Medical Student teaching !

Rheumatoid Arthritis Dafydd Loughran F1

Background• Chronic systemic inflammatory disease

• "Symmetrical, deforming, peripheral polyarthritis" - OSCE quote

• 1% prevalence

• Twice as common in women

• Increased cardiovascular risk in long term

Clinical features• Usually presents with symmetrical swollen,

painful and stiff small joints of hands and feet

• Stiffness worse in mornings

• May present with systemic fatigue, fever, weight loss etc

• PIP's, MCP's, wrists and MTP's most commonly swollen and tender. Usually spares DIP's.

Classic hand signs

1. Ulnar deviation

2. Boutonniere deformity

3. Swan neck deformity

4. Z shaped thumb

5. MCP subluxation

DAS 28• Used to monitor disease activity

• Swollen and tender joint count out of 28 each

• Includes PIP's, MCP's, CMC's, wrists, elbows, shoulders, and knees

• VAS (visual analogue scale) of how the disease has been affecting then in last 2/52 scored from 1-100

• ESR - most recent reading

• Score (use mobile app!): Remission <2.6

Mild 2.6 - 3.2Moderate >3.2 - 5.1

Severe >5.1

Extra-articular• Many but these are the most important:

1. Nodules - look up ulnar side of forearm and elbows

2. Lungs - can be affected by nodules in the lung or by pulmonary fibrosis due to Methotrexate therapy

3. Raynaud's or Carpal tunnel syndrome

4. Felty's syndrome (comes up in exams): RA + splenomegaly + neutropenia

Investigations• Rheumatoid factor: 70% positive

• Anti CCP antibodies: Newer, less sensitive but very specific. Usually check this if RF negative

• Raised ESR + CRP

• Anaemia of chronic disease

• Radiological changes

RA radiology

• Loss of joint space

• Bony Erosions

• Soft tissue swelling

• Osteopenia (juxta-articular)

• Subluxation

Management• Early use of DMARD's and biological agents is beneficial in

slowing disease progression

• Methotrexate or sulphasalazine (both DMARD's) are first line. Can take 6-12 weeks to see benefit

• All DMARD's and biologics can cause bone marrow suppression so close monitoring essential

• Methotrexate SE's: pulmonary fibrosis, oral ulcers, hepatotoxicity

• Sulphasalazine SE's: rash, decreased sperm count, oral ulcers

Biologic therapy• This is where the NHS spends its money!

• To be eligible must continue to have high DAS28 score despite trial with 2 DMARD's at full dose for a few months each

• Most end in -MAB. No need to know many details but the following are good to know for exams:

• Infliximab: murine/human anti-TNF , Adalimumab: human anti-TNF

• Rituximab: anti-CD20, Tocilizumab: anti-IL6

Adjunct therapy• NSAID's are important for symptom

control

• Steroids rapidly improve symptoms and inflammation but due to side effects (osteoporosis, weight gain, skin thinning etc) shouldn't be used long term

• Depo-medrone steroid IM injection can be given in buttock for treating acute flares

• Encourage regular exercise

• Decrease cardiovascular risk factors due to increased risk