Rheumatoid arthritis + Osteoarthritis +Juvenile idiopathic arthritis

Question 1

What is rheumatoid arthritis?

Answer 1

Rheumatoid arthritis is an autoimmune condition that causes chronic inflammation in the synovial lining of joints, tendon sheaths, and bursa. It is a type of inflammatory arthritis, and synovial inflammation is referred to as synovitis. Inflammation of tendons increases the risk of tendon rupture.

Question 2

Describe the pattern of joint involvement in rheumatoid arthritis.

Answer 2

Rheumatoid arthritis tends to affect multiple small joints symmetrically across both sides of the body. This pattern is described as symmetrical polyarthritis.

Question 3

What is the gender predilection for rheumatoid arthritis, and what are the common risk factors?

Answer 3

Rheumatoid arthritis is 2-3 times more common in women than men. It most often develops in middle age but can occur at any age. Smoking and obesity are risk factors. A family history increases the risk, with HLA DR4 being the most common gene associated with rheumatoid arthritis.

Question 4

How does the disease course vary in rheumatoid arthritis patients?

Answer 4

The disease course varies between patients, ranging from mild and remitting to severe and progressive. Disease activity, positive antibodies, and erosions on an x-ray predict worse disease outcomes.

Question 5

What is the significance of HLA DR4 in rheumatoid arthritis?

Answer 5

HLA DR4 is the most common gene associated with rheumatoid arthritis. While there is a family history risk, there is no clear inheritance pattern.

Question 6

What are the antibodies associated with rheumatoid arthritis, and how do they contribute to inflammation?

Answer 6

Rheumatoid factor (RF) is an autoantibody present in around 70% of RA patients. It targets the Fc portion of immunoglobulin G (IgG), causing immune system activation against the patient’s own IgG, resulting in systemic inflammation. Anti-cyclic citrullinated peptide antibodies (anti-CCP antibodies) are more sensitive and specific, being positive in around 80% of patients. They pre-date the development of rheumatoid arthritis.

Question 7

What are the three joint symptoms of rheumatoid arthritis?

Answer 7

The three joint symptoms of rheumatoid arthritis are pain, stiffness, and swelling.

Question 8

Describe the typical joint involvement in rheumatoid arthritis.

Answer 8

Rheumatoid arthritis typically causes symmetrical distal polyarthritis affecting the small joints of the hands and feet. The most commonly affected joints include Metacarpophalangeal (MCP) joints, Proximal interphalangeal (PIP) joints, wrist, and Metatarsophalangeal (MTP) joints in the foot. There is tenderness and synovial thickening on palpation, giving the joints a “boggy” feeling.

Question 9

Which joints are very rarely affected by rheumatoid arthritis, and what condition is more likely if they are enlarged and painful?

Answer 9

Rheumatoid arthritis very rarely affects the distal interphalangeal joints-and 1st carpometacrpal. Enlarged and painful distal interphalangeal joints are more likely to represent Heberden’s nodes due to osteoarthritis.

Question 10

Besides small joints, what are some large joints that can be affected by rheumatoid arthritis?

Answer 10

Large joints such as the ankle, knee, hips, and shoulders can also be affected by rheumatoid arthritis. It can also affect the cervical spine, although not the lumbar spine.

Question 11

What are some associated systemic symptoms of rheumatoid arthritis?

Answer 11

Associated systemic symptoms of rheumatoid arthritis include fatigue, weight loss, flu-like illness, muscles aches, and weakness.

Question 12

How do symptoms of inflammatory arthritis differ from mechanical problems like osteoarthritis?

Answer 12

Inflammatory arthritis symptoms are worse with rest and improve with activity. They are worst in the morning. Symptoms of mechanical problems (e.g., osteoarthritis) are worse with activity and improve with rest.

Question 13

What is palindromic rheumatism, and how does it differ from rheumatoid arthritis?

Answer 13

Palindromic rheumatism involves self-limiting episodes of inflammatory arthritis, with pain, stiffness, and swelling affecting only a few joints. The symptoms last for days and then completely resolve. Joints appear normal between episodes. Rheumatoid factor or anti-CCP antibodies may indicate progression to rheumatoid arthritis.

Question 14

What are the hand signs associated with advanced rheumatoid arthritis?

Answer 14

In advanced rheumatoid arthritis, hand signs include Z-shaped deformity to the thumb, Swan neck deformity (hyperextended PIP and flexed DIP), Boutonniere deformity (hyperextended DIP and flexed PIP), and ulnar deviation of the fingers at the MCP joints.

Question 15

Explain the mechanism behind Boutonniere deformity and Swan neck deformity.

Answer 15

Boutonniere deformity is caused by a tear in the central slip of the extensor components at the proximal interphalangeal (PIP) joint, resulting in hyperextension of the DIP joint and flexion of the PIP joint. Swan neck deformity, on the other hand, is caused by an extensor mechanism imbalance, leading to flexion of the DIP joint and extension of the PIP joint.

Question 16

What is the significance of Z-shaped deformity in advanced rheumatoid arthritis?

