Rheumatoid arthritis (MSK) Flashcards
What is rheumatoid arthritis?
Chronic, erosive, inflammatory autoimmune disorder that primarily affects the joints
What is rheumatoid arthritis associated with?
Other autoimmune diseases e.g. Sjogren’s syndrome
Who does rheumatoid arthritis usually affect?
- F > M
- 40-60 year olds
What assessments are used routinely to provide optimum care for rheumatoid arthritis patients? (4)
- disease activity scores (DAS28)
- clinical disease activity index (CDAI)
- simplified disease activity index (SDAI)
- routine assessment patient index data (RAPID3)
What factors seem to be most abundant in the joint in rheumatoid arthritis? (3)
- TNF
- IL-1
- IL-6
Describe the aetiology of rheumatoid arthritis. (Low yield)
- IgM anti-IgG antibody
- increased angiogenesis, cellular hyperplasia, influx of inflammatory cells, change in expression of cell surface adhesion molecules and cytokines
- infiltration of T cells, B cells, macrophages and plasma cells
- TNF, IL-1, IL-6 most abundant in joint
- high levels of metalloproteinase activity thought to contribute to joint destruction
Describe the pattern of joint involvement in rheumatoid arthritis?
- symmetrical polyarthritis affecting small joints of hands and feet
- MCP, PIP, MTP
- DIP spared
What are the clinical features of rheumatoid arthritis?
- typical picture: symmetrical, swollen, painful, stiff small joints of hands and feet, morning stiffness >30min that improves with activity
- gradual onset
- polyarthritis
- systemic symptoms: fever, fatigue, weight loss, pericarditis, pleurisy
- rheumatoid nodules (non-tender, firm, subcutaneous nodules)
- uveitis/scleritis/episcleritis
- hand deformities (ulnar deviation, swan neck deformity, Boutonniere finger deformity)
What systemic symptoms can be seen in rheumatoid arthritis? (5)
- fever
- fatigue
- weight loss
- pericarditis
- pleurisy
What are some extra-articular features of rheumatoid arthritis? (2 + 1)
- rheumatoid nodules: non-tender, firm, subcutaneous nodules
- uveitis and/or scleritis (erythema and pain) /episcleritis (erythema only)
- can also lead to lymphadenopathy, vasculitis, fibrosing alveolitis, obliterative bronchiolitis, pleural and pericardial effusion, Raynaud’s, carpal tunnel syndrome, peripheral neuropathy, splenomegaly
What hand deformities can be seen in late stage rheumatoid arthritis? (3)
- ulnar deviation
- swan neck deformity (MCP flexion, PIP extension, DIP flexion)
- Boutonniere finger deformity (PIP flexion, DIP hyperextension - like pushing a button)
What are some risk factors for rheumatoid arthritis? (4)
- genetic predisposition: HLA-DR1, HLA-DR4
- smoking
- overweight/obesity
- infection
What is Felty’s syndrome? (3)
Rheumatoid arthritis + splenomegaly + low WCC
What are the 1st line investigations for rheumatoid arthritis? (4)
- rheumatoid factor (RF)
- anti-cyclic citrullinated peptide antibody (anti-CCP)
- radiographs
- ultrasonography
What might bloods show in rheumatoid arthritis?
- FBC - low Hb (anaemia of chronic disease), high platelets (inflammation)
- high CRP&ESR
What do antibody tests show in rheumatoid arthritis?
- rheumatoid factor: +ve in 70% of RA patients, more sensitive
- associated with rheumatoid nodules and extra-articular manifestations
- anti-CCP: (30% patients) highly specific test, +ve in 40% of patients who test negative for RA
What scan do we do in all patients with suspected rheumatoid arthritis?
NICE recommends performing x-rays of hands and feet
What would a joint x-ray show in rheumatoid arthritis?
BONDS
- Bone erosions
- Osteopenia/osteoporosis (juxta-articular)
- Narrowing of joint space
- Deformity
- Soft tissue swelling
What would ultrasound of joints in rheumatoid arthritis show?
Synovitis of wrist and fingers, have more sensitivity in detecting bone erosions
What would joint aspiration show in rheumatoid arthritis?
- high WCC - polymorphonuclear neutrophils
- turbid, yellow
- absence of crystals
What scoring system is used to follow disease activity in rheumatoid arthritis?
DAS28 (and CRP)
What are some differential diagnoses for rheumatoid arthritis? (5)
- psoriatic arthritis - asymmetrical small joints, DIP, psoriasis
- infectious arthritis
- gout - high levels uric acid, larger erosions, urate crustals
- SLE - high ANA and ENA autoantibodies, no erosions
- osteoarthritis - old age, large joints, pain worse with activity, LOSS on XR, morning stiffness only few minutes
How is rheumatoid arthritis GENERALLY managed? (2)
- DMARDs to slow disease progression
- initial: DMARD monotherapy +/- short course of bridging prednisolone
- NSAIDs
How do we manage acute mild rheumatoid arthritis at initial presentation?
- DMARDs (hydroxychloroquine, sulfasalazine, methotrexate)
- PLUS corticosteroid (prednisolone with calcium and vitamin D)
- PLUS NSAIDs (ibuprofen, naproxen, diclofenac - CI in any form of CVD)
How do we manage acute moderate-severe rheumatoid arthritis at initial presentation?
- DMARD
- biological agent e.g. TNF-a inhibitor (etanercept/infliximab/adalimumab)
- PLUS oral Janus kinase (JAK) inhibitor (e.g. tofacitinib, baricitinib, upadacitinib)
How do we manage acute rheumatoid arthritis if pregnant?
Corticosteroid (prednisolone), sulfasalazine or hydroxychloroquine
(Methotrexate is teratogenic)
What needs to be co-prescribed with methotrexate?
Folate to reduce risk of myelosuppression, as methotrexate is an anti-folate
What are some side effects of methotrexate? (4)
- pneumonitis (cough, SOB, fever)
- mucositis
- pulmonary fibrosis
- liver fibrosis
- (immunosuppression if folate not co-prescribed)
What can be prescribed if there is an inadequate response to at least 2 DMARDs in rheumatoid arthritis?
Infliximab (TNF-a inhibitor) - but may reactivate TB
How are acute flares of rheumatoid arthritis managed?
Oral or IM steroids e.g. prednisolone/methylprednisolone
How is ongoing rheumatoid arthritis managed (failure to reach low disease activity after 3 months of therapy)?
- 1st line: methotrexate + biological agent (infliximab)
- 2nd line: methotrexate + hydroxychloroquine + sulfasalazine (triple DMARD therapy)
- consider corticosteroid+NSAID
What are rituximab and abatacept for rheumatoid arthritis?
- emerging treatments
- rituximab: anti-CD20 monoclonal antibody –> B-cell depletion, infusion reactions common
- abatacept: fusion protein that modulates key signal required for T cell activation –> decreased T-cell proliferation and cytokine production
What are some complications of rheumatoid arthritis?
- work disability
- increased joint replacement surgery
- increased coronary artery disease
- increased mortality
- ILD
- Felty syndrome (RA+splenomegaly+low WCC)
- carpal tunnel syndrome
- methotrexate-induced liver toxicity and lung involvement
- TNF-a inhibitor-related infections
- TNF-a inhibitor-related malignancy
Describe the prognosis of rheumatoid arthritis.
Patients treated aggressively and early have a good prognosis with most patients achieving good disease control
