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Pharmacy > 301 Arthritis > Flashcards

301 Arthritis Flashcards

1
Q

What are rheumatic diseases?

A

Autoimmune, inflammatory disease caused by immune system affecting joints, tendons, ligaments muscles, bones & other organs

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2
Q

What is joint pain?

A

Loss of motion in a joint(s), localised inflammation (swelling, redness & warmth in affected area)

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3
Q

Conditions with joint origin

A

Gout
Osteoarthritis
Septic arthritis
Spondylolisthesis
Rheumatoid arthritis
Seronegative spondarthritides
Reactive arthritis

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4
Q

What is osteoarthritis?
Onset
Relation
Affects what?

A
  1. Degenerative joint disease or osteoarthrosis, mechanical abnormalities, degradation of joints include articular cartilage & subchondral bone
  2. Slow
  3. Not related to any significant constitutional disorder
  4. Muscles not directly affected
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5
Q

Osteoarthritis signs and symptoms

A

Pain, causing loss of ability and often stiffness

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6
Q

Osteoarthritis prevalence

A

Most people >50 have some form
Not associated with raised ESR/CRP
Hand OA nodal osteoarthritis DIP joint or Heberden’s nodes
40% people >75 have knee OA

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7
Q

Causes & risk factors of osteoarthritis

A
  • Obesity
  • Traumatic injuries
  • Repetitive stress injuries
  • Aging
  • Metabolic bone diseases
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8
Q

Management and treatment of osteoarthritis:
Lifestyle modification
Medications
Alternative treatments

A
  1. Weight loss, moderate exercise (with advice only), gait training
  2. Acetaminophen - PCM is 1st line
    NSAIDs oral or topical such as naproxen, diclofenac
  3. Glucosamine & chondroitin (help build cartilage), Vit C & fish oil, avocado-soybean, acupuncture, Tai Chi
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9
Q

What is spondylosis?

A

Umbrella term for pain from degenerative conditions of spine
Cervical & lumbar COMMON
OA of spine
Spinal condition degeneration of intervertebral discs L5/S1, L4/5 & neck

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10
Q

Spondylosis causes & risk factors

A

Daily wear & tear over time
Genetic tendency, being overweight, sedentary lifestyle (job) lack of exercise, injured spine or spinal surgery, smoking, mental health conditions, psoriatic arthritis

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11
Q

Spondylosis management

A

Analgesic, physical therapy, improvement in posture, alternative treatments

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12
Q

What is spondylolisthesis?
Cervical presents as?
Treatment

A
  1. More severe form of spondylosis
    Slipped vertebra (1 bone of spine slips forward over another, causing damage to spinal structure)
    Severe nerve pain (sciatica)
    L5/S1 & C2/C3
  2. Cervical presents with finger tingling & headaches
    Treat NSAIDs, amitriptyline
    Cauda equina syndrome - severe spinal stenosis
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13
Q

What is septic arthritis (infectious arthritis)?

A

Caused by bacteria, however, mycobacteria, virus & fungi also implicated in few cases
Increase in use of prosthetic joints is increasing infection (2-10%)

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14
Q

How does septic arthritis happen?

A

Microorganism may invade joint by direct inoculation, by contiguous spread from infected periarticular tissue or bloodstream (more common)
Normal joint has protective components (synovial cells & synovial fluid)
Rheumatoid arthritis & systemic lupus erythematosus hamper this function, resulting in increased infection risk

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15
Q

Septic arthritis aetiology

A
  1. N.gonorrhoea & S.aureus - common with pathogenic invasion
  2. GI pathogens (Salmonella sp., Campylobacter jejuni, C difficile, Shigella sonnei, E histolytica) in reactive/post-exposure process cases
  3. Anaerobes isolated from 10% patients
  4. Viral infections may cause direct invasion
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16
Q

What do septic arthritic patients present with?

