351 Rheumatoid Arthritis Flashcards by Medicine Katorse

Based on the American College of Rheumatism (ACR) and European League Against Rheumatism (EULAR) criteria, what is the score to the fulfills requirement for definite Rheumatoid Arthritis?

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Earliest joints involved in rheumatoid arthritis

Small joints of hands and feet

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Most frequently involved joints

MCP, PIP and wrist

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True or false: DIP frequently involved in RA

False but a when present means coexistent osteoarthritis

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Frequent hallmark of rheumatoid arthritis

Flexor tendon tenosynovitis

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Hypertension of PIP and flexion of DIP

Swan neck deformity

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Subluxation of the MCP joint with subluxation or partial dislocation of the proximal phalanx to volar side of the hand

Ulnar deviation

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Flexion of the PIP with hyper extension of the DIP

Boutonniere deformity

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Subluxation of the first MCP joint with hyper extension of the first interpahalangeal joint

Z line deformity

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Inflammation about ulnar styloid and tenosynovitis of the extensor carpi ulnaris may cause subluxation of the distal iulnar

Piano key movement of ulnar styloid

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What differentiates RA from spondyloarthritides

RA rarely affects thoracic and lumbar spine

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Initial radiographic finding in RA

Periarticular osteopenia

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DMARDS of first choice for the treatment of early RA

Methotrexate

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Ranks as an important long term complication of chronic prednisone use

Osteoporosis

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DMARDS which causes irreversible retinal damage

Hydorxychloroquinee

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Examples of conventional DMARDs

Hydroxychloroquine
Sulfasalazine
Methotrexate
Leflunamide

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most common form of chronic inflammatory arthritis

rheumatoid arthritis

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rheumatoid arthritis

small joints of the hands and feet

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typical complaints of patients with RA

early morning stiffness lasting more than 1 h that eases with physical activity

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joints that standout as the most frequently invovled

MCP, PIP, wrist

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True or false. Involvement of the DIP is usually a manifestation of coexistent OA

True.

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frequent hallmark of RA and leads to decreased range of motion, reduced grip strength and trigger fingers

flexor tendon tenosynovitis

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results from subluxation of the MCP jionts with sublaxation or partial dislocation, of the proximal phalanx to the volar side of the hand

ulnar deviation

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subluxation of the first interphalangeal joint

z line deformity

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hypertension of the PIP with flexion of the DIP

swan neck deformity

flexion of the PIP with hyperextension of the DIP

boutonniere deformity

inflammation of the ulnar styloid and tenosynovitis of the extensor carpi radialis may subluxation of the distal ulna

piano key movement

cause of pes planovalgus in RA

chronic inflammation of the ankle and midtarsal region

True or false. Atlantoaxial subluxation in RA occurs in less than 10% of patient

True.

True or false. Unlike spondyloarthritidies, RA rarely affects the thoracic and lumbar spine

True.

True or false. Approx 10% of patients with RA have secondary Sjogrens syndrome

True.

most common pulmonary manifestation of RA

pleuritis

most frequent site of cardiac involvement in RA

pericardium

True or false. Subcutaneous nodules have been reported in 30-40% of patients and more commonly in those with highest levels of disease activity

True.

rare subset of pulmonary nodulosis characterized by the development of nodules and pneumoconiosis following silica exposure

Caplan syndrome

most common hematologic abnormality of RA

normochronic normocytic anemia

True or false. The degree of anemia correlate with the levels of CRP and ESR

True.

clinical triad of neutropenia, splenomegaly and nodular RA

Felty's syndrome

characterized by chronic indolent clonal growth of Large granular lymphocyte leading to neutropenia and splenomegaly

T cell large granula lymphocyte leukemia

T LGL vs Feltys

T LGL occurs in the early course of RA

True or false. RA patients have 2x-4x increased risk of lymphoma compared to the general population

True.

most common cause of death in RA

true or false. CHF is more common in RA than in the general population

True.

True or false. Osteoporosis is more common in patients with RA than in age sex matched population

True.

HLA that bestow highest risk of disease

HLA DRB1*0401

oral microbiome said to trigger development of RA

Porphyromonas gingivalis

enzyme found on oral microiome that induce anti CCP anitbodies

peptidyl arginine deiminase (PAD)

two cell types of the synovial membrane

Type A synoviocytes (macrophage derived) and Type B synoviocytes (fibroblasts derived)

most abundant type and produce the structural components of joints

Synovial fibroblasts

main constituents of the synovial fluid

Hyaluronan and lubricin

glycosaminoglycan that contributes to vicious nature of synovial fluid

hyaluronan

lubricates the surface of the articular cartilage

pathologic hallmarks of RA

synovial inflammation and proliferation, focal bone erosions, thining of articular cartilage

thickened cellular membrane containing fibroblast like synoviocytes and granulation reactive fibrovascular tissue

pannus

mediates the structural damage to the mineralized cartilage and subchrondral bone in RA

osteoclast

characterize the pre clinical stage of RA

breakdown of self tolerance

score in the ACR classification for definite RA

score more than or equal to 6

components of the ACR classification criteria for RA

joint involved, serology, acute phase reactatns, duration of symptoms

Classification criteria of RA. Serology score of 2? 3?

