Rheumatology: Rheumatoid Arthritis

Question 1

Who does RA most commonly affect and in what percentage of the population?

Answer 1

Aged 30-50, females 3:1, prevalence of 1%

Question 2

What is the common HLA in RA?

Answer 2

HLA-DR4 (+DR1)

Question 3

What is the environmental link to RA?

Answer 3

Worse in smoker, poorer prognosis as less responsive to treatment

Question 4

What is the pathogenesis of RA?

Answer 4

• ->The immune system is initiated against the synovium
• ->The synovium proliferates and becomes thickened and inflamed, releasing cytokines into the synovium space
• ->Synovium membrane expands and eat into the bone and cartilage
• ->Destructive pattern of joints
• ->Tendon ruptures and soft tissue can occur leading to joint instability and subluxation

Question 5

What are some of the clinical signs of RA?

Answer 5

reduced range of movement, swelling, tenderness, deformities such as swan necking of the fingers

Question 6

Is swan necking reversible?

Answer 6

No

Question 7

What are some of the extra-articular features of RA?

Answer 7

Respiratory: effusions and fibrosis

Neurological, skin, eye

Question 8

What investigations should be carried out in RA?

Answer 8

anti CCP, Rheumatoid factor, bloods to check for anaemia of chronic disease, ultrasound to pick up any synovitis

Question 9

What is the prognosis of RA in terms of Physical, Emotional and Life?

Answer 9

Physical: reduced life expectancy
Emotional: time when they are most active with families
Life: reduced life expectancy

Question 10

What are some of the late complications of RA?

Answer 10

• Infection (used to be the biggest killer) due to immobility, bed sores, ankle static and pneumonia
• Cervical myelopathy, can affect any joint, damage to ligament and odontoid process, slipping of C1 and C2 can cause cord compression
• Peripheral neuropathy
• Interstitial lung disease

Question 11

What is the impact of RA on patient’s lives?

Answer 11

Life expectancy reduced by 10 years

Question 12

What co-morbidies are associated with RA?

Answer 12

• Increased risk of developing lymphoma by 2to3x
• Serious risk of infection doubled
• CV mortality occurs for most of excess deaths

Question 13

What are some of the poor prognostic factors for RA?

Answer 13

HLA DR4, many active joints involved, delayed referral, early radiological erosions, extra-articular features, young age at onset, adverse socio-economic circumstances

Question 14

What is the best initial management for RA?

Answer 14

Early diagnosis and specialist referral, 12 weeks from first symptom

Question 15

What is the “window of opportunity” in RA before there is irreversible damage to joints?

Answer 15

3 months

Question 16

What is the principles of treatment for RA?

Answer 16

• Early and aggressive treatment with DMARRs (and steriods to cover lag phase)
• Frequent review until stable with tailoring of drug treatment
• MDT approach, educate patient
• Address CV and infection risk. Flu vaccines and control inflammation

Question 17

What is the first line DMARD treatment for RA?

Answer 17

Methotrexate

Question 18

What should be given to patient with RA if unresponsive to DMARDs?

Answer 18

Biological agents

Question 19

What is the risk and disadvantages with using biological agents to treat RA?

Answer 19

Increased risk if infection, especially TB therefore patients have to be tested first for latent TB.
-Expensive

Question 20

How can biological agents reactivate TB?

Answer 20

Latent TB is contained within a granuloma. These drugs break down the granuloma and release the TB

Question 21

Name some of the biological agents used to treat RA

Answer 21

• 1st line: Anti-TNF drugs
• B cell depletion (Rituximab)
• Disruption of T cell costimulation
• Il-6 inhibitors

Question 22

What are some of the extra-articular features of RA?

Answer 22

Pulmonary fibrosis, pleural effusion, skin rheumatoid macules, osteoporosis (Il-6), dry eye

Question 23

What organ doesn’t tend to be involved in RA?

Answer 23

Kidneys