Established RA – symptoms more than 6 weeks
F>M
Mediated by autoantibodies
Genetics- HLA –DR4
Environmental triggers(Ag)-microbes (EBV, retrovirus, mycobacteria), citrullinated proteins
OA RA
Pathology Cartilage degeneration+/- Synovial inflammation+cartilage and
inflammation bone damage
Age 50-60 All ages
Hand DIP/PIP/CMC PIP/MCP (No DIP)
Feet MTP 1 All MTP
Synovial Low cell count High cell count
fluid
Blood tests normal ESR,CRP high RF,Anti CCP ab +
Case summary: Rheumatoid arthritis
A 43 year old widow and mother of 3 children presented with B/L symmetrical pain and swelling
of the metacarpophalangeal and proximal interphalangeal joints with associated morning stiffness
lasting for more than 1 hour. She also complains of B/L shoulder and knee joint pain. She denies alopecia,
skin rashes or oral ulcers. She also complains of symptoms suggestive of anaemia and peripheral
neuropathy for 2 months duration. She has poor social support and her functional status is poor.
Her examination is significant for pallor, B/L neck deformities and swelling of the MCP and PIP
joints. Examination of the nervous system revealed sensory loss consistent with a polyneuropathy.
Discussion
What is your diagnosis?
Rheumatoid arthritis
Why do you say so?
1. Inflammatory polyarthritis (pain , swelling, warmth, redness, loss of function)
2. Usually symmetrical
3. Joint pain worse in the morning/ after prolonged rest
4. Joint pain improves with working
5. Early morning joint stiffness – more than 30min.
6. Very commonly affect hand joints( not DIP)
(Can involve large joints like knee and elbow)
7. Spine / sacroiliac joint not involved
8. Hand deformities ( late sign)
D/D:
Rheumatoid arthritis
SLE – Is less likely due to lack of cutaneous manifestations or organ involvement
Spondyloarthopathies – Is less likely due to lack of involvement of the spine
Generalized OA – Is less likely due to the inflammatory process and pattern of joint involvement
(sparing of the DIP joint)
How would you establish a diagnosis of rheumatoid arthritis?
The diagnosis of RA is generally clinical, in a patient with symmetrical inflammatory polyarthritis
When patients have atypical presentations, classification criteria can be used to aid the
diagnosis
What are the investigations you would like to perform in this patient?
inflammatory markers( ESR, CRP) , rheumatoid factor/CCP ab
Hand xray ( xray changes – late sign – not useful for diagnosis)
1. periarticular osteopenia
2. symmetric joint space loss – seen more prominently in the wrist as crowding of carpal bones,
subchondral erosions, especially at the MCP and PIP in the free surfaces.
3. Overt rheumatoid deformities are rare in early disease
Other investigations may be required to screen for organ complications and extra-articular
disease.
Perform baseline investigations before commencing drug therapy – FBC, liver function test,
renal function tests
How will you treat the patient?
General management
Patient education
MDT( physiotherapy and occupational therapy , some patients require splints to
overcome deformities and to improve their functional capacity , Home modification)
Commence DMARD as soon as possible you diagnose the disease ( limit joint damage
and disease progression) 1st line - methotrexate
DMARD – minimize joint deformities
- Take 6wks to 6 months to work ( so bridge with steroids- for short course
and then tail off – oral or single shot of IV/IM )
- NSAIDS+ STEROIDS – BEST AVOIDED
MTX – Continue for 3- 6months - if no remission – use 2nd line drugs
At 6 months look for poor prognostic features ( high RF/anticcp , extra articular manifestations, high
disease activity, early joint deformities)
If present if absent
Add Biologics (TNF alpha blocer-Infliximab) add leflunamide/sulfasalazine
Or JAK 2 inhibitor
MTX patient advices
1. Name of the drug and indication
2. Ix- FBC , LFT, RFT
3. Once/ week , same day each week ( folic acid on a different day )
4. Duration –long term
5. side effects- folate antagonism ( hair loss oral ulcers)
i. progressive SOB / dry cough
ii. vomiting, nausea , jaundice go to a doctor
iii. fever , sore throat
6. pregnancy and breast feeding – contraindicated-( proper contraception should cont. >3 months
off MTX)
What are the other important issues in the management of this patient?