Answer 16

Z-shaped deformity in advanced rheumatoid arthritis is observed in the thumb and is a characteristic hand sign associated with the condition.

Question 17

What is atlantoaxial subluxation, where does it occur, and what complications can arise from it?

Answer 17

Atlantoaxial subluxation occurs in the cervical spine, involving synovitis and damage to the ligaments around the odontoid peg of the axis (C2). It allows shifting within the atlas (C1) and can cause spinal cord compression, posing as an emergency. Consideration of this condition is crucial during a patient’s general anesthesia requiring intubation. MRI can visualize changes in these areas as part of a pre-operative assessment.

Question 18

List some extra-articular manifestations of rheumatoid arthritis.

Answer 18

Extra-articular manifestations of rheumatoid arthritis include Felty’s syndrome (rheumatoid arthritis, neutropenia, and splenomegaly),pulmonary fibrosis, Sjögren’s syndrome (with dry eyes and dry mouth), anemia of chronic disease, cardiovascular disease, eye manifestations, rheumatoid nodules, lymphadenopathy, carpal tunnel syndrome, amyloidosis, bronchiolitis obliterans, and Caplan syndrome (pulmonary nodules in patients with rheumatoid arthritis exposed to coal, silica, or asbestos dust).

Question 19

What are some eye manifestations related to rheumatoid arthritis?

Answer 19

Eye manifestations related to rheumatoid arthritis and its treatment include dry eye syndrome (keratoconjunctivitis sicca), episcleritis, scleritis, keratitis, cataracts (secondary to steroids), retinopathy (secondary to hydroxychloroquine).

Question 20

According to NICE clinical knowledge summaries, when is an urgent rheumatology referral recommended for patients with suspected rheumatoid arthritis?

Answer 20

NICE recommends an urgent rheumatology referral for patients with persistent synovitis, to be seen within three weeks. In the meantime, considering an NSAID and arranging baseline bloods are suggested while waiting for specialist assessment.

Question 21

What investigations are helpful in the initial assessment of rheumatoid arthritis?

Answer 21

Investigations helpful in the initial assessment of rheumatoid arthritis include rheumatoid factor, anti-CCP antibodies, inflammatory markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), X-rays of the hands and feet for bone changes, and ultrasound or MRI to detect synovitis, especially when clinical findings are unclear.

Question 22

How is the diagnosis of rheumatoid arthritis made, and what classification criteria can be used?

Answer 22

The diagnosis of rheumatoid arthritis is based on clinical findings and blood results. The American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria from 2010 can be used to make the diagnosis.

Question 23

What are some X-ray changes associated with rheumatoid arthritis?

Answer 23

• Juxta articular osteopenia /Periarticular osteopenia
• Soft tissue swelling
• Narrow of the joint space
• bone erosions
• subchondral cysts

Question 24

What scoring systems are used in assessing rheumatoid arthritis?

Answer 24

The Health Assessment Questionnaire (HAQ) measures functional ability and is recommended for a baseline score at diagnosis to assess the response to treatment. The Disease Activity Score 28 Joints (DAS28) is used in monitoring disease activity and response to treatment, involving the assessment of 28 joints and assigning points for swollen joints, tender joints, and the ESR or CRP result.

Question 25

Who is involved in the multidisciplinary team for rheumatoid arthritis management?

Answer 25

The multidisciplinary team for rheumatoid arthritis management includes rheumatologists, specialist nurses, GPs, physiotherapists, occupational therapists, psychologists, and podiatrists.

Question 26

Why is early treatment initiation crucial in rheumatoid arthritis, and what are the treatment goals?

Answer 26

Starting treatment early in rheumatoid arthritis improves outcomes. The goal is to induce remission or get as close to remission as possible. C-reactive protein and DAS28 are used to monitor the success of treatment.

Question 27

What role do short-term steroids play in rheumatoid arthritis treatment?

Answer 27

Short-term steroids, either oral or intramuscular, may be used at initial presentation, when initiating a new treatment, and during flares to quickly settle inflammation and control symptoms.

Question 28

List some conventional disease-modifying anti-rheumatic drugs (cDMARDs) used in rheumatoid arthritis treatment.

Answer 28

Conventional disease-modifying anti-rheumatic drugs (cDMARDs) used in rheumatoid arthritis treatment include methotrexate, leflunomide, sulfasalazine, azathioprine, ciclosporin, cyclophosphamide, and mycophenolate.

Question 29

When is hydroxychloroquine used in rheumatoid arthritis treatment, and why is it considered a “mild” DMARD?

Answer 29

Hydroxychloroquine may be used in mild disease and palindromic rheumatism. It is considered the “mildest” DMARD.

Question 30

What are some risks associated with NSAIDs in rheumatoid arthritis treatment?

Answer 30

NSAIDs are helpful for pain relief in rheumatoid arthritis, but they have associated risks and side effects.

Question 31

How can pregnancy affect rheumatoid arthritis symptoms, and which DMARDs are considered safe during pregnancy?