0 if RF and anti CCP both negative. 2 if RF and anti CCP elevated but less than 3x ULN. 3 if RF and anti CCP 3x more than ULN

Classification criteria of RA. Joint involvement.

0 if 1 large joint 1 if 10 large joint. 2 if 1-3 small joint, 3 if 4-10 small joints 5 if more than 10 joints at least 1 is small 0-1-2-3-5

Classification criteria of RA. Acute phase reactants.

0 if CRP and ESR normal. 1 if CRP or ESR abnormal

Classification criteria of RA. Duration of symptoms.

0 if less than 6 months. 1 if more than 6 months

most frequently measure isotype if RF in commercial laboratories

IgM RF

Percent IgM RF is positive in RA patient

75-80%

True or false. A negative RF does not exclude the presence of the disease

True.

useful for distinguishing RA from other forms of arthritis

anti CCP

showing the most value for predicting worse outcomes

anti CCP

initial radiographic finding in classical RA

periarticular osteopenia

offers the greatest sensitivity for detecting synovitis and joint effusions as well as early bone and bone marrow changes

MRI

Predictors of extra articular disease manifestation of RA

history of smoking, early onset of significant physical disability

how many percent of RA patient go into remission

10% go into remission in 6 months esp seronegative patients

Predictors of poor outcome in RA

extra articular involvement, RF positivity, Persistent synovitis, persistently high ESR and CRP

early sign of RA on MRI

bone marrow edema

conventional DMARDs

hydroxychloroquine, sulfasalazine, methotrexate, leflunomide

what is the onset of action of DMARDs

delayed of 6-12 weeks

DMARD of choice for treatment of RA

methotrexate

inhibitor of pyrimidine synthesis similar to that of methotrexate

leflunomide

True or false. Hydroxychloroquine is not considered a true DMARD as it does not show delay progression of the disease

True.

first biologicals approved for the treatment of RA

TNF inhibitors

Pharmacologic management of RA

NSAIDS, corticosteroids, DMARDS, biological DMARDS, Small molecule inhibitors ( Jak1, Jak3 inhibitors)

critical upstream mediator of joint inflammation

TNF

Chimeric part human part mouse monoclonal antibody

infliximab

humanized monoclonal antibodies

adalimumab, golimumab

pegylated Fc free fragment of a humanized monoclonal antibody with binding specificity for TNFa

certolizumab

soluble fusionprotein comprising the TNF receptor 2 in a covalent linkage with the Fc portion of the IgG1

contraindications for anti TNF agents

anti TNF approved for monottherapy

Etanercept, adalimumab, certolizumab pegol and golimumab

True or false. Anti TNF are typically used in combination with background methotrexate therapy

True

True or false. There is concern for increased risk of reactivation of latent TB

True.

recombinant form of natrually occuring IL-1 receptor antagonist

Anakinra

soluble fusion protein consisting of the extracellular domain of human CTLA-4 linked to modified portion of human IgG

abatacept

It inhibits co stimulation of T cells by blocking CD28-CD80/86 interaction

abatacept

chimeric monoclonal antibody directed against CD20

rituximab

cell surface molecule expressed by most mature B lymphocytes

CD20

humanized monoclonal antibody directed against the membrane and soluble forms of the IL-6 receptor

tocilizumab

small molecule inhibitor that primarily inhibits Jak1 and Jak2

tofacitinib

DMARDS associated with pulmonary toxicity

methotrexate and leflunamide

effective combinations in RA

triple therapy: methotrexate, sulfasalazine, hydroxychloroquine; methotrexate plus biological, methotrexate plus leflunamide

True or false. Combination of methotrexate and an anti TNF has been shown to be superior to methotrexate alone

True.

ACR/EULAR provisional definition of remission in RA

at any time, the patient must satisfy the follow A. tender joint less than 1, swollen joint less than 1, CRP less than 1 mg/dl patient goal assessment less than 1 OR B. any time point, patient has a simplified disease activity of less than 3.3

True or false. Up to 75% of female with RA will note overall improvement in symptoms during pregnancy but will often flare after delivery

True.

safest DMARDS to use during pregnancy

hydroxychloroquine, sulfasalazine

Creatinine threshold for methotrexate

cannot be given for methotrexate more than 2 mg/dl