Anaemia (one of the most common problems in patients with RA)
1. This is most often due to anaemia of chronic disease,
2. iron deficiency anaemia due to inadequate diet, chronic upper GI bleeding as side effects of
medication – NSAIDs and steroids,
3. folate and B12 deficiency also play a role
4. Rare possibilities include bone marrow suppression and LGL ( large granular lymphocyte –
leukemia)
Pulmonary disease
1. This is also a very common management problem.
2. Start investigations with a CXR and lung function test, and move on to HRCT
3. The most common HRCT findings are of ILD with predominant basal sub pleural involvement
with honeycombing.
4. Lung function test will show a restrictive pattern
How would you identify a flare up
Symptoms – inflammatory joint pain worsens
Inflammation features
Stiffness > 30min
May have fever , fatigue
Cause – compliance issue , too much activity, stress, climate change , infection
How would you follow up this patient?
ideally -rheumatologist for continuing care
At each visit - joint score. CDAI( clinical disease activity index),SDAI( simplified DAI) and
DAS 28 (Disease activity score) scores.
Assess quality of life and restrictions to daily activities
Assess the adverse effects of medication and make necessary adjustments
Set targets for the next visit
The patient complains of severe neck pain. What do you think? How will you evaluate?
Consider the possibility of atlanto-axial subluxation
History
Introduction
Background
Usually a diagnosed patient with RA and the focus will be on management issues
Presenting complaint
This will usually be with an acute flare of the disease
Describe the onset and progression of the disease with the associated features
Describe the current state of functional restriction
Find the cause for flare up
Past history
Go back to the onset of the disease
Describe the initial presentation of the patient and how the diagnosis was made.
(Describe the results of relevant investigations at that time – markers of inflammation,
rheumatoid factor )
Ask for other evidence suggestive of associated connective tissue disorders –SLE , SS,
Sjogren (malar rash, photosensitivity, oral ulcers, skin thickening, Raynaud’s
phenomenon)
initial management of the patient and follow up
Highlight the complications of the disease over time – use a time line
Describe the medication history
Using the same timeline describe the medication history and important changes done
over time
Ask for the adverse effects of medication
Discuss the functional capacity of the patient
Use the activities of daily living (ADL) and instrumental activities of daily living (IADL) as
a guide ( washing clothes, travelling in bus, sewing)
Past medical and surgical history( esp. DM – steroids)
Drug history
This has been described above
Social history
Discuss the impact of the disease on the patient on the person and family
Discuss the support available to the patient
Describe the household environment with relations to the limitations of activity
Fertility wishes
Examination
General
Pallor ( anemia)
Icterus (s/e of drugs)
Red eyes ( episcleritis / scleritis)
Dry eyes ( sjogren)
Rheumatoid nodules
MSK
Joint deformities( swan neck deformities, boutonniere deformities, ulnar deviation, Z
shaped thumb)
Draw a hand – number of tender and swollen joints
Do a functional assessment – buttoning, holding a cup
CVS
Any murmurs
Pericarditis
RS
Pleural effusion
ILD
CNS
Lower limb reflexes ( spastic quadriparesis in atlanto axial subluxation)
Sero negative spondyloarthrits
What are the key features of Spondyloarthropathy?
Predominant axial involvement – spine and sacroiliac joints
Inflammatory back pain
1. Age at onset, <45
2. Duration, >3 months
3. Insidious onset
4. Morning stiffness >30 min
5. Improvement with exercise
6. No improvement with rest
7. Awaking from pain, especially during second half of night, with improvement on arising
8. Alternating buttock pain
Peripheral asymmetric oligoarthritis with predominant large joint involvement – hip, knee, ankle
and shoulder
Evidence of enthesitis – tenderness and pain at insertion points of muscle, tendon sheaths,
ligaments and fascial planes
Clinical evidence of dactylitis – this refers to inflammation of the fingers which usually causes
‘sausage shaped’ digits
Family history of similar disease/psoriasis or other history suggestive of a cause
Extra- articular manifestations – uveitis, cardiac involvement
Good response to NSAIDs
4 types
1. ankylosing spondylitis
2. IBD associated arthritis
3. psoriatic arthritis
4. reactive arthritis
