7: RA Flashcards by Paige Sosebee

Q

What decades have peak incidence of RA?

A

4th and 5th

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Is RA more common in males or females?

A

2.5x more common in females

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Which ethnicity has a high prevalence of RA?

A

Some Native American populations have a rate of 5%.

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

How long must symptoms be present before RA can be diagnosed?

A

6 weeks

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Is RA symmetrical or asymmetrical?

A

Symmetrical

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Is RA in one joint or multiple?

A

Multiple (considered polyarticular)

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Is stiffness in RA more common when getting up in the morning or in the afternoon after using the joints?

A

Morning (of over an hour, but gets better with movement)

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Is it common to have swelling in RA?

A

Yes, there is inflammatory synovitis (palpable synovial swelling).

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Which joints are usually involved in RA (3)?

A

Wrists
MCP Joints
PIP Joints

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Which joints are usually spared in RA (3)?

A

DIPs of the Fingers
Thoracolumbar Spine
IPs of the Toes

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Key features of RA (6)?

A

Symptoms 6+ weeks.
Inflammatory synovitis (palpable synovial swelling).
Morning stiffness.
Symmetrical and polyarticular.
Nodules at pressure points (esp where people lean on their arms).
Serological markers (Rheumatoid factor, anti-CCP).

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Is the rheumatoid factor positive in all cases of RA?

A

No, 50% positive in first 6 months. 85% positive as disease progresses over 2 years. Low titer not specific for RA, but high titer early is a bad sign.

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

T/F If both RF and anti-CCP are positive there is a lower correlation with erosive disease.

A

False. There is a higher correlation with erosive disease.

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

What will an x-ray show in RA?

A

Marginal erosions and joint space narrowing.

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

What is the classification criteria for RA (2)?

A

Must have at least 1 joint with clinical synovitis not better explained by another disease.
Score 6/10.

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

How many RA points do you score for:

1 large joint

A

0 (1 joint inconsequential)

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

How many RA points do you score for:

2-10 large joints

A

1

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

How many RA points do you score for:

1-3 small joints

A

2

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

How many RA points do you score for:

4-10 small joints

A

3

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

How many RA points do you score for:

Over 10 joints (at least 1 small joint)

A

5

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

How many RA points do you score for:

Negative RF and anti-CCP

A

0

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

How many RA points do you score for:

Low positive RF or anti-CCP

A

1

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

How many RA points do you score for:

High positive RF + anti-CCP

A

3

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

How many RA points do you score for:

Normal CRP and ESR

A

0

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

How many RA points do you score for: | Abnormal CRP or ESR

1

How many RA points do you score for: | Duration less than 6 weeks

0

How many RA points do you score for: | Duration more than 6 weeks

1

What is the pathogenesis of RA?

Synovial fluid is over-produced in RA. It can cause pain and inflammation. Panus (old, thickened synovial fluid) will eat away at the cartilage.

What causes RA morning stiffness?

Fluid in joints is thick like bad oil in a car. Stiffness can return during the day, especially after rest.

T/F Early erosion on x-ray leads to more advanced disease.

True

Name extra-articular manifestations that may happen with RA (6).

1. Fatigue 2. Raynaud's Syndrome 3. Dry Eyes/Mouth (secondary Sjogren's syndrome) 4. Interstitial Lung Disease 5. Pleuritis or Pericarditis 6. Vasculitis

T/F RA treatment is aggressive early on.

True. If damage occurs early, then start aggressive treatment early.

How frequently are RA patients monitored?

Monitor treatment for adverse effects at least every 2 months.

What exercise is best for RA (3)?

1. ROM 2. Conditioning 3. Strengthening

Medication treatment for RA (types, not specifics) (2)?

1. Analgesic/anti-inflammatory | 2. Immunosuppressives (cytotoxin, biologic)

T/F Significant radiographic damage may be seen in patients within the first 2 years after presentation of RA.

True. That's why treatment may need to be aggressive.

NSAIDs, low-dose prednisone, intra-articular steroids, DMARDs, immunosuppressive? Symptomatic relief, improved function.

NSAIDs

NSAIDs, low-dose prednisone, intra-articular steroids, DMARDs, immunosuppressive? No change in disease progression.

