Rheumatoid Arthritis Overview
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Questions and Answers

What is the peak age of onset for Rheumatoid Arthritis?

35-50 years

Rheumatoid Arthritis is a common form of inflammatory Arthritis that can affect all ethnic groups and occur globally.

True

What is the female-to-male ratio of Rheumatoid Arthritis?

3:1

What is the annual incidence of Rheumatoid Arthritis per 10,000 people?

<p>3 cases</p> Signup and view all the answers

What are two key components of Rheumatoid Arthritis?

<p>genetic and environmental</p> Signup and view all the answers

Which of these is NOT an environmental risk factor for Rheumatoid Arthritis?

<p>Pregnancy</p> Signup and view all the answers

Cigarette smoking is linked to more severe Rheumatoid Arthritis and a reduced response to treatment.

<p>True</p> Signup and view all the answers

What is a potential cause of remission during pregnancy for Rheumatoid Arthritis?

<p>Suppression of the immune response</p> Signup and view all the answers

Rheumatoid Arthritis is often diagnosed during pregnancy.

<p>False</p> Signup and view all the answers

What is the name for the invasive synovium that erodes cartilage and bone in Rheumatoid Arthritis?

<p>Pannus</p> Signup and view all the answers

Pannus is present in all forms of arthritis.

<p>False</p> Signup and view all the answers

What is the most common sign of inflammatory polyarthritis?

<p>Joint swelling</p> Signup and view all the answers

Morning stiffness in Rheumatoid Arthritis usually improves as the day progresses.

<p>True</p> Signup and view all the answers

Which of these joints are commonly affected in Rheumatoid Arthritis?

<p>PIP and MCP joints of the hands</p> Signup and view all the answers

Ulnar deviation is a characteristic hand deformity in Rheumatoid Arthritis.

<p>True</p> Signup and view all the answers

Boutonnière deformities involve the MCP joints.

<p>False</p> Signup and view all the answers

Swan-neck deformities make the PIP joint hyperextended and the DIP joint flexed.

<p>True</p> Signup and view all the answers

Erythema, commonly seen in Rheumatoid Arthritis, can indicate sepsis.

<p>False</p> Signup and view all the answers

What is a common articular complication in Rheumatoid Arthritis?

<p>All of the above</p> Signup and view all the answers

Popliteal (Baker’s) cysts are commonly seen in patients with Rheumatoid Arthritis.

<p>False</p> Signup and view all the answers

Fatigue is a common constitutional symptom in Rheumatoid Arthritis.

<p>True</p> Signup and view all the answers

Which of these is NOT a constitutional symptom in Rheumatoid Arthritis?

<p>Swelling</p> Signup and view all the answers

Cervical spine involvement at C1-C2 is a rare occurrence in Rheumatoid Arthritis.

<p>False</p> Signup and view all the answers

Instability of the cervical spine in Rheumatoid Arthritis is always asymptomatic.

<p>False</p> Signup and view all the answers

Nearly half of Rheumatoid Arthritis patients might have cervical spine involvement.

<p>True</p> Signup and view all the answers

Disease-modifying antirheumatic drugs (DMARDs) can completely eliminate the need for cervical spine surgery in Rheumatoid Arthritis.

<p>False</p> Signup and view all the answers

Extra-articular features in Rheumatoid Arthritis are more common in men who present with seropositive erosive disease.

<p>False</p> Signup and view all the answers

What are the primary extra-articular features in Rheumatoid Arthritis?

<p>All of the above</p> Signup and view all the answers

Rheumatoid nodules are exclusively found in Rheumatoid factor-positive individuals.

<p>False</p> Signup and view all the answers

Rheumatoid nodules can only be found in the extensor tendons.

<p>False</p> Signup and view all the answers

Rheumatoid nodules are typically symptomatic.

<p>False</p> Signup and view all the answers

Felty's syndrome, a systemic manifestation of Rheumatoid Arthritis, involves neutropenia and splenomegaly.

