Rheumatoid Arthritis

Another vivacast from our resident PACES expert - Jean Lee. This one is all about presenting a patient, and answering questions about rheumatoid arthritis.

 

Lecture by

Video Duration: 7 minutes

  • Rheumatoid Arthritis
    Created by Eve Fordyce
    General
    Epidemiology

    Rheumatoid arthritis is a chronic, seropositive, inflammatory, autoimmune form of arthritis.

    As with other autoimmune conditions, it is more common in women (four times in this case).

    Approximately 10,000 new RA cases diagnosed annually.

    Pathology

    Again, similar to other autoimmune diseases, the exact pathology remains unknown. Most likely it is a combination of genetic predisposition, environmental stimuli, foetal factors, hormonal environment.

    Rheumatoid arthritis is commonly associated with other autoimmune conditions such as type one DM. It has also been suggested that there is a link between the presence of HLA DR4 and severe disease.


    Top three causes

    Unknown

    Clinical Features
    Symptoms

    There is now an emphasis on diagnosis and initiating treatment as early as possible in RA. ? starting treatment within the first 12 weeks of symptoms can alter the course of the disease?

    Bilateral and symmetrical arthritic joints (must be synovial). this can occur anywhere, but there is a high incidence of it occurring in the joints of the hands and feet.

    Morning stiffness lasting over an hour in duration.

    progressive disability/activity limitation due to deformity.

    Signs
    • Swollen joints
    • Redness
    • Muscular atrophy
    • In the hands: ulnar deviation of phalanges, swan neck deformities, Boutonnière's deformity.
    • Rheumatoid nodules (often present on bony surfaces such as the elbow).

    Complications:

    • RA is a systemic disease, and although it primarily affects the joints it can also have other multisystem effects.
    • Lungs: fibrosis, nodules in lungs, plural involvement.
    • Neurological: carpal tunnel syndrome, sensory polyneuropathies, radiculopathies, nerve entrapment.
    • Cardiovascular: Pericarditis, myocardial fibrosis, vasculitis. people suffering from RA have an increase risk of ishaemic heart disease.
    Investigations
    Cultures

    None

    Bloods

    Venous: FBC (increased CPR and ESR), Anti-cyclic citrullinated peptide (anti-CCP) antibodies, rheumatoid factor. Note that approximately 1/3 of people suffering from RA are seronegative for Rheumatoid factor, so a negative result does not necessarily exclude a diagnosis of rheumatoid arthritis.

    Imaging

    Recommended that all patients have and X-ray of their hands and feet as well as a chest x-ray prior to starting therapy.

    Scopic/Biopsy

    None

    Functional

    None

    Treatment
    Conservative

    Early referral to a rheumatologist is essential. However, GP should prescribe NSAID's and possibly neuropathic pain killers such as amitriptyline to reduce level of pain.

    RA patients should be reffered to the likes of podiatrists, physiotherapists and occupational therapists.

    Medical

    Rheumatologists may prescribe the likes of corticosteroids, DMARD's (disease modifying anti rheumatic drugs) or biologics. The prescription of these will vary from patient to patient depending on severity of disease, ADR's, what has been previously tried etc.

    Currently popular are methotrexate and sulfasalazine due to being less toxic than some other options.

    Patients are commonly initiated on multi-drug therapy.

    Biologicals are second line where patients may be resistant to the likes of methotrexate. These are cytokine modulating therapies.

    Patients should have a yearly review.

    Surgical

    Orthopaedic surgeons may be involved to improve joint mobility in patients who are on maximum therapy but are still in a significant amount of pain.

  • Rheumatoid Arthritis
    Created by Nitin Lamba
    General
    Epidemiology

    Chronic, inflammatory autoimmune disease, causing a symmetrical polyarthritis

    Global prevalence ~ 0.5-1%

    Peak prevalence at 30-50 years

    Increased prevalence in pre-menopausal women than men (3:1), but post-menopause, male:female prevalence ~1:1


    Pathology

    Inflammatory infiltration of the synovial lining of joints leads to synovitis and eventually pannus formation. This causes destruction of the articular cartilage and subchondral bone.

    Top three causes
    • Genetic inheritance
    • Smoking
    • Other autoimmune disorders, e.g. Sjogren's syndrome
    Clinical Features
    Symptoms

    Gradual onset of symptoms.

    For RA to be diagnosed, symptoms must be present for at least 6 weeks.

    Early morning joint stiffness, lasting > 1 hour.

    Symmetrical distribution of affected joints.

    Tender swelling of hand joints, especially MCP, PIP and Wrist (but DIPJ is spared)

    Other joints that can be affected include wrist, elbow, knee, ankle, MTP.

    More general symptoms include:

    • Hearing difficulties
    • Pleuritic chest pain
    Signs
    • Ulnar deviation of fingers
    • Swan neck deformity of fingers
    • Boutonierre's deformity of thumb
    • Presence of Rheumatoid Nodules
    • Muscle wasting
    • Palmar erythema

    Neurological findings include:

    • Carpal Tunnel Syndrome
    • Sensory Polyneuropathy
    • Mononeuritis multiplex

    Pulmonary findings include:

    • Pleural effusion
    • Pulmonary fibrosis
    • Pulmonary nodules

    Vasculitic features include:

    • Nail fold vasculitis
    • Peripheral neuropathy
    • Cutaneous ulceration
    • Digital gangrene

    Cardiovascular features include:

    • Pericarditis
    • Pericardial Effusion
    • Amyloidosis
    • Valvular incompetence
    Investigations
    Cultures

    None

    Bloods

    FBC

    Acute Phase Reactants (CRP, ESR)

    Auto-antibodies (Rheumatoid Factor, Anti-CCP)

    Imaging

    Chest X-Ray

    Ultrasound scan (to detect synovitis)

    Annual X-ray of affected joints

    Scopic/Biopsy

    Joint aspirate for synovial fluid analysis

    Functional

    None

    Treatment
    Conservative

    Early recognition and rapid referral to a rheumatologist

    NSAIDs

    Medical

    DMARDs, e.g. Methotrexate, Sulphasalazine

    Corticosteroids

    Biological agents, e.g. Infliximab (Anti-TNF-alpha monoclonal antibody)

    Optimize cardiovascular risk factors

    Surgical

    None