Answer 31

Pregnancy can improve symptoms in rheumatoid arthritis, but some pregnant women may experience a symptom flare. Hydroxychloroquine and sulfasalazine are considered the safest DMARDs in pregnancy (extra folic acid is required with sulfasalazine). Methotrexate and leflunomide are very harmful in pregnancy and are teratogenic.

Question 32

What are the main targets of biological therapies in rheumatoid arthritis, and can you name some examples?

Answer 32

Biological therapies in rheumatoid arthritis target various components of the immune system. Examples include:

Question 33

What are the various targets of biological therapies used to treat rheumatoid arthritis?

Answer 33

• tumour necrosis factor (TNF) inhibitors (e.g., adalimumab, infliximab, etanercept, golimumab and certolizumab)
• Anti-CD20 on B cells (e.g., rituximab)
• Anti-interleukin-6 inhibitors (e.g., sarilumab and tocilizumab)
• JAK inhibitors (e.g., upadacitinib, tofacitinib and baricitinib)
• T-cell co-stimulation inhibitors (e.g., abatacept)

Question 34

What is the role of Tumour Necrosis Factor (TNF) in inflammation, specifically in the context of rheumatoid arthritis?

Answer 34

TNF is a cytokine involved in stimulating inflammationand stimulate synovial fulid to profilate . In rheumatoid arthritis, blocking TNF is a therapeutic strategy to reduce inflammation.

Question 35

According to the TOM TIP, what are the main biologics to remember in rheumatoid arthritis treatment, and what is their common target?

Answer 35

The main biologics to remember in rheumatoid arthritis treatment are adalimumab, infliximab, and etanercept (TNF inhibitors), and rituximab (a monoclonal antibody targeting CD20 proteins on the surface of B cells). Their common target is TNF, and they cause immunosuppression, increasing the risk of infection, certain cancers (e.g., skin), and reactivation of latent TB.

Question 36

How has the use of cDMARDs and biologics impacted the need for orthopaedic surgery in rheumatoid arthritis management?

Answer 36

The use of cDMARDs and biologics has dramatically reduced the need for orthopaedic surgery in rheumatoid arthritis management, especially when joint deformities develop.

Question 37

How does Methotrexate impact folate metabolism, and what is its dosing frequency?

Answer 37

Methotrexate interferes with folate metabolism and suppresses the immune system. It is given once a week.

Question 38

What side effects are associated with Methotrexate?

Answer 38

Side effects of Methotrexate include: Mouth ulcers and mucositis
Liver toxicity
Bone marrow suppression and leukopenia (low white blood cells)
Teratogenicity (harmful to pregnancy) and needs to be avoided before conception in both women and men |
| How does Leflunomide function as an immunosuppressant, and what is its impact on pyrimidine production? | Leflunomide is an immunosuppressant that interferes with the production of pyrimidine, an essential component of RNA and DNA. |
| List the side effects associated with Leflunomide. | Side effects of Leflunomide include:
Mouth ulcers and mucositis
Increased blood pressure
Liver toxicity
Bone marrow suppression and leukopenia (low white blood cells)
Teratogenicity (harmful to pregnancy) and needs to be avoided before conception in both women and men
Peripheral neuropathy |
| What is the mechanism of action of Sulfasalazine, and what are its side effects? | Sulfasalazine is an immunosuppressive and anti-inflammatory medication. Its exact mechanism is not clear. Side effects include:
Orange urine
Reversible male infertility (reduced sperm count and quality)
Bone marrow suppression |

Question 39

What is the dosing frequency of Methotrexate, and how does it affect folate metabolism?

Answer 39

Methotrexate is given once a week, and it interferes with folate metabolism while suppressing the immune system.

Question 40

What are the side effects associated with Methotrexate?

Answer 40

Mouth ulcers and mucositis Liver toxicity Bone marrow suppression and leukopenia (low white blood cells) Teratogenicity (harmful to pregnancy) and needs to be avoided before conception in both women and men |

Question 41

What is the mechanism of action of Leflunomide, and what does it interfere with in the body?

Answer 41

Leflunomide is an immunosuppressant that interferes with the production of pyrimidine, a crucial component of RNA and DNA.

Question 42

List the side effects associated with Leflunomide.

Answer 42

Side effects of Leflunomide include: Mouth ulcers and mucositis Increased blood pressure Liver toxicity Bone marrow suppression and leukopenia (low white blood cells) Teratogenicity (harmful to pregnancy) and needs to be avoided before conception in both women and men Peripheral neuropathy

Question 43

What is the traditional use of Sulfasalazine, and what are its side effects?

Answer 43

Sulfasalazine is an immunosuppressive and anti-inflammatory medication, and its exact mechanism is unclear. Side effects include: Orange urine Reversible male infertility (reduced sperm count and quality) Bone marrow suppression

Question 44

How does Hydroxychloroquine suppress the immune system, and what are its side effects?

