Rheumatoid Arthritis Flashcards
What is rheumatoid arthritis?
Chronic autoimmune condition involving inflammation of the synovial lining of the joints, tendon sheaths, and bursa.
Is rheumatoid arthritis symmetrical or asymmetrical?
Symmetrical usually
What is this a presentation of?
Middle aged woman with symmetrical distal joint pain, swelling, and stiffness, some systemic symptoms.
Rheumatoid arthritis
Which genes are associated with rheumatoid arthritis?
- HLA DR4 - often present in RF +ve patients
2. HLA DR1 - occasionally present in RF +ve patients
Which antibodies are present in rheumatoid arthritis?
- Rheumatoid factor (70%) - targets Fc portion of Ig
2. Cyclic citrullinated peptide antibodies (anti-CCP) - more sensitive and specific
What is palindromic rheumatism and what condition is it associated with?
- Self-limiting episodes of inflammatory arthritis, last 1-2 days, +ve RF/anti-CCP may indicate it will progress.
- Rheumatoid arthritis
Which joints are commonly affected in rheumatoid arthritis?
- PIP, MCP
- Wrist and ankle
- MTP
- Cervical spine
- Knees, hips, shoulders
What is atlanto-axial subluxation, what causes it, what are the complications, and how is it identified?
- C2 and odontoid peg shift within C1.
- Local synovitis and damage to structures around peg.
- Spinal cord compression (emergency)
- MRI visualises changes
What does z-shaped deformity of the thumb indicate?
Rheumatoid arthritis
What is swan neck deformity and what does it indicate?
- Hyperextended PIP with flexed DIP
2. Rheumatoid arthritis
What is Boutonnière deformity and what does it indicate?
- Hyperextended DIP with flexed PIP
2. Rheumatoid arthritis (uncommon finding)
Which joint is affected in ulnar deviation of the fingers at the knuckle and what does it indicate?
- MCP
2. Rheumatoid arthritis
Is a boggy feeling in the joints more typically OA or RA?
Rheumatoid arthritis
What are the lung manifestations of rheumatoid arthritis?
- Pulmonary fibrosis with pulmonary nodes (Caplan’s syndrome)
- Bronchiolitis obliterans (inflammation causing small airway destruction)
What are the haematological manifestations of rheumatoid arthritis?
- Felty’s syndrome (RA, neutropenia, splenomegaly)
2. Anaemia of chronic disease
What is the exocrine manifestation of rheumatoid arthritis?
Secondary Sjogren’s syndrome (sicca syndrome)
What are the ophthalmological manifestations of rheumatoid arthritis?
Scleritis and episcleritis
Which investigations are required alongside a clinical presentation to diagnose rheumatoid arthritis?
- Rheumatoid factor, if negative check anti-CCP
- Inflammatory markers - CRP and ESR
- X-ray of hands and feet
- USS to confirm synovitis (when clinical examination findings are unclear)
What are the x-ray changes in rheumatoid arthritis?
- Joint destruction and deformity
- Soft tissue swelling
- Periarticular osteopenia
- Bony erosions
When should rheumatoid arthritis be referred to rheumatology?
- Persistent synovitis (even if Abs -ve)
2. Involving small joints/multiple joints/symptoms present over 3 months - URGENT referral
What is the basis for scoring a patient suspected of having rheumatoid arthritis?
- Joints involved - more points for small joints
- Serology - RF/anti-CCP
- Inflammatory markers - CRP/ESR
- Duration of symptoms - more or less than 1 week
Greater than or equal to 6 = rheumatoid arthritis
What is the DAS28?
Disease activity score, based on assessment for 28 joints, rheumatoid arthritis.
Which factors indicate a worse prognosis in rheumatoid arthritis?
Younger, male, more joints and organs involved, presence of RF and anti-CCP, erosions on x-ray.
What is the pharmaceutical management of rheumatoid arthritis?
- Short course of steroids/NSAIDs/COX-2 inhibitors
- DMARDs - methotrexate/leflunomide/sulfasalazine
- Try combining, then try with biological therapy
- Hydroxychloroquine for mild cases
How does methotrexate work and what needs to be taken alongside it?
- Interferes with folate metabolism to suppress components of immune system.
- Folic acid taken on different day
What is the major notable side effect of methotrexate?
Pulmonary fibrosis
How does leflunomide work and what are the two notable side effects?
- Immunosuppression, interferes with pyrimidine production.
2. Hypertension and peripheral neuropathy
What is sulfasalazine for and what is it’s notable side effect?
- Immunosuppression and anti-inflammatory
2. Temporary male infertility (low sperm count)
What are the major notable side effects of hydroxychloroquine?
Nightmares and reduced visual acuity (macular toxicity)
What are the major notable side effects of anti-TNF medications?
Reactivation of TB and hepatitis B
What are the major notable side effects of rituximab?
Night sweats and thrombocytopenia