<p>True</p> Signup and view all the answers

Which of these ocular manifestations is most common in Rheumatoid Arthritis?

<p>Keratoconjunctivitis sicca</p> Signup and view all the answers

Rheumatoid Arthritis can cause digital arteritis and ulcers.

<p>True</p> Signup and view all the answers

Pericarditis is a rare cardiac complication seen in Rheumatoid Arthritis.

<p>False</p> Signup and view all the answers

Caplan’s syndrome is a pulmonary manifestation of Rheumatoid Arthritis associated with pneumoconiosis.

<p>True</p> Signup and view all the answers

The diagnosis of Rheumatoid Arthritis primarily relies on clinical assessment, but investigations can aid in confirmation and disease monitoring.

<p>True</p> Signup and view all the answers

Anticitrullinated peptide/protein antibodies (ACPAs) are highly specific for Rheumatoid Arthritis.

<p>True</p> Signup and view all the answers

Rheumatoid factor is more specific than ACPA, making it the preferred test for confirming Rheumatoid Arthritis.

<p>False</p> Signup and view all the answers

High titers of rheumatoid factor indicate a more severe Rheumatoid Arthritis.

<p>True</p> Signup and view all the answers

Elevations in ESR and C-reactive protein are specific markers for Rheumatoid Arthritis.

<p>False</p> Signup and view all the answers

Radiographs are essential for diagnosing Rheumatoid Arthritis.

<p>False</p> Signup and view all the answers

Loss of juxta-articular bone mass is a common radiographic finding in Rheumatoid Arthritis.

<p>True</p> Signup and view all the answers

Narrowing of the joint space in Rheumatoid Arthritis is usually seen early in the condition.

<p>False</p> Signup and view all the answers

Marginal joint erosions are a common feature of Osteoarthritis.

<p>False</p> Signup and view all the answers

Ultrasound is a preferred imaging method for assessing suspected Baker's cysts.

<p>True</p> Signup and view all the answers

The ACR/EULAR classification system for Rheumatoid Arthritis utilizes a score-based algorithm that considers numerous factors.

<p>True</p> Signup and view all the answers

The 1987 ACR criteria for Rheumatoid Arthritis were known for their ability to accurately detect early disease.

<p>False</p> Signup and view all the answers

The DAS28 score is solely used for confirming a diagnosis of Rheumatoid Arthritis.

<p>False</p> Signup and view all the answers

A higher DAS28 score indicates less disease activity.

<p>False</p> Signup and view all the answers

A primary aim of Rheumatoid Arthritis management is to promote education about the condition, its investigation, treatment, and prognosis.

<p>True</p> Signup and view all the answers

The management of Rheumatoid Arthritis only involves pharmacological interventions.

<p>False</p> Signup and view all the answers

Regular exercise is discouraged in individuals with Rheumatoid Arthritis.

<p>False</p> Signup and view all the answers

Obesity can worsen Rheumatoid Arthritis symptoms by increasing mechanical strain on joints.

<p>True</p> Signup and view all the answers

NSAIDs are the first-line treatment for pain control in Rheumatoid Arthritis.

<p>True</p> Signup and view all the answers

Corticosteroids are generally recommended for long-term use in Rheumatoid Arthritis.

<p>False</p> Signup and view all the answers

Prednisolone is administered at a starting dose of 30 mg daily for patients newly diagnosed with Rheumatoid Arthritis.

<p>True</p> Signup and view all the answers

Methotrexate, a DMARD, is considered a second-line treatment option for Rheumatoid Arthritis.

<p>False</p> Signup and view all the answers

Methotrexate can cause mild alopecia and bone marrow suppression.

<p>True</p> Signup and view all the answers

Methotrexate is frequently associated with an increased risk of pulmonary fibrosis.

<p>False</p> Signup and view all the answers

Methotrexate is typically combined with folic acid to minimize bone marrow suppression.

<p>True</p> Signup and view all the answers

Triple therapy for Rheumatoid Arthritis consists of methotrexate, hydroxychloroquine, and sulfasalazine.

