rheumatoid arthritis

Rheumatoid Arthritis

TTL 5/18/21

Hannah Aucoin, PGY-2

Definition/ Presentation

• symmetric, inflammatory, peripheral polyarthritis

• Causes deformity through stretching of tendons/ligaments and destruction of joints through erosion of cartilage and bone

• >6 weeks duration, if acute think viral

Multiple Select

Which Symptoms are Consistent with RA?

• affects multiple joints

• GI symptoms

• affects all joints equally

• skin rashes

• worse in the morning

Multiple Choice

Which is NOT a systemic manifestation seen in RA?

• Osteopenia

• Eye involvement

• Muscle Weakness

• Liver Dysfunction

• Skin Disease

Systemic Manifestations

• Osteopenia/Osteoporosis- immobility and drug-induced

• Muscle Weakness- inflammation and drug-induced myopathies

• Skin Disease- rheumatoid nodules, ulcers

• Eye involvement- mostly dryness

• Lung Disease- drug-induced or 2/2 disease

• Cardiac Disease- pericarditis, myocarditis, CAD, HF, A fib

• Non-cardiac valvular disease-PAD, vasculitis, CVA

Systemic Manifestations continued...

• Kidney Disease- rare glomerulonephritis

• Sjogren's syndrome- ocular and oral dryness

• Neurologic/Psychiatric disease- carpal tunnel, depression

• Hematologic abnormalities- Anemia, neutropenia

• Altered Body composition- increased fat and decreased muscle

Fill in the Blank

Which joints are most commonly affected? (two possible answers)

Multiple Choice

Which test is sensitive for RA?

• ANA

• Anti-cyclic citrullinated Peptide Antibodies

• c-ANCA

• p-ANA

Initial Testing

• RF and anti-CCP positive test increases overall sensitivity, both tests negative in up to 50% of patients and remain negative in 20% on follow up. Repeat in 6-12 mo

• ESR and CRP typically elevated

• ANA to rule out SLE and other rheumatologic disease

• CBC often shows anemia and thrombocytosis due to chronic inflammation

• Liver and kidney function normal

• Normal Uric Acid

• Radiographs of hands/wrists/feet to monitor disease progression

Diagnostic Criteria- when all are present

• Inflammatory arthritis involving 3+ joints

• Positive RF and/or anti-CCP

• Elevated CRP or ESR

• Diseases with similar clinical features have been excluded

• Duration of symptoms more than 6 weeks

Management

• Treat initial symptoms with NSAIDS or glucocorticoids

• Early intervention with DMARDs- either non-biologic (MTX, HCQ, SSZ, LEF) or Biologics

• Treat flares with intraarticular or systemic steroids

Multiple Choice

A 54-year-old man comes to the physician for a follow-up examination because of progressive rheumatoid arthritis unresponsive to high dose nonsteroidal anti-inflammatory drugs (NSAIDs). Treatment with prednisone and hydroxychloroquine was started six weeks earlier. The patient is concerned about steroid-induced osteoporosis, because his father, a type 2 diabetic, recently fell and broke his hip. Laboratory studies and a dual energy x-ray absorptiometry (DEXA) test of the spine and hip are ordered to address the patient's concerns.

Which of the following additional tests would be recommended for this patient?

• 1,25-dihydroxy vitamin D levels

• High-density lipoprotein levels

• Intact parathyroid hormone levels

• Serum glucose levels

• Serum protein electrophoresis

Multiple Choice

A 42-year-old woman is evaluated for a 2-month history of fatigue, tingling in the fingers of both hands, and pain radiating into the hands and forearms. She also has difficulty opening bottles. The tingling symptoms occasionally are alleviated when she shakes her hands in the morning, but she typically has 2 to 3 hours of morning stiffness in her wrists and fingers. She takes no medications. On physical examination, vital signs are normal. BMI is 21. Soft-tissue swelling and tenderness is palpable at the wrists and metacarpophalangeal joints bilaterally. She has sensory loss over the palmar surface of the first three digits and weakness of abduction and opposition of the thumbs bilaterally. What initial testing should be performed?

• Nerve conduction study

• Vitamin B-12 level

• Rheumatoid Factor

• Basic metabolic profile