A

Infected joint with triad of fever (40-60%), pain (75%) and impaired range of motion along with low grad fever
Most common joint is knee (50%)

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17
Q

Septic arthritis treatment

A
  1. Adequate & timely infected synovial fluid drainage
  2. Appropriate antimicrobial therapy
  3. Immobilisation of joint to control pain
    Antibiotic therapy (ceftriaxone, ciprofloxacin, cefixime, oxacillin, vancomycin, linezolid)
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18
Q

Seronegative spondyloarthropathy: family of joint disorders

A
  1. Ankylosing spondylitis (AS)
  2. Psoriatic arthritis (PsA)
  3. Inflammatory bowel disease (IBD) associated arthritis
  4. Reactive arthritis (formerly Reiter syndrome; ReA)
  5. Undifferentiated SpA
    Often present with inflammatory joint pain with morning stiffness lasting for hours & improves with activities
    NSAIDs often used to improve symptoms
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19
Q

Ankylosing spondylitis: prevalence

A

More common young men>women
Starts as lower back pain-joints where spine attaches to pelvic (sacroiliac joints) - stiffness, pain and poor sleep
Link males with human leucocyte antigen HLA B27
Movement with gentle exercise
NSAIDs, sulfasalazine, hydroxychloroquine & adalimumab or etanercept for severe active ankylosing spondylitis

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20
Q

What is psoriatic arthritis?
Common symptoms
Treatments

A

Synovitis which occurs in psoriasis individuals but without serum rheumatoid factor (a form of inflammatory seronegative spondyloarthropathy)
60% people psoriasis precedes arthritis
Spondylitis common & finger swelling
Methotrexate is commonly used
Etanercept & infliximab severe case

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21
Q

What is reactive arthritis?

A

Short-lived painful joint swelling shortly after a bowel, genital infection

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22
Q

What is systemic lupus erythematosus?

A

Polyarthritis with acute onset and attacks own healthy organs and tissues
Less joint disturbance than rheumatoid

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23
Q

Symptoms of systemic lupus erythematosus:
Mouth
Skin
Heart
Abdomen
Blood
Muscle and joints
Kidneys
Lungs
Others

A
  1. Mouth & nose ulcers
  2. Butterly flash & red patches
  3. Endocarditis, atherosclerosis, inflammation of the fibrous sac
  4. Severe abdo. pain
  5. Anaemia, high BP
  6. Pain & arthritisaches, swollen joints
  7. Haematuria
  8. Pleuritis, pneumonitis, pulmonary embolism, pulmonary haemorrhage
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23
Q

Systemic lupus erythematosus:
Counselling points
Treatments

A
  1. Avoid sun, more common in younger women, autoimmune
  2. Hydroxychloroquine, low dose prednisolone, methotrexate, rituximab if severe
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23
Q

What is rheumatoid arthritis?
Signs and symptoms
Causes

A
  1. Autoimmune disease due to chronic, systemic inflammatory disorder, usually affects joints symmetrically, may initially begin in couple of joints only, most frequently attacks wrists, hands, elbows, shoulders, knees & ankles
  2. Flexible synovial joins are affected
  3. Herpes virus, hormone, environment, multiple genetic alleles, family Hx of RA, autoimmunity
23
Q

Sarcoidosis:
Symptoms
Types
Treatment

A
  1. Weight loss, fever
  2. Red swollen tissue called granulomas mainly in lungs & skin
  3. Acute, chronic
  4. MTX, prednisolone, hydroxychloroquine, infliximab
23
Q

Rheumatoid arthritis progression

A

Progressive involvement of joints usually starts in small joints
Anaemia common
Rheumatoid factor
TATT (tired all the time)

23
Q

Changes in RA affected joints:
Synovial membrane
Synovial liquid
Cartilage
Capsule
Bone

A
  1. Inflamed
  2. Major cell types - neutrophils
  3. Cartilage thinning/loss
  4. Inflammation, pannus (major cells T-lymphocytes, macrophages), pannus (minor cells - fibroblasts, plasma cells, endothelium, dendritic cells)
  5. Bone loss
23
Q

Rheumatoid arthritis symptoms

A

Lumps
Fatigue
Joint pains
Anaemia
Tenderness
Joint stiffness

23
Q

Diagnostic criteria (patient must present t least 4 of below criteria)

A
  • Morning stiffness
  • At least 3 joints involved
  • Hand joints
  • Symmetrical arthritis
  • Rheumatoid nodules
  • Positive rheumatoid factor
  • Radiographic changes
24
Q

Rheumatoid arthritis: treatment

A
  • Analgesic and NSAIDs
  • Steroids
  • Disease modifying anti-inflammatory drugs (DMARDs)
  • Biologics
  • Improved QoL
25
Q

