Rheumatoid Arthritis - workbook ONLY (lecture in intro)

Question 1

What is RA?

Answer 1

• Autoimmune disease associated with antibodies to the Fc portion of IgG (rheumatoid factor) and anti citrullinated cyclic peptide

Question 2

Pathogenesis of RA

Answer 2

• Citrullination of self antigens which are then recognised by T and B cells
• These then produce antibodies (RF and anti-CCP)
• Stimulated macrophages and fibroblasts release TNF-a
• Inflammatory cascade = proliferation of synoviocytes (=boggy joint swelling)
• These grow over cartilage = restriction of nutrients and cartilage is damage
• Macrophages stimulate osteoclast differentiation –> bone damage

Question 3

Typical history of RA

Answer 3

• Female
• 3-50yrs old
• Progressive, peripheral, symmetrical arthiritis
• History more than 6 weeks
• Morning stiffness lasts more than 30 minutes
• Fatigue and malaise

Question 4

Which joint does RA often affect?

Answer 4

• MCPs
• PIPs
• MTPs
• SPARES DIPs (unlike OA)
• Can affect any joint though inc hips, knees, shoulders, c-spine

Question 5

Examination findings RA

Answer 5

• Soft tissue swelling and tenderness
• Ulnar deviation/palmar subluxation of MCPs
• Swan neck and Boutonierre deformity to digits
• Rheumatoid nodules - most common at elbow
• Check median nerve - carpal tunnel association

Question 6

Investigations findings of RA

Answer 6

• RF and anti-CCP
• FBC - normocytic anaemia (chronic disease)
• Do WCC if concerned septic arthiritis
• Inflammatory markers - elevated
• X-ray changes apparent in established disease - USS/MRI more sensitive in early disease
• Others guided by history and exam eg may need PFTs and HRCT if lungs involved

Question 7

Treatment for RA

Answer 7

• Initially DMARD monotherapy - usually MTX
• Consider combination of DMARDs eg leflunomide, hydroxychloroquine, sulfasalazine
• Steroids - acute PO/IM or intra-articular
• Symptom control with NSAIDs (+PPI cover) as long as no contraindication
• If still severe –> biologics eg etanercept anti-TNF)
• Non drug - OT/PT, podiatry, psychological

Question 8

3 C’s associated with RA

Answer 8

• Carpal tunnel
• Elevated Cardiac risk
• Cord compression - due to atlantoaxial subluxation

Question 9

3 A’s associated with RA

Answer 9

• Anaemia - normocytic and normochromic
• Amyloidosis - very rare now due to good treatment but can cause nephrotic syndrome and CKD
• Arteritis - rarer now as better treatment but can cause nail fold infarcts, cutaneous vasculitis, mononeuritis multiplex

Question 10

3 P’s associated with RA

Answer 10

• Pericarditis (uncommmon)
• Pleural disease (common)
• Pulmonary disease eg bronchiectasis, bronchiolotis obliterans, fibrosis (common)

Question 11

3 S’s associated with RA

Answer 11

• Sjogrens - common
• Scleritis/episcleritis - uncommon
• Splenic enlargement (if + neutropenia = Feltys syndrome = rare

Question 12

X-ray features of RA

Answer 12

• Loss of joint space
• Erosions- periarticualr
• Soft tissue swelling
• Subluxation

LESS

Question 13

Monitoring required with DMARDs

Answer 13

• Liver function tests
• FBC
• U&E
• Eye assessement

Every 2 weeks blood tests until stable/for 6 weeks
Then every 12 weeks
If dose increases restart process

Question 14

Features distinguishing RA from other arthropathies

Answer 14

• Symmetrical
• Affects small joints - spares DIPs
• Multisystem effects
• Specific deformities - Swan neck, Boutonierre, Ulnar deviation