Answer 44

Hydroxychloroquine, traditionally an antimalarial medication, suppresses the immune system by interfering with Toll-like receptors, disrupting antigen presentation, and increasing the pH in the lysosomes of immune cells. Side effects include: Retinal toxicity (reduced visual acuity, macular toxicity) Blue-grey skin pigmentation Hair lightening (bleaching)

Question 45

What unique side effects are associated with Methotrexate, according to TOM TIP?

Answer 45

According to TOM TIP, unique side effects of Methotrexate are: Bone marrow suppression and leukopenia Highly teratogenic

Question 46

According to TOM TIP, what are the unique side effects of Leflunomide?

Answer 46

According to TOM TIP, unique side effects of Leflunomide are: Hypertension Peripheral neuropathy

Question 47

Name the unique side effects of Sulfasalazine according to TOM TIP.

Answer 47

According to TOM TIP, the unique side effects of Sulfasalazine are: Orange urine Male infertility (reduced sperm count

Question 48

What unique side effects of Hydroxychloroquine are highlighted by TOM TIP?

Answer 48

According to TOM TIP, unique side effects of Hydroxychloroquine are: Retinal toxicity Blue-grey skin pigmentation Hair bleaching

Question 49

According to TOM TIP, what is a specific side effect associated with Anti-TNF medications?

Answer 49

According to TOM TIP, a specific side effect associated with Anti-TNF medications is the reactivation of tuberculosis.

Question 50

What unique side effects are associated with Rituximab, as per TOM TIP?

Answer 50

According to TOM TIP, unique side effects of Rituximab are: Night sweats Thrombocytopenia

Question 51

What is rheumatoid arthritis and how is it characterized?

Answer 51

Rheumatoid arthritis is an inflammatory autoimmune disorder characterized by joint pain, swelling, and synovial destruction.

Question 52

What are the proposed factors contributing to the etiology of RA?

Answer 52

Genetic predisposition, environmental triggers (infection, smoking), and hormonal factors play a role in the development of RA.

Question 53

How does genetic predisposition relate to RA?

Answer 53

Genetic predisposition is associated with specific HLA types, such as the HLA DRB1 gene.

Question 54

What are some environmental triggers for RA?

Answer 54

Infection and smoking are environmental triggers that can increase anti-CCP and contribute to the development of RA.

Question 55

What is the prevalence pattern of RA in terms of age?

Answer 55

The prevalence of RA peaks between 35-50 years of age.

Question 56

Describe the initial inflammatory process in RA.

Answer 56

Non-specific inflammation initially affects the synovial tissue, later amplified by activation of T cells.

Question 57

What factors may trigger the progression of RA?

Answer 57

Triggers such as smoking, infection, or trauma have been implicated in the progression of RA.

Question 58

What is the role of inflammatory pannus in RA progression?

Answer 58

Inflammatory pannus, or inflammatory granulation tissue, forms and produces proteinases that destroy cartilage extracellular matrix.

Question 59

What happens in the chronic phase of RA?

Answer 59

The chronic phase is characterized by fibrosis and deformity.

Question 60

How do susceptibility genes contribute to RA development?

Answer 60

Susceptibility genes lead to the conversion of arginine into citrulline, and the unfolded protein acts as an antigen, triggering an autoimmune response.

Question 61

What is the role of auto-reactive CD4+ T cells in RA?

Answer 61

Auto-reactive CD4+ T cells, including Th1 and Th17 effector cells, are involved in the autoimmune response in RA.

Question 62

How is rheumatoid factor (RF) related to RA?

Answer 62

RF is an IgM or IgA antibody that binds to the Fc region of IgG. It is found in about 80% of RA patients, and high titres increase the risk of extra-articular disease.

Question 63

What is Anti-CCP, and how is it associated with RA?

Answer 63

Anti-CCP can be present for several years before articular symptoms, is associated with erosive damage, and correlates with disease activity. It is linked to a current/previous smoking history.

Question 64

Is the absence of Anti-CCP a reliable indicator for the absence of RA?

Answer 64

No, the absence of Anti-CCP does not exclude the presence of RA.

Question 65

How does rheumatoid arthritis (RA) typically manifest in terms of onset?

Answer 65

RA can present acutely, subacutely, or insidiously. In most cases (55–65%), onset is insidious over weeks to months.

Question 66

What are the articular manifestations of RA?

Answer 66

• Polyarthralgia with symmetrical pain and swelling in affected joints, most commonly in the small joints of the hands and feet. - Rapid onset. - Early morning stiffness lasting more than 30 mins, improving with activity. - Reduction in grip strength. - Joint deformities, including the ‘rheumatoid hand’ with Swan neck and Boutonniere deformities. - Atlanto-axial subluxation.

Question 67

What signs may be observed in patients with RA?

Answer 67

• Swelling of affected joints with symmetrical synovitis (doughy swelling). - Positive compression tests of MCP and MTP joints. - Bouchard’s nodes (bony swellings of proximal IPJ). - Rheumatoid nodules in 25% of patients. - Synovial herniation, such as Baker’s cysts.

Question 68

Name some extra-articular manifestations of RA.