<p>True</p> Signup and view all the answers

Glucocorticoids are typically used at a low-dose when combined with DMARDs for patients who don't respond adequately to initial Rheumatoid Arthritis treatment.

<p>True</p> Signup and view all the answers

Biologic therapies are typically initiated when the DAS28 score is below 5.1.

<p>False</p> Signup and view all the answers

Biologics, a category of medications, target specific cytokines, receptors, and cell-surface molecules involved in the immune response.

<p>True</p> Signup and view all the answers

The primary adverse effect of biologics in managing inflammatory diseases is an increased risk of infections.

<p>True</p> Signup and view all the answers

TNF inhibitors are the only type of biologics used to manage Rheumatoid Arthritis.

<p>False</p> Signup and view all the answers

When a patient has been stabilized on biologic therapy for at least 12 months, a dose reduction should be considered.

<p>True</p> Signup and view all the answers

JAK inhibitors are typically used as first-line treatment for patients with Rheumatoid Arthritis.

<p>False</p> Signup and view all the answers

Intra-articular glucocorticoid injections are used for managing sustained flares of Rheumatoid Arthritis.

<p>False</p> Signup and view all the answers

Synovectomy, a surgical procedure, is typically performed on joints that have not responded to adequate systemic therapy.

<p>False</p> Signup and view all the answers

Joint replacement surgery is a common initial intervention for managing Rheumatoid Arthritis.

<p>False</p> Signup and view all the answers

Which of these factors is associated with an unfavorable prognosis in Rheumatoid Arthritis?

<p>All of the above</p> Signup and view all the answers

It is common for individuals with Rheumatoid Arthritis to experience remission during pregnancy.

<p>True</p> Signup and view all the answers

Methotrexate is the preferred treatment for Rheumatoid Arthritis during pregnancy.

<p>False</p> Signup and view all the answers

Leflunomide is also contraindicated during pregnancy due to its potential teratogenic effects.

<p>True</p> Signup and view all the answers

Paracetamol is generally considered safe for pregnant individuals with Rheumatoid Arthritis.

<p>True</p> Signup and view all the answers

NSAIDs are safe to use during pregnancy.

<p>False</p> Signup and view all the answers

Glucocorticoids are frequently used to control disease flares in pregnant individuals with Rheumatoid Arthritis.

<p>True</p> Signup and view all the answers

Hydroxychloroquine and azathioprine are generally considered safe for use during pregnancy.

<p>True</p> Signup and view all the answers

Cyclophosphamide is a safe DMARD for use during pregnancy.

<p>False</p> Signup and view all the answers

Biologic therapies are generally considered safe for use during pregnancy.

<p>False</p> Signup and view all the answers

Certolizumab is a biologic therapy that is known to cross the placenta.

<p>True</p> Signup and view all the answers

Breastfeeding is typically contraindicated for mothers taking methotrexate or leflunomide.

<p>True</p> Signup and view all the answers

Study Notes

Rheumatoid Arthritis

  • Rheumatoid arthritis (RA) is a common inflammatory arthritis
  • It affects people worldwide
  • Peak age of onset is 35-50 years, with a female to male ratio of 3:1
  • Characterized by exacerbations and remissions
  • Involves synovium of joints, leading to cartilage and bone damage
  • Has both genetic and environmental components
  • Higher concordance in monozygotic twins (12-15%) compared to dizygotic twins (3%)
  • Environmental factors, like infection, trigger autoimmunity in susceptible individuals
  • Cigarette smoking is a significant environmental risk factor, associated with more severe disease and reduced treatment response
  • Remission can occur during pregnancy; sometimes RA first manifests postpartum
  • Hormonal changes may play a role in the remission during pregnancy
  • The etiology of RA is poorly understood, though environmental factors are suspected to trigger autoimmune response in genetically susceptible individuals
  • Smoking is another risk factor
  • Genetic predisposition is evident in increased frequency of the disease in patients' first-degree relatives

