Seropositive Inflammatory Arthropathies (mainly RA)

Question 1

What are symptoms suggestive of inflammatory arthropathies?

Answer 1

joint pain & swelling
morning stiffness
improvement of symptoms with exercise
synovitis with examination
raised inflammatory markers
extra-articular symptoms

Question 2

What are general options for treatment of inflammatory arthropathies?

Answer 2

analgesia
anti-inflammatory medications: steroids & NSAIDs
steroid injections
DMARDs

Question 3

What are seropositive inflammatory arthropathies?

Answer 3

Rheumatoid Arthritis
SLE
Scleroderma
Vasculitis
Sjogren's

Question 4

What is the most common seropositive inflammatory arthropathy?

Answer 4

Rheumatoid artritis

Question 5

Pathogenesis of RA

Answer 5

Auto-immune inflammatory systemic polyarthropathy

There is an immune response against synovium - inflammatory pannus forms which attacks & denudes articular cartilage
joint destruction, tendon ruptures, soft tissue damage
joint instability, subluxation

Question 6

F:M ratio of RA

Answer 6

3:1

Question 7

prevalence of RA

Answer 7

1% of population, increasing prevalence with age

Question 8

Age RA usually diagnosed at

Answer 8

35-50

Question 9

Genetic & Environmental factors of RA

Answer 9

genetic factors: 50% of the risk

smoking & RA association

Question 10

Signs & Symptoms Of RA

Answer 10

symmetrical synovitis (doughy swelling)
mainly small joints of hands & feet
DIP spared!!!
morning stiffness

Question 11

extra-articular manifestation of RA

Answer 11

rheumatoid nodules - 25$ extensor surfaces/mechanical irritation sites
lung: pleural effusion, interstitial fibrosis, pulmonary nodules
CV: morbidity & mortality increased
ocular involvement

Question 12

ocular involvement of RA

Answer 12

keratoconjunctivitis sicca
episcleritis
uveitis
nodular scleritis - sleromalacia

Question 13

What is a joint that RA may affect and could be life-threatening?

Answer 13

C1-2

Question 14

investigations of RA

Answer 14

X-Ray: peri-articular osteopenia, periarticular erosions later in disease (at onset it may not show anything)
US: synovial inflammation
Serology: Rheumatoid Factor, Anti-CCP (more specific)

Question 15

Serology of RA

Answer 15

Rheumatoid Factor
Anti-CCP (more specific)
15-20% of RA patients are seronegative

Question 16

Diagnosis of RA is based on

Answer 16

clinical presentation
radiographic findings
serological analyiss
ACR & EULAR RA criteria scoring system

Question 17

Disease activity is measured by

Answer 17

DAS28: tender joint count, swollen joint count, CRP/ESR, visual analogue score

Question 18

DAS28 score limits

Answer 18

DAS28 < 2.6 - remission
DAS28 2.7-3.2 - low disease activity
DAS28 3.3-5.1 - moderate disease activity
DAS28 > 5.1 - high disease activity (eligible for biologic)

Question 19

Symptom relief in RA

Answer 19

simple analgesia
NSAIDs
steroids: IM/intra-articular/oral

Question 20

Treatment pattern for RA

Answer 20

1 DMARD: methotrexate (1st line)
2 DMARDs: methotrexate & sulfalazine
Biologic therapy (if it doesn’t respond to DMARDs & has high DAS28 score)

Question 21

What is the critical window for DMARD therapy to be started?

Answer 21

It should be started within the first 3 months of symtpom onset

Question 22

DMARDs

Answer 22

methotrexate
sulphalazine
hydroxychloroquine
leflunomide

Question 23

Side effects of DMARDs

Answer 23

immunosuppressive - need to monitor bloods

Question 24

What does taking the drugs look like for someone on methotrexate?

Answer 24

pregnancy test before starting
contraception has to be taken
regular blood tests

methotrexate 1/ week - 15 mg start
folic acid 1/week (3 days after drug)

Question 25

What happens if you’re low on folate?

Answer 25

nausea, alopecia

Question 26

What to do if the patient wants to be pregnant

Answer 26

stop methotrexate for 3 months before conception - still take contraceptive pill
RA gets better during pregnancy
after pregnancy it gets worse - give sulphalazine
(not methotrexate due to breastfeeding)

Question 27

Options for biologic therapy

Answer 27

anti-TNF
toxlizumab
rituximab
abatacept

Question 28

Risk of biologics

Answer 28

infection

latent TB reactivation (need to screen - if positive, you give them latent TB therapy and then start biologics)

Question 29

Other therapies for RA

Answer 29

physiotherapy, OT, podiatrist, orthotists, surgery for resistant disease

Question 30

Surgery for RA

Answer 30

synovectomy
joint replacement
joint excision
tendon transfers
arthrodesis (fusion)
cervical spine stabilization