Answer 68

Systemic inflammation in RA can lead to: - Constitutional symptoms (low-grade fever, myalgia, malaise, fatigue, weight loss, night sweats). - Pulmonary involvement (interstitial fibrosis, pleuritis, pleural effusions). - Cardiac complications (pericarditis, myocarditis, increased CVD risk). - Skin issues (pyoderma gangrenosum, Raynaud’s phenomenon, rheumatoid skin nodules). - Ocular complications (keratoconjunctivitis). - Other musculoskeletal problems (osteopenia/osteoporosis, Sjogren syndrome).

Question 69

What investigations are useful in diagnosing RA?

Answer 69

Blood tests can reveal raised inflammatory markers and autoantibodies, including rheumatoid factor (60-70% specific) and anti-CCP antibodies (90-99% specific). Imaging techniques like X-rays, ultrasound (USS), and MRI are employed for diagnosis and determining disease severity.

Question 70

How does X-ray imaging contribute to the diagnosis of RA?

Answer 70

X-ray imaging of hands and feet helps in diagnosing and determining disease severity in RA. In early disease, X-rays may be normal or show soft tissue swelling and periarticular osteopenia, while late-stage disease may exhibit erosions and subluxation.

Question 71

When might ultrasound (USS) be useful in RA diagnosis?

Answer 71

USS may be useful in detecting synovial inflammation, especially in early RA, when there is clinical uncertainty. It is also employed for making treatment changes.

Question 72

In what situations is MRI used in the context of RA?

Answer 72

MRI is extremely sensitive and is used in cases of diagnostic doubt in RA.

Question 73

How is disease severity and treatment efficacy monitored in RA?

Answer 73

Disease severity and treatment efficacy in RA are often monitored using the DAS28 score, a composite score that includes CRP or ESR, the number of swollen or tender joints, and a patient-reported measure of global health.

Question 74

What are the symptomatic treatments for RA?

Answer 74

Analgesics, NSAIDs, and steroids can be used short-term for symptomatic relief in RA. Rheumatoid nodules, if problematic, may be excised, although recurrence is common.

Question 75

When should disease-modifying treatment be initiated in RA patients?

Answer 75

All patients with RA should be treated with disease-modifying treatment, and the aim is to start patients on DMARDs within 3 months of symptom onset.

Question 76

What are conventional disease-modifying anti-rheumatic drugs (csDMARDs) and examples of first-line options?

Answer 76

csDMARDs are immunomodulatory medications, and examples of first-line options include methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine. Oral methotrexate is usually the first choice, and it can also be given subcutaneously.

Question 77

What are the important side effects and monitoring requirements for methotrexate?

Answer 77

Methotrexate may cause gastrointestinal side effects, oral ulcers, photosensitivity, hepatic toxicity, cytopenia, immunosuppression, pneumonitis, flu-like symptoms, and teratogenicity. Monitoring includes baseline chest X-ray, hepatitis B and C serology, and regular monitoring of FBC, U&Es, and LFTs.

Question 78

Which csDMARD has the potential for retinal toxicity, and how is it monitored?

Answer 78

Hydroxychloroquine has the potential for retinal toxicity, and monitoring involves retinal screening 5 years after starting, with baseline screening required in those with risk factors.

Question 79

What are the common side effects and monitoring requirements for leflunomide?

Answer 79

Leflunomide may cause nausea, vomiting, diarrhea, cytopenia, rash, hypertension, hyperlipidemia, and teratogenicity. Monitoring includes regular checks of FBC, U&Es, LFTs, and blood pressure.

Question 80

What side effects and monitoring are associated with sulfasalazine?

Answer 80

Sulfasalazine may cause gastrointestinal side effects, rash, agranulocytosis, oral ulcers, reduced sperm count, haemolysis (in G6PD deficiency). Monitoring involves regular checks of FBC, U&Es, and LFTs.

Question 81

When are biological disease-modifying anti-rheumatic drugs (bDMARDs) considered in RA treatment?

Answer 81

bDMARDs are considered if a patient has tried two DMARDs and still has a DAS28 score > 5.1. Examples include anti-TNF agents and T cell receptor blockers. They are usually taken in addition to other DMARDs but may be discontinued if the patient does not see a significant improvement.

Question 82

What are targeted synthetic DMARDs (tsDMARDs), and what are some examples?

Answer 82

tsDMARDs are selective, small-molecule oral DMARDs, including Janus kinase inhibitors. Examples include Baricitinib, Tofacitinib, and Filgotinib, the latter being the first tsDMARD licensed for the treatment of moderate-activity RA.

Question 83

What additional medications are recommended for patients on DMARDs, and why?

Answer 83

Patients on DMARDs should receive the annual influenza vaccine and the pneumococcal vaccine every 5 years. Those aged over 50 years should receive the zoster vaccination before starting bDMARDs or tsDMARDs. These measures are taken to prevent infections, and none of the mentioned vaccines are live.

Question 84

What non-medical management strategies are recommended for RA?

