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Rheumatoid Arthritis (RA)

Rheumatoid Arthritis (RA) is an autoimmune, symmetrical polyarthritic condition of chronic inflammation of the synovial lining in joints, tendon sheaths and bursa. Its risk factors include:

  • Female - 3x more common than men

  • Family hx

  • Smoking

  • Genetic associations - HLA DR4/DR1


Presentation

  • Symmetrical, poly-articular pain and stiffness of joints of the hand, wrists and feet

  • Prolonged morning stiffness (> 30 mins)

  • Improves with movement, worse with rest

  • DIP is usually spared in RA, so if affected, it’s most likely OA (Heberden’s)


O/E:

  • Swollen, red, warm, and tender joints

  • Swan-neck deformity

  • Boutonniere’s deformity

  • Ulnar deviation at knuckles

  • Z shaped deformity of thumb

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“A hand severely affected by rheumatoid arthritis.” © James Heilman, MD CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0/)

Palindromic Rheumatism - Recurrent, short lived (hours to days) episodes of arthritis in different joints before settling into a more permanent form.


Extra-articular manifestations:

  • Carpal tunnel syndrome

  • Pulmonary Fibrosis

  • Raynauds phenomenon

  • Pleural Effusion

  • Bronchiolitis Obliterans (inflammation causing bronchiole destruction)


Investigations

Diagnosed clinically.


Bloods:

  • RF - +ve in ~70%

    • If -ve, check anti-CCP - very specific for RA (if -ve, you can rule it out)

  • FBC - common for these patients to have anaemia of chronic disease

  • CRP and ESR


XR - Joint destruction and deformity, soft-tissue swelling, periarticular osteopenia, and bony erosions


Management

For symptomatic relief:

  • Paracetamol and NSAIDs for pain, swelling and stiffness

  • Intra-articular/oral Steroids during flare-ups

  • Physiotherapy


To monitor disease activity, the DAS28 (Disease Activity Score) is used. It's out of 28, and includes:

  • Swollen joints

  • Tender joints

  • CRP/ESR levels


DMARDs (D) and Biologics (B) - To slow down disease progression, and an early use of these improves long-term outcome. This is typically given when the DAS28 score > 5.1. 1st line options are:

  • Methotrexate (D) - Avoid in pregnancy as it’s teratogenic

  • Sulfasalazine (D)

  • Hydroxychloromide (D)

  • Infliximab (B)


Patients on DMARDs/Biologics should be given the annual Influenza vaccine and pneumococcal vaccine every 5 years as they'll be immunosupressed.



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