Rheumatoid Arthritis

Scenarios: Joint pain, joint swelling,

joint deformities, aches, shortness of
breath.

Questions to ask:
▪ Do you have joint pains – which joints are
a ected, when is the pain at its worst, do they
ever become hot or swollen, do they feel sti in
the morning and how long does this sti ness last?
▪ Do you take pain killers – which ones, do they
help, if you’ve used things like ibuprofen did they
give you any heartburn?
▪ Have you noticed your eyes being red, painful,
or dry and gritty?
▪ Have you had any rashes or noticed any lumps
and bumps?
▪ Have you had any shortness of breath, cough
or chest pain?
▪ Any recent infections?
▪ Do have any other medical problems, are you
on any medications?
▪ Are there any conditions that run in the family?
▪ Who’s at home with you and how are you
coping at home, do you have any adaptations in
place to make things easier?
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 ▪ Are you still working, when did you retire,what
made you stop?
▪ Do you smoke, ever smoked, drink alcohol or
use recreational drugs?
▪ Do you have any questions or particular
worries that you would like me to address today?

Systems to examine: For this routine,

start at the hands, checking there are no psoriatic
nail changes given that this is your main
di erential, and work your way down the joints,
look dorsal and feel the joints and radial area
sensory, check for synovitis, check for nodules on
the extensor surface of the arms, then as they
place the hands back down get them to do it so
you’re now looking at the palms, check again for
scars, wasting, erythema, and check sensation
and capillary re l time, move on to function by
asking them to copy movements like grip, nger
pincer and wrist movements, before asking them
to do speci c tasks like writing or doing a button.
Once you’ve satis ed yourself that this is a
symmetrical deforming polyarthropathy of the
small joints of then hands – move up to the eyes
for dryness and conjunctival pallor, sit them
forward and look behind the ears and in the
hairline for psoriatic rashes, check the neck for
scars from atlantoaxial subluxation, and listen at
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 the lung bases for brotic changes, then lie them
at and try to feel if there is any splenomegaly
before checking the shins for ulceration and
rashes.
▪ Cutaneous: Vasculitic rashes, nail fold
vasculitis, palmar erythema, rheumatoid nodules
at the elbows, erythema nodosum, pyoderma
gangrenosum.
▪ Musculoskeletal: Symmetrical arthropathy of
the small joints of the hands with ulnar deviation
and dorsal subluxation, z-thumb, boutonier’s and
swan neck deformities, wasting, features of
carpal tunnel syndrome (thenar wasting,
weakness of thumb abduction and opposition,
sensory loss over lateral 3.5 digits on palmar
aspect, positive Tinel’s and Phalen’s tests, carpal
tunnel release scar); comment on the presence or
absence active synovitis, and the functional loss
caused by the disease (buttons, writing, grip
strength).
▪ Ocular:Erythematous,dryeyes.
▪ Respiratory: Fine end-inspiratory basal
crepitations of the lungs; stony dull percussion
note,
reduced air entry, and reduced vocal resonance.
▪ Abdomen: Splenomegaly (Felty’s syndrome).
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 ▪ Neurological: Atlantoaxial subluxation can lead
to cervical cord compression (spastic quadri- or
para-paresis).

Di erentials to exclude:
▪ Osteoarthritis, nodal osetoarthritis.
▪ In ammatory: HLA B27 associated (psoriatic,
in ammatory bowel disease associated, sexually
acquired infection or infective diarrhoea related
such as reactive arthritis), systemic lupus
(usually Jaccoud’s –
erythematosus
reducible deformities), sarcoidosis.
▪ Crystal: Gout, pseudogout.
▪ Infective: Septic arthritis (staphylococcus
aureus, gonococcal, tuberculous), parvovirus
related,
hepatitis, Lyme’s disease.
▪ Rarities:Multicentric reticulohistiocytosis (coral
beading around the nailfold), paraneoplastic (e.g.:
hypertrophic pulmonary osteoarthropathy).

Investigations:
▪ Bedside tests: Urine dipstick (proteinuria
secondary to membranous nephrotic syndrome or
amyloidosis), temperature (infection), oxygen
saturations (lung brosis), calculate DAS28 using
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phone app (baseline disease activity score, useful
for monitoring activity from visit to visit and
response to treatment).
▪ Bloods: FBC (anaemia of chronic disease,
raised in ammatory markers, platelets pre-
aspiration), U&Es (NSAID use, pre-
immunsuppressants starting), LFTs (pre-
immunsuppressants starting), clotting (pre-
aspiration), CRP/ESR (raised), rheumatoid factor
(positive, not speci c, very commonly positive in
presence of rheumatoid nodules and Felty’s
syndrome), anti-cyclic citrullinated peptide
(positive, more speci c; test if RF negative);
optimise cardiovascular risk facts such as blood
pressure, diabetes and cholesterol as this is the
main cause of death in these individuals.
▪ Imagining: Plain radiographs of the joints (soft
tissue swelling, joint space narrowing, erosions,
peri-articular osteopaenia, subluxations,
deformities), musculoskeletal USS (soft tissue
swelling), MRI joints (more detailed structural
information and early in ammation).
▪ Special tests: Joint aspiration (raised white cell
count
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 Management:
▪ Non-pharmacological: Education, information
lea ets, support groups, physiotherapy,
occupational therapy, podiatry; speci c advice for
hot and swollen joints (ice and elevate,
intermittent use of splints), and sti and achey
joints (warm bath or compress).
▪ Medical: Analgesia (pain ladder, topical
NSAIDs, oral NSAIDs often useful, consider
gastroprotection and check U&Es), intra-articular
steroids, intramuscular steroids (if are and
waiting for DMARDs to take e ect), oral steroids
(consider gastroprotection, bone protection,
medic alert bracelets), disease modifying anti-
rheumatic medications (start early; methotrexate
plus sulphasalazine, le unomide,
hydroxychloroquine), monoclonal antibody
therapies (if x2 DMARDs fail – anti-TNF, anti-IL6,
abatacept).
▪ Surgical: Joint replacement, joint fusion, tendon
transfer.
▪
▪Questions:
1. What do you need to tell a patient
before they start on methotrexate?
Explain that it is not a painkiller, that it works
by reducing in ammation over a longer period
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 of time and prevents ares from happening
and long term joint damage progressing. As a
result, we’ll often start it at the same time as a
short course of steroids so that they get the
disease under control while we wait for the
methotrexate to kick in. Because it suppresses
the immune system they are more at risk of
infections, and simple infections may become
more severe than normal, so we would advise
them to seek medical advice early, even for
mild infections like a sore throat. Other
common side e ects include sickness,
diarrhoea, mouth ulcers, and hair loss. Some
of these are improved by changing the dose,
and by giving an additional tablet called folic
acid. The methotrexate is taken once a week,
followed by a 6 day break. They will need a
baseline blood test and chest x-ray, and then
need to have regular blood tests after this. We
advise against drinking lots of alcohol on it,
avoiding some vaccinations, and patient’s
shouldn’t get pregnant on it.

2. What diagnostic criteria are used in

rheumatoid arthritis? The American College
of Rheumatology criteria can be applied in those
with synovitis and a clinical suspicion of RA. They
look at 4 key areas including the number and size
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of joints a ected, the duration if symptoms,
serology (rheumatoid factor or anti-CCP), and
elevation of ESR or CRP.
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