Answer 84

Non-medical management involves the collaboration of physiotherapists, occupational therapists, podiatrists, and orthotists. Surgery, including synovectomy, joint replacement, joint excision, tendon transfers, arthrodesis, and cervical spine stabilization, can be used for resistant disease or to control pain and improve/maintain function.

Question 85

What complications may arise in longstanding RA?

Answer 85

In longstanding RA, involvement of the cervical spine may cause atlanto-axial subluxation, leading to cervical cord compression.

Question 86

How is osteoarthritis often described in terms of its impact on joints?

Answer 86

Osteoarthritis is often described as “wear and tear” in the joints, occurring in synovial joints and resulting from genetic factors, overuse, and injury.

Question 87

What is thought to be the underlying cause of osteoarthritis, and what imbalance is implicated in its development?

Answer 87

Osteoarthritis is thought to result from an imbalance between cartilage damage and the chondrocyte response, leading to structural issues in the joint.

Question 88

What are the risk factors associated with osteoarthritis?

Answer 88

Risk factors for osteoarthritis include obesity, age, occupation, trauma, being female, and family history.

Question 89

Name some commonly affected joints in osteoarthritis.

Answer 89

Commonly affected joints in osteoarthritis include hips, knees, distal interphalangeal (DIP) joints in the hands, carpometacarpal (CMC) joint at the base of the thumb, lumbar spine, and cervical spine (cervical spondylosis).

Question 90

What are the four key x-ray changes in osteoarthritis, and how can they be remembered?

Answer 90

The four key x-ray changes in osteoarthritis are remembered with the “LOSS” mnemonic: Loss of joint space, Osteophytes (bone spurs), Subarticular sclerosis (increased density of the bone along the joint line), and Subchondral cysts (fluid-filled holes in the bone).

Question 91

How might x-ray findings of osteoarthritis be described, and is there always a correlation with symptoms?

Answer 91

X-ray findings of osteoarthritis might be described as “degenerative changes.” However, there is not always a correlation between x-ray changes and symptoms; a patient may have significant signs on an x-ray but minimal symptoms, or vice versa.

Question 92

What are the general signs of osteoarthritis?

Answer 92

General signs of osteoarthritis include bulky, bony enlargement of the joint, restricted range of motion, crepitus on movement, and effusions (fluid) around the joint.

Question 93

How does osteoarthritis typically present in terms of joint pain and stiffness?

Answer 93

Osteoarthritis presents with joint pain and stiffness, which tend to worsen with activity and at the end of the day. This is in contrast to inflammatory arthritis, where symptoms are worse in the morning and improve with activity. Osteoarthritis can lead to deformity, instability, and reduced function of the joint.

Question 94

What are some general signs of osteoarthritis in the hands?

Answer 94

General signs of osteoarthritis in the hands include Heberden’s nodes (in the DIP joints), Bouchard’s nodes (in the PIP joints), squaring at the base of the thumb (CMC joint), weak grip, and reduced range of motion.

Question 95

What distinguishes the carpometacarpal joint at the base of the thumb, and why is it prone to wear in osteoarthritis?

Answer 95

The carpometacarpal joint at the base of the thumb is a saddle joint, with the metacarpal bone sitting on the trapezius bone, using it like a saddle. It is prone to wear due to its extensive use.

Question 96

What tip is provided regarding referred pain in osteoarthritis, and how might this present in clinical scenarios?

Answer 96

Patients with osteoarthritis may present with referred pain, particularly in adjacent joints. For example, osteoarthritis in the hip could be considered in patients presenting with lower back or knee pain.

Question 97

According to the NICE guidelines, what criteria are suggested for diagnosing osteoarthritis without investigations?

Answer 97

The NICE guidelines (2022) suggest that a diagnosis of osteoarthritis can be made without any investigations if the patient is over 45, has typical pain associated with activity, and has no morning stiffness (or stiffness lasting under 30 minutes).

Question 98

What non-pharmacological management strategies are recommended for osteoarthritis?

Answer 98

Non-pharmacological management for osteoarthritis involves patient education and lifestyle changes. This includes therapeutic exercise to improve strength and function and reduce pain, weight loss if overweight to reduce the load on the joint, and occupational therapy to support activities and function (e.g., walking aids and adaptations to the home).

Question 99

What pharmacological management options are recommended by NICE for knee osteoarthritis?

Answer 99

NICE recommends topical NSAIDs as first-line for knee osteoarthritis. Oral NSAIDs are recommended where required and suitable, co-prescribed with a proton pump inhibitor for gastroprotection. Weak opiates and paracetamol are only recommended for short-term, infrequent use. NICE advises against using any strong opiates for osteoarthritis.

Question 100

How might intra-articular steroid injections be utilized in osteoarthritis management?

Answer 100

Intra-articular steroid injections may be used in osteoarthritis to temporarily improve symptoms, with the effect lasting up to 10 weeks according to NICE guidelines.

Question 101

In severe cases of osteoarthritis, what intervention might be considered?

Answer 101

In severe cases of osteoarthritis, joint replacement may be considered. The hips and knees are the most commonly replaced joints.

Question 102

What are some potential adverse effects of NSAIDs used for osteoarthritis pain?