External triggers of rheumatoid arthritis

A

Cigarette smoking, infection or trauma lead to autoimmune reaction

26
Q

Clinical presentation of rheumatoid arthritis

A
  • Insidious onset with fever, malaise, arthralgias, weakness before progress to joint inflammation
  • Persistent symmetric polyarthritis (synovitis) of hands & feet, progressive articular deterioration, difficulty performing activities of daily living (ADLs), other constitutional symptoms
27
Q

Common sides of rheumatoid arthritis:
Upper extremities
Lower extremities

A
  1. Metacarpophalangeal joints, wrists, elbows, shoulders
  2. Ankles, feet, knees, hips
28
Q

Rheumatoid arthritis: epidemiology

A
  • Globally 3 per 10,000 cases with 1% prevalence (peak 35-50 yrs)
  • Women 3x more affected, difference diminished with older age
  • 1st degree relactive with 2-3 fold increase risk
  • About 1% of UK population
  • Adults & children: common onset (30) 40-50 years, older onset in men
29
Q

Rheumatoid arthritis: risk factors
Genetics
Lifestyle
Hormonal

A
  1. HLA-DR4 allele increases severity & development
  2. Increased smoking duration linked with increasing complexity/symptoms, red meat intake, vit D deficiency, excessive coffee consumption, high salt intake
  3. Disproportionate between female & male (prolactin)
30
Q

Rheumatoid arthritis pathophysiology:
Phase I
Phase II
Phase III
Phase IV

A
  1. Interaction (genetic & environmental risk factors)
  2. Production of RA autoantibodies (rheumatoid factor & anti-cyclic citrullinated peptide (anti-CCP)
  3. Begin arthralgia or joint stiffness with no clinical evidence of arthritis
  4. Development of arthritis (early undifferentiated arthritis)
31
Q

Rheumatoid arthritis pathophysiology: cytokines

A

B and T cells inappropriately enter joint releasing…
TNF-a
IL-1, 6, 8
TGF-b (transforming growth factor)
FGF (fibroblast growth factor)
PDGF (platelet-derived growth factor)
Which cause synovium to release proteolytic enzymes, destroying bone & cartilage

32
Q

Rheumatoid arthritis diagnosis:
Combination of
Differential diagnosis

A
  1. History, symptoms, blood tests, X-ray
  2. Ankylosing spondylitis, gout, polymyalgia, psoriatic arthritis, systemic lupus erythematous, tuberculosis
33
Q

Diagnostic criteria of rheumatoid arthritis

A

ACR/EULAR 2010 Rheumatoid Arthritis Classification Criteria
Joint involvement, serology, acute-phase reactant, duration of symptoms

34
Q

Rheumatoid arthritis lab test findings:
Inflammatory markers (ESR/CRP)
IgM-RF
Anti-CCP
ANA
ENA
Alk phos, platelets, WCC
Albumin

A
  1. Usually raised in active disease
  2. Present 80% of RA
  3. Present in most of RA
  4. Differentiate types of disease
  5. Same as above
  6. Raised
  7. Decreased
35
Q

Serology in rheumatoid arthritis: C reactive protein (CRP)

A
  • Measures a specific acute-phase reactant and is more specific
  • Rises and falls more quickly than ESR
  • More expensive
    Present peaks in levels during flare ups and troughs in remission
36
Q

Serology in rheumatoid arthritis: erythrocyte sedimentation rate (ESR)

A
  • Affected by different factors therefore is less accurate than CRP
  • Decreases slowly after inflammation subsides
    Present peaks in levels during flare ups and troughs in remission
37
Q

Serology in rheumatoid arthritis: rheumatoid factor (RF)

A
  • Not an indicator of RA but in already diagnosed RA being RF seropositive indicates inclination towards a more aggressive symptomatology
38
Q

Serology in rheumatoid arthritis: Anti-cyclic citrullinated peptide antibody (Anti-CCP)

A
  • More specific than RF with less false positives
  • More expensive than RF
39
Q

Non-pharmacological management of RA

A

Physiotherapy
Exercise, diet
Psychological/education
Stress reduction
Surgical interventions

