10. Clinical Approach to RA Seronegative Arthropathies and Gout Flashcards
RA is AI chronic systemic inflammatory disease, symmetrical targeting synovial tissues, assoc with fatigue fever anemia, elevated acute phase reactants such as ESR and CRP, constitutional sx include malaise, myalgia, and depression, RF is produced by RA synovium B cells, RF fixes complement, complement consumed in RA joint which recruits what?
PMNs- Neutrophils
also see anti-cyclic citrullinated peptides
RA is associated with genetics, there is increased risk of severe RA, pathologic changes in joints precedes synovitis in RA by 5-10 yrs, there is infiltration of leukocytes, cytokines and mø which act as antigen presenting cell to activate T cells*, B cells produce abs which release cyotkines (TNFa/IL1/6) causing synovial proliferation and increased synovial fluid leading to pannus that invades carilage and bone, what is the HLA most strongly associated?
HLA DRB4 allele
Imaging for RA includes xray of areas to detect symmetrical involvement of MCP/MTP joints with erosions, CT are more sensitive to detecting EROSIONS, can see joint deformity, ulnar deviation, decreased joint space with ankylosis, tx includes NSAIDs, DMARDs, which should be given early to?
PREVENT progression and hopefully remission
MC in women,improves during preg, common after infections
RA is associated with significant mortality*, inc. CAD, *HF due to endothelial damage from chronic inflammation, peak incidence in young adults, frequently diables patients and theres no perfect treatment, there is a large increase risk of infection, renal disease, malignancy and most importantly?
HEART DISEASE 60% inc if + for RA
2010 RA classification criteria are used for diagnosis, must have one joint with definite clinical synovitis not better explained by other dz, points given for different joint involvements, serology, acute phase reactants, and duration, what out of 10 is scored as definitive RA?
6/10
Remember 30% of RA pts with have negative RF and Anti CCP. RA typically starts in hands and feet, MC at MTP and PIP* NOT DIPS (OA), later moves to large joints, increased risk of osteoporosis and what is a common axial spine issue?
C1-2 issues* (subluxation) - dont force into flexion
*due to erosion of odontoid process causing peripheral neuropathy and cervical myelopathy
RA see swan neck = hyperextension of PIP
boutonniere (button hole)= hyperflexion of PIP, and see pannus which is expansion of synovium, if there are nodules present, what should be expected always?
ALWAYS RF +++
Clinically RA is associated with pain, swelling, warmth in multiple small joints, morning stiffness of GREATER than 1 year for more than 30 minutes, dx via active signs of inflammation for 6 weeks. Extraarticular manifestations of RA are MC in pts with RF and anti CCP, usually include nodules, rheumatoid vasculitis (purpura, petechial, splinter hemorrhages and digital infarcts), increased risk of CAD due to endothelial inflammation and what, which are tender reddish purple papules which leads to necrotic non healing ulcer?
Pyoderma gangrenosum
Note: rheumatoid nodules can be in lungs = interstitial lung disease?
RA could be due secondary to what, which presents with keratoconjunctivitis sicca, dry mouth, decreased tearing, sandy gritty feeling of eyelids, increased tooth decay, tested withAnti-Ro/SSA or anti-La/SSB- salivary gland abs, do schirmers test (paper to eyes to see how much tears), and or slit lamp exam?
Sjogrens Syndrome– seen in 65% of pts
TX: artificial tears, oral hygeine and encourage water, anti inflams and immunosupressive
What syndrome is RA, with splenomegalia, neutropenia, fever, anemia, thrombocytopenia and RF and antiCCP positive?
Feltys Syndrome
Remember ANA can be positive in RA, + RF/CCP, increased ESR/CRP, anemia, thrombocytosis, sometimes RF+ in health patients or in viral infections, SLE, sjogrens, and RA is treated with nsaids, DMARDS with the main goal of what?
disease remission - treat early to prevent irreversible cartilage and bone damage
Corticosteroids are used to bridge therapy and for flares, since DMARDs taken 3-6 months to be effective, using steroids during that time is good for sx management, what is first line DMARD which shouldnt be given during pregnancy and has toxicities associated with liver, BM and lungs?
Methotrexate
What antimalarial non biological drug is used in RA and needs to follow up w opthalmologist yearly to check for macular damage to the retina, can use with methotrexate and is SAFE** in pregnant patients?
Hydroxychloroquine
NOTE: all biologics have toxicities that include: increased risk of infection, reactivation of latent TB**, neoplasia, MS and autoimmune disease, what is last line treatment for RA after non biologic DMARDS and NSAIDs fail to help?
ANTI TNF Agents = biological DMARDs
Spondyloarthropathies SpA include ankylosing spondylitis, reactive arthritis (reiters), psoriatic arthritis, enteropathic arthritis (d/t crohns or UC), and undifferentiated, they are SERONEGATIVE with commonalities that include predilection for spine/SI, new bone formation at sites of inflam, joint ankyloses with fusion rigidity and kyphosis, asymmetric peripheral arthritis, ocular inflam and what which is inflam of insertion points of tendons and ligaments onto bones?
Enthesitis
