Rheumatoid Arthritis (RA)

Outline

Background 

• Rheumatoid Arthritis is an autoimmune condition in which the immue system predominantly attacks the lining of the joints (synovium) causing synovitis

• Complications: 

  • Increase in cardiovascular deaths- biggest source of increased mortality (x2)

  • Rheumatoid Lung

    • ILD (Interstitial Lung Disease): lower lobe distribution

    • Pulmonary Nodules

    • Bronchiectasis

Assessment

History:

• 50F with polyarthritis

• Arthralgia lasts more than 30-60 minutes in morning & improves with exercise

• Lethargy, systemic upset

Examination:

• PIPJ & MTPJ swelling

• Signs

  • Swan neck deformity- late

  • Boutionnaire's

  • Z thumb

  • Ulnar deviation

  • Nodules (typically at elbow)

• Maculopapular rash

Investigations

Sensitivity Specificity

• Rheumatoid Factor: 70% 50%

• anti-CCP: 75% 95%

• ANA:  90% 20%

• CRP/ ESR 80% 20%

• XR joints: synovitis

Diagnosis

Diagnostic criteria: clinical

Differentials: 

• Sero +ve arthritis: Systemic Lupus Erythematous , Systemic Sclerosis, Sjogren's Syndrome 

• Sero -ve arthritis (PEAR): psoriatic, enteritis, ankylosing spondylitis, reactive arthritis

Management

1. Prednisolone

2. Methotrexate

3. Sulfasalazine

4. Etanercept (TNF antagonist)

Screen for Tuberculosis and HBV & HCV prior to starting etanercept. 

Deeper Dive Notes

Referral to Rheumatology

Rheumatoid arthritis outcomes are better with early aggressive interventions to prevent join destruction. Therefore suspicions of rheumatoid arthritis should result in prompt referral to Rheumatology, to start treatment before irreversible joint destruction occurs. 

Cardiovascular disease 

Increase rates of:

• Coronary artery disease

• Congestive heart failure- particularly HFpEF (diasytolic)

  • Constrictive pericarditis

References and Resources

1. https://cks.nice.org.uk/topics/rheumatoid-arthritis/

2. https://nras.org.uk/resource/diagnosis/

3. https://www.nhs.uk/conditions/rheumatoid-arthritis/diagnosis/

4. Crowson CS, Liao KP, Davis JM 3rd, Solomon DH, Matteson EL, Knutson KL, Hlatky MA, Gabriel SE. Rheumatoid arthritis and cardiovascular disease. Am Heart J. 2013 Oct;166(4):622-628.e1. doi: 10.1016/j.ahj.2013.07.010. Epub 2013 Aug 29. PMID: 24093840; PMCID: PMC3890244. 

Page written in 2024.