

What surgical management options are available?

Answer 20

Arthroplasty or replacement.

Question 21

What treatment option is available for non-pregnant patients?

Answer 21

Methotrexate.

Question 22

What complications may occur?

Answer 22

· Work disability. 
· Increased joint replacement surgery. 
· Increased CAD. 
· Increased mortality. 
· Carpal tunnel syndrome.