Week 2 - B - Rheumatoid arthritis - joints affected, symptoms, ACR/EULAR, DAS28, scans, treatment

Question 1

Rheumatism or rheumatic disorder is an umbrella term for conditions causing chronic, often intermittent pain affecting the joints and/or connective tissue Describe rheumatoid arthritis in a sentence?

Answer 1

Rheumatoid arthritis is a chronic systemic inflammatory disease characteristic by a symmetrical inflammatory arthritis infecting mainly the peripheral joints

Question 2

Which sex is rheumatoid arthritis more common in? When is it the opposite?

Answer 2

Rheumatoid arthritis is 3 times more common in females

However, it is more common in males when it comes to affecting extra-articular structures

Question 3

What is the approximate prevalence of rheumatoid arthritis? What type of joints are affected by RA and how?

Answer 3

Affects approximately 1% of the population It can affect any synovial joints - typically affects the small joints -

RA targets the synovium lining the joint capsules and tendon sheaths

Question 4

Which joints in the neck are affected by RA and why?

Answer 4

Commonly affects the antlatno-occipital joint (C1 and occipital bone) and atlanto-axial joint (C1 and C2)

Less commonly it affects the facet joints It can affect these spinal joints because they are synovial joints (between normal vertebral bodies they are secondary cartilaginous joints)

Question 5

Which haplotype is RA mediated by? What is thought to be a major risk factor for RA due to increase one of the autoantibodies associated with the disease?

Answer 5

HLA-DR4 and sometimes HLA-DR1

A major risk factor linked to RA is smoking as it is associated with a large increased in anti-CCP antibodies (anti cyclic citrillunated peptide antibodies)

Question 6

How much synovial fluid usually exists in synovial joints? What does inflammation of synovium in rheumatoid arthriits cause?

Answer 6

Normally there is about 1-2 mls of synovial fluid existing in a joint

Inflammation of the synovium causes more synovial fluid to be excreted.

When the synovium is inflamed it brings in inflammatory cells into the fluid causing damage

Question 7

What type of bone change is caused by rheumatoid and osteoarthritis * Hypotrophic or hypertrophic

Answer 7

Hypoptrophic bone changes are typically seen on xray in rheumatoid

Rather than hypertrophic picture seen in OA

* Gout and rheumatoid show an erosive athritis

Question 8

Rheumatoid arthritis (RA) causes an inflammatory response in joints that leads to synovial tissue proliferation (vascular hypetrophy of the synovium). What is this known as?

Answer 8

This is known as Pannus - this is where there is vascular hypertrophy of the synovium due to inflammation of the joint

Question 9

What is activated in rheumatoid arthritis that causes bone erosion?

Answer 9

There is increased osteoclast activity due to rheumatoid factor

Question 10

How does synovitis present and how can it affect the muscles?

Answer 10

Synovitis presents as swelling and inflammation

It can lead to muscle wasting

Question 11

What is the syndrome known as that describes increased swelling of the extensor tendons in the hand which leads to atraumatic rupture of these tendons most commonly associated with rheumatoid arthritis? In which order do the tendons rupture in this syndrome?

Answer 11

This is known as Vaughan Jackson Syndrome

The presentation is with reduced extension of the fingers 1-5.

Typically, the fifth digit is the first to lose extension, and then sequentially the fourth, the third, and then finally the second digit

Question 12

What is early rheumatoid defined as? When is the therapeutic window for most beneficial effects in the treatment of early RA?

Answer 12

Early rheumatoid is defined as less than 2 years since symptoms onset

Therapeutic window for most beneficial effects in treatment of early RA is within the first 3 months

Question 13

Diagnosis of rheumatoid arthritis is based on the clinical presentation, radiograph findings and serological analysis What s the classification system for diagnosis RA? What are the four categories measured?

