Rheumatology [RHEUMATOID ARTHRITIS]

Introduction BONUS POINTS: Felty’s syndrome

Rheumatoid Arthritis is an autoimmune disorder. The Rheumatoid Arthritis + Neutropenia + Splenomegaly = Felty’s
pathology is a result of pannus formation at the joint, which
leads to erosions and bony destruction. We don’t know why it if you see RA + Splenomegaly think Neutropenia
happens, but we know how to spot it and what to do about it. if you se RA + Neutropenia think Splenomegaly

Presentation BONUS POINTS: Cervical X-ray

Classically there’ll be Prolonged morning stiffness affecting If a patient with RA is going into surgery for any reason a
many small joints (3 or more, usually in the hands), that’s cervical film should be done since rheumatoid arthritis
symmetric; vignettes will often use an older woman. affects the cervical spine and the cervical spine only.

“Morning Stiffness” + “The Spine” might come up. The reaction Ø Spine Involvement except C1 + C2
is to go for Ankylosing Spondylitis. If it involves the lower back
it’s ank spond. If it involves the neck (C1, C2) it’s RA.

Diagnosis Clinical Criteria

Symmetrical Arthritis, often of the hands, Sparing DIP
There are a number of clinical criteria available to diagnose
Morning Stiffness for > 60 minutes, improves with use
rheumatoid arthritis. They’re not all needed, but some common Multiple Joint Involvement ( > 3)
findings are almost always present on a vignette. The old “wait 6 Radiographic Destruction of Joints (erosions)
weeks,” is now out; RA can be diagnosed right off the bat. + Rheumatoid Factor or + Anti CCP
Rheumatoid Nodules
Serology. Either the Rheumatoid Factor (cheap, sensitive) or the
Anti-CCP (expensive, specific) can be used. If either is positive
it counts for serology. Nobody Should Have Rheumatoid Symptoms 3 times (X)
N: Nodules
Joints. There must be symmetric arthritis that involves more S: Symmetric
than three joints and spares the DIPs. Both the number of joints H: Hands
involved and the symmetry are crucial. Look for small joints like R: RF or CCP
hands, feet, and wrists. S: Stiffness
3: 3 or more joints
Radiology. An X-ray can be used to assess for periarticular X: X-ray findings of erosions
osteopenia and marginal bony erosions. These findings will
also be symmetric. The x-ray can also identify regular old arthritis Be Careful
if osteophytes are seen. In life, you can have Rheumatoid Arthritis with negative RF
and negative Anti-CCP, or no Rheumatoid Arthritis with
Nodules. Biopsy of a Rheumatoid Nodule will reveal cholesterol positive RF and positive Anti-CCP. On a test it’s always
deposits. This finding rules out another potential deposition black and white: if positive, then disease, if negative, then
disease. These are pathognomonic. no disease.

Treatment
Get these patients on disease modifying agents as soon as
possible. Start the treatment of RA with DMARDs as soon as NSAIDs + DMARDS + Biologics …. Steroids
possible. Methotrexate is first line for RA. Leflunomide can be (Sxs) (everyone) (severe) (flares)
used if methotrexate can’t be. Hydroxychloroquine and
Sulfasalazine have long-acting effects that may be used together Treatment
with methotrexate to avoid biologic therapy (doubling up is ok). DMARD Methotrexate (1st line)
Leflunomide (2nd line)
Hydroxychloroquine is also appropriate for non-erosive mild
Hydroxychloroquine (pregnancy)
disease and during pregnancy. The goal is treat-to-target Sulfasalazine (additive)
(disease remission). If DMARDs fail add biologics. Before Anti-TNF Etanercept
starting biologics a TB screen and vaccines must be given as they Infliximab
significantly compromise immune function. Corticosteroids Rituximab
should be avoided - except during life threatening flares - to Glucocorticoid Flares, get off this as soon as
reduce long-term systemic side effects. NSAIDs can be used to possible
NSAIDs Supplemental only,
control symptoms and are adjunctive therapy. NEVER use
NEVER MONOTHERAPY
NSAID MONOTHERAPY.

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