Week 2 - Rheumatoid Arthritis

Question 1

what is the most prevalent seropositive arthropathy?

Answer 1

rheumatoid arthritis (RA)

Question 2

what is RA?

Answer 2

autoimmune inflammatory symmetrical polyarthropathy which commonly affects the small joints of the hands and feet

Question 3

where does RA affect?

Answer 3

usually small joints of the hands and feet but can affect larger joints (knees etc) as disease progresses

Question 4

who is more commonly affected by RA?

Answer 4

women

most commonly peaks between 35-50

Question 5

what increased risk of RA?

Answer 5

genetic factors account for 50% of risk

first degree relatives have 2-3X higher risk

Question 6

describe the pathogenesis of RA?

Answer 6

immune response is initiated against synovium
inflammatory pannus forms which then attacks and denudes articular cartilage leading to joint destruction
tendon ruptures and soft tissue damage can occur leading to joint instability and subluxation

Question 7

what can trigger RA?

Answer 7

smoking
infection
trauma
stress

Question 8

how is RA diagnosed?

Answer 8

clinical presentation
radiography
serological analysis

Question 9

what are the clinical features of RA?

Answer 9

symmetrical synovitis (doughy swelling)
pain
morning stiffness (>30 mins - 1 hr)
sparing of DIP joints in hand

Question 10

what are the early features of RA?

Answer 10

small joint synovitis

wrists, MCPs and PIPs affected

Question 11

late features of RA?

Answer 11

deformities of the joint if aggressive or untreated

Question 12

how can RA affect the spine?

Answer 12

atlanto-axial subluxation can be seen in longstanding disease which can result in cervical cord compression

Question 13

how can RA affect the skin?

Answer 13

can cause rheumatoid nodules in 25% of RA patients

usually on extensor surfaces or sites of frequent mechanical irritation

Question 14

how can RA affect the lungs?

Answer 14

pleural effusions
interstitial fibrosis
pulmonary nodules

Question 15

how can RA affect the heart?

Answer 15

increases cardiovascular morbidity and mortality

Question 16

how can RA affect the eyes?

Answer 16

keratoconjunctivitis sicca (dry eyes?)
episcleritis
uveitis
nodular scleritis

Question 17

how is RA investigated?

Answer 17

autoantibodies
- rheumatoid factor
- anti CCP (more specific)
raised CRP, ESR and plasma viscosity
X ray/US

Question 18

what is seen in X ray in RA?

Answer 18

often normal in early stages but can show
- peri-articular osteopenia (bone thinning)
- soft tissue swelling
later stages show periarticular erosions

Question 19

what is the goal in RA treatment?

Answer 19

early and aggressive treatment

aim to commence DMARD therapy within 3 months of symptoms onset

Question 20

what treatments are used for short term symptoms relief?

Answer 20

simple analgesia
NSAIDs
steroids - intramuscular/intra-articular/oral

Question 21

name 4 DMARDs, which one is first line?

Answer 21

Methotrexate (first line)
hydroxychloroquinone
leflunomide
sulfasalazine

Question 22

what are the risks with DMARDs? how is this managed?

Answer 22

they are immunosuppressive so can increase infection risk and suppress bone marrow
regular blood monitoring needed

Question 23

what is used if DMARDs don’t work and what do they do?

Answer 23

biological agents

target different parts of the immune response

Question 24

what is the most common biological agent used?

Answer 24

anti TNF

- e.g adalimumab, etanercept etc

Question 25

what are the risks with biological agents?

Answer 25

they suppress immune response so increased infection risk

anti TNF also increases TB reactivation risk

Question 26

how do patients qualify for biological agent therapy?

Answer 26

DAS28 > 5.1

2 DMARDs tried

Question 27

what are the 4 domains of the DAS28 score?

Answer 27

tender joint count
swollen joint count
CRP/ESR
visual analogue score

Question 28

what are the cut off points for DAS28 score?

Answer 28

<2.6 = remission
2.7 - 3.2 = low disease activity
3.3 - 5.1 = moderate disease activity
>5.1 = high disease activity

Question 29

name some surgeries used in RA

Answer 29

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