Answer 13

Classification system is the ACR and EULAR

Rheumatoid arthritis classification criteria

Four categories measured

* Joint involvement

* Serology

* Acute phase reactants

* Duration of symptoms

Question 14

According to the ACR and EULAR Classification * What is look for in joint involvement? * What is tested for in serology? * What acute phase reactants are measured? * What duration is significant?

Answer 14

* Joint involvement - swelling or tenderness of joints +/- imaging evidence

* Serology - rheumatoid factor and/or anti-cyclic citrillunated peptide (anti-CCP)

* Acute phase reactants - ESR and/or CRP raised

* Duration - >/= 6 weeks

Question 15

What is the score needed in the ACR/EULAR classification for a diagnosis of RA?

Answer 15

A score of greater than or equal to 6 out of a possible 10 is diagnostic of rheumatoid arthritis

Question 16

What are three clinical features of rheumatoid arthritis? (how long is the prolonged stiffness)

Answer 16

* Morning stiffness greater than 30 minutes (relieved by exercise)

* Symmetrical, swollen, painful joints

* Involvement of the small joints of the hands and feet

Question 17

What test can be done to test for synovitis? (involves the metacarpophalngeal (MCP) and metatarsophalngeal (MTP) joints)

Answer 17

Compression test (aka Gaenslen’s squeeze test) can be done to test for synovitis

Gaenslen’s test (GT) positivity is characterized by tenderness upon lateral compression (squeezing) of the metacarpophalangeal (MCP) or metatarsophalangeal (MTP) joints

Question 18

Is monoarthritis a common feature of rheumatoid arthritis? What is carpal tunnel syndrome? What causes the compression?

Answer 18

Monoarthritis is not a common feature of rheumtoid arthritis

Carpal tunnel syndrome is where there is compression of the median nerve under the flexor retinaculum (fibrous tissue forming the carpal tunnel) of the hand

Compression is due to the swelling of a tendon or tissue in the carpal tunnel

Question 19

What is the type of rheumatoid where it is intermittent and the joint is the same before and after the episode? What percentage of this type of rheumatism go on to have RA?

Answer 19

Palindromic rheumatoid arthritis - recurring mono-polyarthritis of various joints 50% of palindromic RA go on to have rheumatoid arthritis

Question 20

What are the systemic effects of rheumatoid arthrtis?

Answer 20

Systemic effects (constitutional symptoms) - weight loss, night sweats, cachexia (weakness and wasting of the body due to chronic illness)

Question 21

In RA, there can often be a common swelling on the ulnar aspect of the hand. Which tendon is swollen here? It is usually this tendon that is the first to rupture in Vaughan Jackson syndrome

Answer 21

It is usually the extensor carpi ulnaris tendon which is inflamed causing a swelling - this is known as extensor tenosynovitis (inflammationn of the synovium around the extensor tendon) - it often presents as a painful swelling on the ulnar dorsal aspect of the hand

Question 22

What are the two auto-antibodies raised in rheumatoid arthritis? How sensitive are the two antibodies when testing for RA? Which antibody is more specific?

Answer 22

Rheumatoid factor and anti-CCP antibodies are raised in rheumatoid arthritis

Both antibodies are approx 70% sensitive for the condition

* (proportion of people who correctly identified as positive over those who actually have the disease)

Anti-CCP is more specific for RA (90-99% specific)

* (proportion of people who correctly identified as negative over those who do not have the disease)

Question 23

If the antibodies are negative (RA and anti-CCP), is rheumatoid arthritis ruled out? What risk factor is associated with an increase in anti-ccp?

Answer 23

If antibodies are negative in RA, the disease is not ruled out

Smoking is associated with an increase in anti-ccp

Question 24

What are the three imaging techniques mainly used in diagnosis / disease monitoring for RA?

Answer 24

Plain Xray of hands and feet

Ultrasound scanning MRI scans

Question 25

What are the advantages of xray scans in rheumatoid arthritis? What are the disadvantages?

