Rheumatoid arthritis

Question 1

What is RA?

Answer 1

Autoimmune seropositive inflammatory arthropathy

Question 2

Where is most commonly affected?

Answer 2

Small joints in hands and feet

Question 3

Can large joints be affected?

Answer 3

Yes as disease progresses

Question 4

Which joints are affected?

Answer 4

PIP

Question 5

Which joints are unaffected?

Answer 5

DIP - minimal synovium

Question 6

Who gets it?

Answer 6

Women more likely
Inc with age
35- 50 is peak
Genetic factors

Question 7

Causes?

Answer 7

HLA- DR4 mediated

Cause unknown

Question 8

Potential triggers?

Answer 8

Infections, stress, cigarette smoking, bereavement

Question 9

Pathogenesis?

Answer 9

Immune response initiated against synovium

Inflammatory panes forms which attacks auricular cartilage -> joint destruction

Question 10

Clinical features?

Answer 10

Pain & stiffness in small joints (PIP, MCP, MTP's), not DIPs
Prolonged morning stiffness
Symmetrical
Positive compression tests 
Can't make fists
Rapid onset
Swelling

Question 11

S factor for inflammatory ?

Answer 11

Stiffness (morning, >30 mins)
Swelling
Squeezing is painful

Question 12

Extra- articular manifestations?

Answer 12

Rheumatoid nodules (extensor surfaces or areas of freq irritation)
Lung involvement
CVS mortality >
OCular involvement
Dry eyes, mouth
Persistent synovitis in hands

Question 13

Ocular involvement?

Answer 13

Keratoconjunctivitis
Sicca
Episcleritis
Uveitis
Nodular scleritis

Question 14

Investigations?

Answer 14

Anti- CCP antibody (very specific & preferred)
Rheumatoid factor
CRP, ESR, plasma viscosity - raised
X-rays
Ultrasound
MRI - gold standard

Question 15

X-ray findings?

Answer 15

Often none
Early features:
- Peri- articular osteopenia, soft tissue swelling
Late:
- Erosions, subluxations

Question 16

Diagnosis?

Answer 16

≥6 ACR/ EULAR criteria

Question 17

Management?

Answer 17

Methotrexate (DMARD)
Sulfasalazine 
Leflunomide
Hydrochloroquine
Steroids (flare up)

Question 18

When is biologic therapy considered?

Answer 18

If been on 2 DMARDs and still have DAS28 of >5.1

Question 19

Biologic therapy?

Answer 19

Anti- TNF agents (infliximab)
T cell receptor blocker (Abatacept)
B cell depletion (rituximab)
IL-6 blocker (tocilizumab)

Question 20

DAS28 score?

Answer 20

Disease activity score for RA

Question 21

Characteristic signs?

Answer 21

Rheumatoid nodules
Swan neck deformity (flexion at distal interphalangeal joints (DIP))
Boutonnieres deformity (DIP flexion, PIP hyperextension)
Extra- articular symptoms e.g. vasculitis

Question 22

Radiographic features?

Answer 22

Narrowing of joint space
Bone erosions
Periarticular osteopenia
Subluxation