Answer 102

NSAIDs (e.g., ibuprofen or naproxen) can have potential adverse effects, including gastrointestinal side effects such as gastritis and peptic ulcers (leading to upper gastrointestinal bleeding), renal side effects like acute kidney injury and chronic kidney disease, and cardiovascular side effects such as hypertension, heart failure, myocardial infarction, and stroke.

Question 103

Why are opiates not recommended for regular use in osteoarthritis?

Answer 103

Opiates are not recommended for regular use in osteoarthritis due to little evidence supporting their effectiveness in chronic pain. They are associated with side effects, risks, tolerance, dependence, and withdrawal, often resulting in dependence without objective benefits.

Question 104

What caution is advised when using NSAIDs in patients with a history of high blood pressure?

Answer 104

NSAIDs cause hypertension by blocking prostaglandins, which cause vasodilation. Therefore, they should be used very cautiously in patients with a history of high blood pressure.

Question 105

How is osteoarthritis (OA) defined in terms of its pathophysiology and its impact on joint tissues?

Answer 105

Osteoarthritis is defined as a chronic disease involving the imbalance between wear and repair of articular (hyaline) cartilage, leading to progressive cartilage loss and accompanying periarticular changes. It is a metabolically active dynamic process that affects all joint tissues, including cartilage, bone, synovium/capsule, ligaments, and muscles. Key pathological changes include localized loss of hyaline cartilage, remodelling of adjacent bone with new bone formation (osteophyte) at joint margins, increased pressure on bony surfaces, inflammation, pain, swelling, thickening of the capsule, and stiffness.

Question 106

What are the primary risk factors for primary OA, and what joints does it commonly affect?

Answer 106

Primary OA, defined as a common complex disorder, has multiple risk factors including genetic factors (40-60%), constitutional factors (aging, female sex, obesity), and biomechanical factors (joint injury, occupational/recreational usage, reduced muscle strength, joint laxity, joint malalignment). It affects weight-bearing or active joints and typically presents in individuals over 50 years old.

Question 107

When does secondary OA occur, and what conditions can lead to its development?

Answer 107

Secondary OA occurs when OA affects an unexpected site due to overuse, previous injury, or previous arthritis. Conditions such as rheumatoid arthritis and gout are examples that can lead to secondary OA.

Question 108

What are the key pathological changes involved in the development of OA?

Answer 108

The key pathological changes in the development of OA include chondrocyte injury (due to genetic and biochemical factors), chondrocyte proliferation (releasing inflammatory mediators, proteases, collagen, and proteoglycans), remodelling and degradation of cartilage, stimulation of inflammatory changes in synovium and subchondral bone, repetitive injury, chronic inflammation, and long-term consequences such as complete wear away of cartilage, subchondral cysts, surface polishing (eburnation), and formation of osteophytes.

Question 109

What are the consequences of long-term OA development, and how does it affect the joint?

Answer 109

Long-term consequences of OA development include the complete wear away of cartilage (bone on bone), subchondral cysts (accumulation of synovial fluid), surface polishing (eburnation or subchondral sclerosis), and the formation of osteophytes (disorganized bone remodelling) that can irritate nerves.

Question 110

What are the types of OA based on its localization, and what is a clinical marker of generalized OA?

Answer 110

Types of OA include localized OA (affecting hips, knees, finger interphalangeal joints, facet joints of lower cervical and lower lumbar spines) and generalized OA (defined as OA at either the spinal or hand joints and in at least 2 other joint regions, e.g., DIP joints, thumb bases, first MTP joints, knees, hips). A clinical marker of generalized OA is the presence of multiple Herbeden’s nodes.

Question 111

What are the common symptoms associated with osteoarthritis (OA)?

Answer 111

Common symptoms of OA include pain, which worsens with joint use, night pain, morning stiffness lasting less than 30 minutes, inactivity gelling, instability, and poor grip in thumb OA.

Question 112

What signs can be observed in individuals with OA?

Answer 112

Signs of OA include joint line tenderness, crepitus, deformity, stiffness on testing range of motion (ROM), and bony swelling due to osteophytes. Osteophytes can manifest as Heberden’s nodes (DIP joints) and Bouchard’s nodes (PIP joints). Squaring of the thumb is observed in 1st CMC OA.

Question 113

How does knee OA manifest in terms of symptoms and signs?

Answer 113

Knee OA is characterized by osteophytes, effusions, crepitus, restriction of movement, genu varus and valgus deformities, and the presence of Baker’s cysts.

Question 114

What symptoms may individuals with hip OA experience, and how might the pain be perceived?

Answer 114

Individuals with hip OA may experience pain in the groin, radiating to the knee or anterior thigh. Pain felt in the hip may also radiate from the lower back. Additionally, hip movements are often restricted in hip OA.

Question 115

How does spine OA affect individuals in terms of pain and movement restriction?

Answer 115

In cervical spine OA, individuals may experience pain and restriction of movement, with possible occipital headaches if osteophytes impinge on nerve roots. In lumbar spine OA, osteophytes can cause spinal stenosis if they encroach on the spinal canal, leading to pain and movement restriction.

