Rheumatoid arthritis

Question 1

What is rheumatoid arthritis

Answer 1

A chronic systemic inflammatory disease characterised by a symmetrical deforming peripheral polyarthritis

Question 2

What does RA increase the risk of?

Answer 2

Cardio and cerebro vascular disease

Question 3

Who does RA typically affect

Answer 3

Women
Age 50-60
Smokers

Question 4

Name the genetic link to increased severity of RA

Answer 4

HLA-DR4/DR1

Question 5

Describe the typical symptoms of RA

Answer 5

Symmetrical, stiff, swollen, painful small joints of hands and feet
Worse in morning
Can fluctuate and larger joints may be involved
Can have less common presentation with widespread arthritis, recurring polyarthritis (palindromic), persistent monoarthritis or systemic illness (extra-articular features)

Question 6

What are some signs of RA?

Answer 6

Swollen MCP, PIP, wrist or MTP joints
Look for tenosynovitis or bursitis
Ulnar deviation and subluxation of the wrists
Boutonnière and swan neck deformity of the fingers and Z deformity of the thumb
Foot changes are similar
Atlanto-axial subluxation is rare but can threaten the spinal cord

Question 7

List the extra-articular manifestations of RA

Answer 7

Nodules on elbows, lungs, cardiac and CNS
Vasculitis
Lymphadenopathy 
Pleural disease, interstitial fibrosis, bronchiolitis obliterans, organising pneumonia
IHD, pericarditis, pericardial effusion 
Carpal tunnel syndrome
Peripheral neuropathy 
Feltys syndrome 
Episcleritis, keratoconjunctivitis sicca
Osteoporosis
Amyloidosis (rare)

Question 8

What is feltys syndrome

Answer 8

Splenomegaly
RA
Neutropenia

Question 9

What are the investigations for RA

Answer 9

Rheumatoid factor - positive in 70% and high levels associated with poorer outcomes
Anti-CCP - highly specific for RA and predict progression
Anaemia of chronic disease, increased platelets, increased ESR/CRP
Xrays - soft tissue swelling, bony erosion, subluxation and complete carpal destruction

Question 10

What is needed for diagnosis of RA

Answer 10

Clinical suspicion - those with > 1 swollen joint and suggestive clinical history not explained by another disease. Scores greater than 6
A - joint involvement (5 for >10 joints)
B- serology (3 for high positive RF or anti-CCP)
C- acute phase reactants (1 for abnormal CRP/ESR)
D - duration of symptoms (1 for >6weeks)

Question 11

How is RA managed

Answer 11

Rheum referral
Disease activity - DAS28 score - treat to target
Early DMARDs and biologics
IM steroids for flares
NSAIDs for symptomatic relief - do not alter progression
OT and physio referral
Lifestyle - CVD RF adjustment
Surgery - relieve pain, improve function and reduce deformity

Question 12

Name the 4 types of biological and give examples

Answer 12

TNF alpha inhibitors - infliximab, etanercept, adalimumab
B cell depletion - rituximab
IL-1 and IL-6 inhibition - tociluluzimab
Inhibition of T cell co-stimulation - abatacept

Question 13

How long does methotrexate take to work?

Answer 13

6-12 weeks

Question 14

When should DMARDs ideally be started?

Answer 14

Within 3 months of persistent symptoms

Question 15

What are the SEs of methotrexate

Answer 15

Pneumonitis, oral ulcers, hepatotoxicity, teratogenic

Question 16

What are the SEs of sulfalazine

Answer 16

rash, decreased sperm count, oral ulcers, GI upset

Question 17

What are the SEs of lefulomide

Answer 17

Teratogenicity, oral ulcers, hypertension, hepatotoxicity

Question 18

What are the SEs of hydroxychloroquine

Answer 18

Retinopathy

Question 19

What is the fatal SE of DMARDs and biologics?

Answer 19

Immunosuppression - pancytopenia and neutropenic sepsis

Question 20

What is required before starting biologics and DMARDs?

Answer 20

TB, HIV, HepB/C screen and CXR