Medical Student teaching

Rheumatoid Arthritis
Dafydd Loughran F1
Background
Chronic systemic inammatory 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 - 3.2
Moderate >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 brosis 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 specic. 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 benecial in
slowing disease progression
Methotrexate or sulphasalazine (both DMARD's) are rst line.
Can take 6-12 weeks to see benet
All DMARD's and biologics can cause bone marrow
suppression so close monitoring essential
Methotrexate SE's: pulmonary brosis, 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:
Iniximab: 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 inammation 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 ares
Encourage regular exercise
Decrease cardiovascular risk factors
due to increased risk