Answer 25

Xrays are cheap and reproducible

Soft tissue swelling also appears on the CXR

Disadvantage - absence of findings ine arly disease

Question 26

What scan is useful for detecting synovitis in early disease and how? What is useful for detecting erosions also in early disease?

Answer 26

Ultrasound scan and MRI are useful as when there is synovitis, there is increase blood flow that is picked up

Ultrasound and MRI are also both more sueful at detecting bone erosions than conventional Xrays

Question 27

What is the difference in what is seen on CXR in OA vs RA?

Answer 27

Osteoarthritis xray

• L – loss of joint space
• O – osteophytes
• S – subchondral sclerosis
• S – subchondral cysts

Rheumatoid arthritis xray

• L – loss of joint space
• E – erosions
• S – soft tissue swelling
• S – soft bones (osteopenia - bone thinning (less white))

Question 28

The ACR/EULAR is used to confirm RA. What assessment is used to assess the activity of the disease? How many joints are taken into consideration in this scoring system?

Answer 28

Disease is activity is measured using the DAS-28 score

This is a composite of 4 domains and takes into account 28 different joints

Question 29

What are the four domains of the DAS 28 scoring system that are considered?

Answer 29

* Tender joint joint

* Swollen joint count

* CRP/ESR

* Visual analogue score - patients own assessment of their disease progression

Gives a maximum score out of 10

Question 30

The DAS 28 scoring system has four stages of disease activity What are the four stages and what score is needed for each stage?

Answer 30

Remission = 2.6

Low disease activity 2.6 < DAS 28 = 3.2

Moderative disease activity, 3.2 < DAS 28 = -5.1

High disease activity >5.1

Question 31

When giving treatment for rheumatoid arthritis, what is the initial therapy?

Answer 31

NSAIDs + Steroids + DMARD should be started early as this improves long term outcomes

NSAID - non-steroidal anti-inflammatory drug

DMARD - disease modifying anti-rheumatic drug

Question 32

How do each of the initial drugs work in managing the patient with RA? * How are the steroids given? * When should DMARDs ideally be started?

Answer 32

NSAIDs- good for symptom relief, no effect on disease progression

Steroids - rapidly reduce symptoms and inflammation - can be given intra-articular if few joints involved or oral

DMARDs - 1st line and should be ideally started within 3 months of persistent symptoms

Question 33

What are the first, second, third and fourth line DMARDs that are typically given?

Answer 33

* First line - methotrexate

* Second line - sulfasalazine

* Third line - hydroxychloroquine

* Fourth line - leflunomide

Typically would trial for 3 months before changing or adding another medication

Question 34

Which DMARD is typically prescribed for palindromic rheumatoid arthritis?

Answer 34

Typically hydroxychloroquine is prescribed for palindromic RA

Question 35

What score is required for a patient to be eligible for biological therapy to treat the rheumatoid arthritis? What are the other requirements?

Answer 35

DAS 28 score of >5.1 - therefore high disease activity is required for biological therapy

The patient must have a high disease activity DAS 28 score despite adequate trial of at least 2 DMARDs

Question 36

What are the most commonly used biological drugs for RA? Give 2 examples What is given in combination with the biological agent?

Answer 36

The most commonly used biologics are anti-TNF alpha drugs, all of which are given by injection.

* eg inflixamab, etanercept, adalimumab

Methotrexate is usually given in combination with the biological agent

Question 37

What steroid is usually used in rheumatoid arthriits? What are some of the side effects that can be caused by steroids?

Answer 37

If intra-articular injections - methylprednisolone

If oral steroids - prednisolone

Side effectts

* Increased risk of osteoporosis - leading to wedge fractures

* Delay in wound healing

* Striae (stretch marks)

* Bruising

* Cushing’s

* DIabetes

Question 38

What is the primary aim of treatment in rheumatoid arthritis? Which DMARD is not an immunosuppresant and therefore may be able to be used during pregnancy?

Answer 38

The primary target in RA should be a state of clinical remission

Sulfasalazine may be able to be used in pregnancy