Pathogenesis

  • Characterized by synovial hyperplasia (increased synovial membrane cell number and size)
  • Inflammatory cell infiltration (lymphocytes, plasma cells, dendritic cells, and macrophages)
  • Joint effusion (fluid accumulation in the joint space)
  • Formation of pannus (invasive synovium that erodes cartilage and bone)

Clinical Features

  • Typical presentation includes pain, joint swelling and stiffness affecting small joints of hands, feet, and wrists.
  • Often symmetrical
  • Inflammatory polyarthritis; morning stiffness lasting >1 hour, improving throughout the day
  • Common joints involved include hands (PIP, MCP), wrists, knees, ankles, elbows, hips, and shoulders
  • Characteristic hand deformities include:
    • Ulnar deviation of the MCP joints
    • Boutonnière deformities of the PIP joints (PIP flexed; DIP hyperextended)
    • Swan-neck contractures of the fingers (MCP flexed; DIP hyperextended)
  • Examination typically reveals swelling and tenderness of affected joints, but not necessarily erythema
  • Other articular symptoms include triggering of fingers, cock-up toe deformities, and Baker's cyst (in the knee) development

Extra-articular Features

  • Most common in patients with long-standing seropositive erosive disease
  • Often includes serositis, granuloma and nodule formation, or vasculitis
  • Rheumatoid nodules often present; almost exclusively in patients positive for RF or ACPA and typically appear in extensor tendons
  • May cause involvement of visceral structures (lungs, pleura, pericardium)
  • May be asymptomatic but can be complicated by ulceration and secondary infection
  • Can cause systemic symptoms such as fever, weight loss, fatigue, anemia, susceptibility to infection; osteopenia or osteoporosis and musculoskeletal problems

Systemic, Hematological, and Ocular Manifestations

  • Includes fever, weight loss, fatigue, susceptibility to infections
  • Muscle wasting, tenosynovitis, bursitis, osteoporosis
  • Anemia, thrombocytosis, eosinophilia
  • Episcleritis, scleritis, scleromalacia
  • Keratoconjunctivitis sicca
  • Digital arteritis; ulcers; pyoderma gangrenosum; mononeuritis multiplex
  • Visceral arteritis.
  • Caplan syndrome (a pulmonary complication of RA)

Cardiac and Pulmonary Manifestations

  • May involve: pericarditis, myocarditis, endocarditis, conduction defects, coronary vasculitis, granulomatous aortitis, nodules, pleural effusions, fibrosing alveolitis, bronchiolitis

Neurological Manifestations

  • Include compression neuropathies, cervical cord compression, peripheral neuropathy, mononeuritis multiplex, and amyloidosis (nephrotic syndrome)

Investigations

  • Diagnosis is primarily clinical based on symptoms and physical examination
  • Helpful for confirmation and activity assessment
  • Rheumatoid factor (RF) positive in about 70% of cases, but less specific than ACPA
  • ACPA (Anti-citrullinated protein antibodies); highly specific for RA, often present before clinical symptoms appear
  • Investigations of use may include Elevated ESR, CRP and anemia of chronic disease
  • Radiographs-not required for diagnosis but helpful. Signs of RA in radiographs can include loss of juxta-articular bone mass; joint space narrowing, marginal erosions; and atlanto-axial disease.

Radiographs

  • X-rays and other images are valuable but not required for diagnosis
  • Juxta-articular osteoporosis, and joint space narrowing are common findings; these features are typically seen late in disease progression
  • Marginal joint erosions
  • X-rays of atlanto-axial joints are important to check

Classification Criteria

  • 1987 and 2010 ACR/EULAR criteria for classification of rheumatoid arthritis.
  • Presence of synovitis in at least one joint.
  • Absence of another better diagnosis explaining the synovitis
  • Score greater than 6/10 on:
    • Number and site of involved joints (range 0-5)
    • Serological abnormality (range 0-3)
    • Elevated acute phase response (range 0-1)
    • Symptom duration (two levels, range 0-1)

