Rheumatoid Arthritis Pre-lecture

Question 1

Rheumatoid arthritis

Answer 1

chronic disease
symmetrical joint involvement
most common systemic inflammatory disease

Question 2

Epidemiology

Answer 2

prevalence: 2.1 mil (1-2% of pop)
age: any age, onset usually 30-50 yrs, shortens lifespan by 3-18 yrs
sex: female > male
race: no discrimination

Question 3

MHC

Answer 3

major histocompatibility complex
HLA: hyman lymphocyte antigen typing: HLA-DR4 and HLA-DR1
consider possibility of a genetic etiology/redisposition

Question 4

Pathogenesis of RA

Answer 4

synovial space is infiltrated with inflammatory cells: macrophage, T cells, plasma cells –> development of pannus - inflamed proliferating synovia invades into healthy cartilage + bone –> erosions, destroys joint
the release of cytokines, mediators of the immune/inflammatory response, leads to cell proliferation + death

Question 5

RA progression

Answer 5

inflammation might decline but disability increases

Question 6

Clinical presentation - prodromal effects

Answer 6

non-specific sx found early in presence of RA; difficult to link these sx to RA
fatigue, weakness, loss of appetite, joint pain, low grade fever, stiffness + muscle ache –> joint swelling

Question 7

Diagnostic criteria

Answer 7

joint involvement
serology
duration of sx
acute phase reactants
diagnosed with RA if score is 6 or more

Question 8

Joint involvement

Answer 8

most common joints: hands, wrists, feet
may involve: elbows, shoulders, hip, knees, ankles

Question 9

Joint involvement in hands

Answer 9

wrist, metacarpal, proximal interphalangeal

Question 10

Extraarticular manifestations

Answer 10

rheumatoid nodules, vasculitis, pulmonary, ocular, cardiac, felty’s, other

Question 11

Rheumatoid nodules

Answer 11

common: hands, elbows, forearms (pressure points)
more common in erosive disease (happes longer the pt has the disease or the less control the pt has over the disease)
20% of pts affected
asymptomatic = 0 intervention

Question 12

Vasculitis

Answer 12

inflammation of small, superficial blood vessels
depends upon duration of disease
stasis ulcers
infarction –> necrosis

Question 13

Pulmonary

Answer 13

pleural effusions
pulmonary fibrosis
nodules
rare: interstitial pneumonitis or arteritis

Question 14

Ocular

Answer 14

keratoconjunctivitis sicca: itchy dry eyes + inflammation; sjogrens syndrome (KS + RA)
inflammation: sclera, espisclera, cornea
nodules

Question 15

Cardiac

Answer 15

increased risk of CV mortality
pericarditis
conduction abnormalities
rare: myocarditis

Question 16

Felty’s

Answer 16

have all 3: splenomegaly, neutropenia, RA

Question 17

Other

Answer 17

lympadenopathy, renal disease, thrombocytosis, anemia

Question 18

Laboratory indicators

Answer 18

help diagnose + assess disease progression
anemia, thrombocytosis, ESR, CRP, RF, anti-CCP/ACPA, ANA, joint aspirations, radiographic findings

Question 19

Erythrocyte sedimentation rate (ESR)

Answer 19

non-specific (diagnostic indicator)
normal: 0-20 mm/hr
elevated in RA > 20

Question 20

C-reactive protein (CRP)

Answer 20

normal 0-0.5 mg/dL
+ –> > 0.5 mg/dL
> 10 mg/dL can indicate bacterial infection

Question 21

Rheumatoid factor

Answer 21

hallmark diagnostic criteria!
antibody specific for IgM
not all pts with RA diagnosis are RF+
60-70% are RF+
higher the titer –> poorer the prognosis

Question 22

Anti-CCP/ACPA

Answer 22

auto-antibody presence test
high specificity, present earlier in disease, predictive value for erosive disease, marker of poor prognosis

Question 23

Antinuclear antibodies (ANA)

Answer 23

elevated titers suggest autoimmune disease, more indicative of SLE (less specific for RA), reported as a titer

Question 24

Joint aspiration

Answer 24

turbid, WBC 5,000-50,000/mm^3, glucose: normal to low compared to serum

Question 25

Radiographic changes

Answer 25

joint space narrowing
erosions of bone

Question 26

Poor prognosis - social factors

Answer 26

low socioeconomic status, lack of formal education, psychological stress, poor health assessment questionnaire scores

Question 27

Poor prognosis - physical factors

Answer 27

extra-articular manifestations, elevated ESR and CRP, high titers of RF, elevated anti-CCP/ACPA, erosions on x-ray, duration of disease, swelling of >20 joints

Question 28

Treatment goals

Answer 28

improve/increase QOL, reduce morbidity and mortality
alleviate s/sx of disease, preserve fx, prevent structural damage and deformity, control/avoid extra-articular manifestations

Question 29

Early treatment of RA

Answer 29

goal of preventing long-term disability
early, more aggressive tx helps prevent long-term disability
can improve fx and decrease inflammation with earlier treatment

Question 30

Nonpharmacologic treatment

Answer 30

education, emotional support, rest, weight reduction, physical/occupational therapy, heat, splints/prosthetics, surgery
should NOT be used as monotherapy

Question 31

Pharmacologic treatment

Answer 31

NSAIDs, corticosteroids, DMARDs, biologic agents anti-TNF and non-TNF, monoclonal antibodies, targeted synthetic DMARDs