Rheumatoid Arthritis

Presentation

Joint pain - classically symmetrical inflammatory arthropathy of the small joints of the hands (MCPJs and PIPJs) and feet (MTPJs)

Constitutional symptoms of fever, malaise, fatigue

History

Smoking history - smoking is the biggest modifiable risk factor for RA

Examination

At presentation, or with poorly controlled disease, affected joints will be inflamed (erythematous, warm, swollen and tender)

The textbook desciptions of deformity are a consequence of long-term poorly controlled disease, and are therefore becoming increasingly rare. These include:

Boutonniere deformity (PIP flexion, DIP hyperextension)

Swan neck deformities (PIP hyperextension, DIP flexion, left image)

Ulnar deviation of the carpal or MCP joints

MCP subluxation

Dorsal wrist subluxation

z-deformity of the thumbs (MCP subluxation, IP hyperextension)

Laboratory investigations

Immunological investigations

** Rheumatoid factor** (RF) and anti-cyclic citrullinated peptide (anti-CCP)

Radiological investigations

Management

First line

Steroids are used to control flares (or at first presentation) - eg IM methyprednisolone, and 15mg prednisolone PO (with a reducing regimen)
Early diagnosis and treatment with DMARDs is key.

Second line

Prior to discharge

Follow up

Clinic follow-up with rheumatology to assess response to treatment.

Scoring systems (eg DAS-28) can be used to monitor disease activity

Regular bloods tests to monitor for DMARD toxicity

MTX: U&Es, LFTs
HCQ:
SSZ:

Complications

Prognosis

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