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Information about RA, including presentation, management, investigations and diagnosis
General InformationAutoimmune condition causing synovitis of joints, tendon sheaths, and bursae | Symmetrical and affects multiple joints | 3x more common in women | Associated with HLA DR4 and HLA DR1 | 70% of RA patients have +ve RF | Some patients will be anti-CCP +ve |
Hand SignsBoggy feeling in synovium
Z-shaped deformity to thumb
Swan neck deformity (hyperextended PIP, flexed DIP)
Boutonnieres deformity (hyperextended DIP, flexed PIP)
Ulnar deviation of MCP joints Diagnostic CriteriaMore than 4/7 = diagnosis: | Morning stiffness for >1hr for 6+ weeks | 3+ joints affected for 6+ weeks | 1+ joints in hand/wrist for 6+ weeks | Symmetrical involvement of 1+ joints | Presence of rheumatoid nodules | High serum RF | Consistent radiographic changes of hand or wrist |
Worse PrognosisYounger onset | Male | More joints + organs | RF + anti-CCP | Erosions on XR |
| | PresentationKey symptoms | Symmetrical distal polyarthropathy | | | Pain, swelling, stiffness | | | Improves with activity | | | Morning stiffness >1hr | Systemic symptoms | Fatigue | | | Weight loss | | | Flu | | | Myalgia |
Extra-Articular ManifestationsCaplan's syndrome - pulmonary fibrosis, pulmonary nodules | Bronchiolitis obliterans | Felty's syndrome - RA, neutropenia, splenomegaly | Secondary Sjogren's syndrome - sicca syndrome | Anaemia of chronic disease | CVD | Episcleritis and scleritis | Rheumatoid nodules | Lymphadenopathy | Carpel tunnel syndrome | Amyloidosis |
Important Side EffectsMethotrexate | Pulmonary fibrosis | Leflunomide | HTN
Peripheral neuropathy | Sulfasalazine | Male infertility (reduced sperm count)
Orange fluids | Hydroxychloroquine | Nightmares
Reduced visual acuity | Anti-TNF medication | Reactivation of TB or Hep B | Rituximab | Night sweats
Thrombocytopenia |
| | Joint InvolvementPIP joints | MCP joints | Wrist + ankle | Cervical spine | Can involve large joints (knees, hips, shoulders) | Does not involve DIP joints |
Palindromic RheumatismSelf-limiting, short episodes of inflammatory arthritis | Presents with joint pain, stiffness and swelling | Episode lasts 1-2 days then completely resolves | A +ve RF and anti-CCP can indicate it will progress to RA |
InvestigationsRF | If -ve, check anti-CCP | CRP + ESR | XR of hands and feet | USS to confirm synovitis |
XR ChangesJoint destruction and deformity | Soft tissue swelling | Periarticular osteopenia | Bony erosions |
ManagementMDT | Steroids | Short course initially + flare ups | NSAIDs (+PPI) | DMARDs | 1. Monotherapy with methotrexate/leflunomide/sulfasalazine
Hydroxychloroquine if mild
Take folic acid 5mg if on methotrexate | | | 2. Dual therapy with above | | | 3. Methotrexate + biological therapy (usually TNF inhibitor) | | | 4. Methotrexate + rituximab | | | If pregnant - sulfasalazine or hydroxychloroquine | Surgery |
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