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Rheumatoid Arthritis Cheat Sheet by

Information about RA, including presentation, management, investigations and diagnosis

General Inform­ation

Autoimmune 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 Signs

Boggy 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 Criteria

More 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 Prognosis

Younger onset
Male
More joints + organs
RF + anti-CCP
Erosions on XR
 

Presen­tation

Key symptoms
Symmet­rical distal polyar­thr­opathy
 
Pain, swelling, stiffness
 
Improves with activity
 
Morning stiffness >1hr
Systemic symptoms
Fatigue
 
Weight loss
 
Flu
 
Myalgia

Extra-­Art­icular Manife­sta­tions

Caplan'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 Effects

Methot­rexate
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 Involv­ement

PIP joints
MCP joints
Wrist + ankle
Cervical spine
Can involve large joints (knees, hips, shoulders)
Does not involve DIP joints

Palind­romic Rheumatism

Self-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

Invest­iga­tions

RF
If -ve, check anti-CCP
CRP + ESR
XR of hands and feet
USS to confirm synovitis

XR Changes

Joint destru­ction and deformity
Soft tissue swelling
Periar­ticular osteopenia
Bony erosions

Management

MDT
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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  • Published: 4th August, 2022

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