Disease Activity Measures

  • DAS28 index is commonly used for assessing RA activity, treatment response, and biological therapy requirement
  • Combination of swollen and tender joint count, ESR, and patient-reported disease activity on a visual analog scale
  • Data input into calculator to provide numerical score
  • Higher score indicates more active disease

Principles of Management

  • Aims to educate patients about their disease
  • Control pain, minimize symptoms, and optimize function
  • Modify the course of the disease
  • Identify and treat comorbidities
  • Combination of pharmacological and non-pharmacological therapies, considering factors like age (especially pregnancy)
  • Education on diet and lifestyle is crucial

Education and Exercise

  • Crucial components
  • Improves quality of life and treatment outcomes
  • Includes aerobic fitness training, local strengthening exercises, and physical and occupational therapy
  • Local heat, ice packs, splints, and orthoses
  • Weight control; obesity increases mechanical strain and is a progression risk factor for joint damage

Symptomatic Treatment

  • NSAIDs for pain control
  • Short-term corticosteroid use for flares; avoid long-term use

Disease-Modifying Antirheumatic Drugs (DMARDs)

  • Methotrexate is best initial DMARD, with improvement evident within 4-6 weeks
  • Side effects include gastrointestinal upset, mild alopecia, bone marrow suppression and potential liver/interstitial pulmonary issues
  • Supplemental folic acid is often necessary
  • Other DMARDs given if primary fails or toxicity occurs, often in combination
  • Dose-limiting toxicity or lack of response prompts addition or switching of DMARDs
  • Low-dose glucocorticoids might be needed during the transition period, if symptoms persist.

Biologic Therapies (for high disease activity)

  • Used if disease activity persists despite other treatment modalities.
  • Include monoclonal antibodies, fusion proteins and decoy receptors for cytokines, receptors.
  • Target specific cytokines, receptors, and other immune molecules
  • Target specific cells or molecules in the immune system to reduce inflammatory processes
  • Examples include TNF inhibitors (etanercept, infliximab), abatacept, and rituximab
  • JAK inhibitors (tofacitinib and baricitinib) are alternative treatment choices

Surgery

  • Synovectomy (surgical removal of synovium): beneficial for joints that haven't responsive to other treatments, especially in intra-articular injections.
  • Joint replacement may be necessary/required for severe joint damage but has become less common due to early aggressive management
  • Other possible procedures include excision of metatarsal heads, neurosurgery, and fusion of joints to correct subluxation or other damage

Long-term Prognosis

  • Factors correlating with an unfavorable prognosis include HLA-DRB1*04/04 genotype
  • High serum titers of autoantibodies (eg, RF, ACPA)
  • Extra-articular manifestations
  • Large number of involved joints
  • Age younger than 30 years
  • Female sex
  • Insidious onset

Rheumatoid Arthritis and Pregnancy

  • Immunological changes influence RA during pregnancy.
  • Conception planning—certain medications such as methotrexate and leflunomide should be stopped before pregnancy
  • Paracetamol is the analgesic of choice during pregnancy
  • Oral NSAIDs and COX-2 inhibitors are generally considered safe from implantation to 20 weeks
  • Glucocorticoids can be used in flare-ups but come with risks like hypertension, glucose disorders, and osteoporosis

Pregnancy and Medications

  • DMARD choices during pregnancy are limited due to potential risks to the fetus.
  • Avoid methotrexate, leflunomide, cyclophosphamide, and gold
  • Some biologics, like certolizumab, cross the placenta to some extent but may be relatively safe
  • Breastfeeding is contraindicated with these medications.

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Description

Explore the key aspects of Rheumatoid Arthritis (RA), including its onset age, gender prevalence, and environmental triggers. This quiz delves into the genetic factors, known risk factors like smoking, and the complexities of remission during pregnancy. Understand the interplay between genetics and environment in RA's pathophysiology.

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