40
Q

Pharmacological management of RA

A

NSAIDs
Glucocorticoids
DMARDs
Biologicals

41
Q

Rheumatoid arthritis: analgesics and NSAIDs

A

Pain is predominantly inflammatory
NSAIDs can worse CV risk factors associated to RA
Role for paracetamol, opioids and TCAs
Pro-thrombotic effect of COX2 inhibitors
Consider oral NSAIDs (including traditional and COX2 selective) to control pain or stiffness
Acknowledge GI, liver & cardio-renal toxicity & risk factors like age & pregnancy

42
Q

Rheumatoid arthritis: glucocorticoids

A

Offer short-term treatment to manage flares in adults with recent-onset or established disease to rapidly decrease inflammation
In adults with established, continue long-term when long-term complications have been discussed AND all other treatments offered

43
Q

Rheumatoid arthritis: steroids

A

Medium length course of oral prednisolone starting with 60mg/day gradually reduced to 7.5mg over 7 weeks
Methylprednisolone acetate (Depo-Medrone) 120mg IM on PRN basis

44
Q

DMARDs: Methotrexate
S/Es

A

Gold standard for RA but with associated risks
Liver impairment, neutropenia, anaemia, pneumonitis, nausea

45
Q

DMARDs: sulfasalazine
S/Es

A

Pro-drug, activated in colon in sulfapyridine with anti RA effects due to inhibition of transcription factors
Cough, diarrhoea, fever

46
Q

DMARDs: leflunamide
S/Es

A

Inhibits replication of activated lymphocytes
Diarrhoea

47
Q

DMARDs: hydroxychloroquine

A

Interferes with antigen presentation & activation of immune response
Ocular toxicity

48
Q

Rheumatoid arthritis: DMARDs

A

Offer 1st line cDMARD monotherapy ideally within 3 months of diagnosis
(Methotrexate, leflunomide, sulfasalazine)
Escalate dose as tolerated
Consider short-term bridging with glucocorticoid
Offer additional cDMARD in combo
(Oral methotrexate, leflunomide, sulfasalazine, hydroxychloroquine)

49
Q

Rheumatoid arthritis: biologicals

A

Biologic meds. originated from living cells
Large, highly complex molecular structures
Classified according to MOA: TNF-alpha inhibitors, interleukin inhibitors, Janus Kinase inhibitors, phosphodiesterase type 4 inhibitor, T cell co stimulator
1st TNF alpha inhibitor was infliximab
Expensive

50
Q

Rheumatoid arthritis: biologicals in combination

A

Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab & abatacept, ALL in combo with methotrexate recommended if:
- Disease is severe, DAS28 >5,1 and
- Disease not responded to intensive combo of DMARDs and
- Companies provide certolizumab pegol, golimumab, abatacept & tocilizumab as agreed with patient access schemes
(Can be used without methotrexate due to C/I or intolerance when above criteria met)

51
Q

Rheumatoid arthritis: treatment for adults with severe active RA who have inadequate response to DMARDs including 1 TNF inhibitor

A

Rituximab in combo with methotrexate
Given no more frequently than every 6 months
Only give if adequate response from initiation (improved DAS28 1.2 points or more)

52
Q

Rheumatoid arthritis: typical patient journey

A

Patient present to GP
Initiation analgesia/NSAIDs and referred to rheumatology
If diagnosis RA confirmed treatment with 1 or 2 DMARDs start
If patient DAS29 remains >5.2 after 6 months, biologic started

53
Q

What autoimmune conditions are related to reactive arthritis?

A

RA: A disease where the immune system attacks the body, which can cause symptoms similar to lupus
Ankylosing spondylitis: A disorder in the group of spondyloarthritidies, which also includes ReA

54
Q

How is tuberculosis linked to autoimmune disorders?

A
  1. Tricks immune system into attacking own lung tissue - autoimmunity, causing eye and joint inflammation & skin rashes
  2. Have autoantibodies as result of imbalanced immune response
  3. Pulmonary TB and Vit D deficiency have high autoantibodies
  4. Immune dysregulation related to TB can reactive TB in inflammatory diseases
55
Q

Infliximab MOA

A

Binding to soluble and insoluble forms of TNF-a so cannot bind to receptors
Inhibiting TNF-a by blocking intracellular signalling that leads to gene transcription & biologic activity
Infliximab suppresses immune system, reducing inflammation

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