Question 116

What are the specific bony swellings associated with OA, and where are they commonly observed?

Answer 116

Bony swellings in OA are caused by osteophytes, which are bony spurs due to chronic trauma. Heberden’s nodes (DIP joints) are specific to OA and are not seen in RA. Bouchard’s nodes (PIP joints) are less common but can also be seen in RA. Squaring of the thumb is associated with 1st CMC OA.

Question 117

How is crepitus described in the context of OA?

Answer 117

Crepitus in OA refers to a crackling or grating sound or sensation observed during joint movement.

Question 118

What is “inactivity gelling” in the context of OA symptoms?

Answer 118

“Inactivity gelling” refers to stiffness or reduced mobility experienced after periods of inactivity.

Question 119

What deformities are commonly associated with OA?

Answer 119

Deformities commonly associated with OA include genu varus and valgus deformities in knee OA, and squaring of the thumb in 1st CMC OA.

Question 120

What types of imaging can be used for investigating osteoarthritis, and when are they typically performed?

Answer 120

Imaging for osteoarthritis includes plain x-rays, MRI scans, and ultrasound (USS). However, these are not typically performed unless there is doubt over the diagnosis, as clinical evaluation based on signs and symptoms is often sufficient.

Question 121

What does the acronym “LOSS” stand for in the context of X-ray findings in osteoarthritis?

Answer 121

The acronym “LOSS” in the context of X-ray findings in osteoarthritis stands for Loss of joint space, Marginal Osteophytes, Subchondral Sclerosis, and Subchondral Cysts.

Question 122

What are the pitfalls associated with X-ray imaging in osteoarthritis diagnosis?

Answer 122

Pitfalls of X-ray imaging in osteoarthritis include its insensitivity, especially in early disease, poor correlation with disease activity, and the common occurrence of incidental asymptomatic findings in older people.

Question 123

What are the non-pharmacological approaches to managing osteoarthritis?

Answer 123

Non-pharmacological management includes education to ensure patients continue to exercise, lifestyle management (e.g., weight loss, exercise, walking aids), physiotherapy, and activity modification (e.g., occupational therapy, hobbies).

Question 124

What pharmacological options are recommended for managing osteoarthritis symptoms?

Answer 124

Pharmacological management for osteoarthritis includes analgesia with paracetamol and NSAIDs (with avoidance of opiates) as needed. Local intra-articular steroid injections can be used for flare-ups, with a limit of up to 3 injections per year to avoid potential joint damage.

Question 125

What are the potential surgical interventions for osteoarthritis management?

Answer 125

Surgical management options for osteoarthritis include joint replacements (e.g., knee, hip) and arthroscopic surgery to remove loose bodies and address other issues.

Question 126

What distinguishes rheumatoid arthritis (RA) from osteoarthritis (OA) in terms of their causes and characteristics?

Answer 126

Rheumatoid arthritis (RA) is an autoimmune inflammatory disease causing progressive and symmetric destruction of at least three joints. It is characterized by morning stiffness lasting more than an hour and improving with use. RA may present with extra-articular symptoms like uveitis, pulmonary fibrosis, and rheumatoid nodules. Treatment involves non-biological and biological DMARDs, NSAIDs, and glucocorticoids. Osteoarthritis (OA) is a chronic condition characterized by the breakdown of joint cartilage and underlying bone due to mechanical stress. Unlike RA, it is considered a mechanical degenerative joint disorder. Symptoms of OA include joint pain, stiffness, and decreased range of motion. Treatment involves weight loss, physical therapy, and pain management with acetaminophen and NSAIDs.

Question 127

What are the key features of rheumatoid arthritis?

Answer 127

Rheumatoid arthritis is characterized by autoimmune inflammatory processes leading to progressive and symmetric destruction of at least three joints, especially the proximal interphalangeal joints. It causes morning stiffness lasting more than an hour and improving with use. Extra-articular symptoms may include uveitis, pulmonary fibrosis, and rheumatoid nodules. Treatment includes non-biological and biological DMARDs, NSAIDs, and glucocorticoids.

Question 128

How does osteoarthritis differ from rheumatoid arthritis in terms of its nature and causes?

Answer 128

Osteoarthritis is a chronic condition characterized by the breakdown of joint cartilage and underlying bone due to mechanical stress. It is considered a mechanical degenerative joint disorder. Unlike rheumatoid arthritis, which is an autoimmune disorder, osteoarthritis results from the daily stress applied to joints throughout one’s lifetime, especially weight-bearing joints like those in the ankle, knee, and hip. Symptoms include joint pain, stiffness, and decreased range of motion. Treatment involves weight loss, physical therapy, and pain management with acetaminophen and NSAIDs.

Question 129

What are the symptoms of osteoarthritis, and how is it managed?

Answer 129

Symptoms of osteoarthritis include joint pain, stiffness, and decreased range of motion. Management involves losing weight, physical therapy, and pain management with drugs like acetaminophen and NSAIDs.