NSAIDs

NSAIDs, low-dose prednisone, intra-articular steroids, DMARDs, immunosuppressive? May substitute for NSAIDs.

Low-dose prednisone (<10 mg/day)

NSAIDs, low-dose prednisone, intra-articular steroids, DMARDs, immunosuppressive? Use as bridge therapy

Low-dose prednisone (<10 mg/day)

NSAIDs, low-dose prednisone, intra-articular steroids, DMARDs, immunosuppressive? If used long-term, consider prophylactic treatment for osteoporosis.

Low-dose prednisone (<10 mg/day)

NSAIDs, low-dose prednisone, intra-articular steroids, DMARDs, immunosuppressive? Specific for 1-2 joints

Intra-articular steroids

NSAIDs, low-dose prednisone, intra-articular steroids, DMARDs, immunosuppressive? Sulfasalazine

DMARDs

NSAIDs, low-dose prednisone, intra-articular steroids, DMARDs, immunosuppressive? Hydroxychloroquine (Plaquenil)

DMARDs

NSAIDs, low-dose prednisone, intra-articular steroids, DMARDs, immunosuppressive? Leflunomide

DMARDs

NSAIDs, low-dose prednisone, intra-articular steroids, DMARDs, immunosuppressive? Methotrexate

Immunosuppressive (effective single DMARD)

NSAIDs, low-dose prednisone, intra-articular steroids, DMARDs, immunosuppressive? Azathioprine

Immunosuppressive

Sulfasalazine, Hydroxychloroquine (Plaquenil), Leflunomide, Methotrexate, Azathioprine, Cyclophosphamide, or Cyclosporine? Moderate effect. Low Cost.

Sulfasalazine | Hydroxychloroquine (Plaquenil)

Sulfasalazine, Hydroxychloroquine (Plaquenil), Leflunomide, Methotrexate, Azathioprine, Cyclophosphamide, or Cyclosporine? Toxicity similar to Methotrexate.

Leflunomide

Sulfasalazine, Hydroxychloroquine (Plaquenil), Leflunomide, Methotrexate, Azathioprine, Cyclophosphamide, or Cyclosporine? Combo with Methotrexate improves s/s in Methotrexate-failing RA.

Leflunomide

Sulfasalazine, Hydroxychloroquine (Plaquenil), Leflunomide, Methotrexate, Azathioprine, Cyclophosphamide, or Cyclosporine? Effective single DMARD.

Methotrexate

Sulfasalazine, Hydroxychloroquine (Plaquenil), Leflunomide, Methotrexate, Azathioprine, Cyclophosphamide, or Cyclosporine? Good benefit-to-risk ratio.

Methotrexate

Sulfasalazine, Hydroxychloroquine (Plaquenil), Leflunomide, Methotrexate, Azathioprine, Cyclophosphamide, or Cyclosporine? Slow onset. Reasonably effective.

Azathioprine

Sulfasalazine, Hydroxychloroquine (Plaquenil), Leflunomide, Methotrexate, Azathioprine, Cyclophosphamide, or Cyclosporine? Effective for vasculitis. Less so for arthritis.

Cyclophosphamide

Sulfasalazine, Hydroxychloroquine (Plaquenil), Leflunomide, Methotrexate, Azathioprine, Cyclophosphamide, or Cyclosporine? Superior to placebo. Renal toxicity.

Cyclosporine

Sulfasalazine, Hydroxychloroquine (Plaquenil), Leflunomide, Methotrexate, Azathioprine, Cyclophosphamide, or Cyclosporine? Gold standard in RA treatment.

Methotrexate

Sulfasalazine, Hydroxychloroquine (Plaquenil), Leflunomide, Methotrexate, Azathioprine, Cyclophosphamide, or Cyclosporine? Long-term data shows efficacy in relieving s/s of RA.

Methotrexate

Sulfasalazine, Hydroxychloroquine (Plaquenil), Leflunomide, Methotrexate, Azathioprine, Cyclophosphamide, or Cyclosporine? Limited data on inhibition of structural damage.

Methotrexate

Sulfasalazine, Hydroxychloroquine (Plaquenil), Leflunomide, Methotrexate, Azathioprine, Cyclophosphamide, or Cyclosporine? Main concerns are hepatotoxicity and bone marrow suppression.

Methotrexate

Sulfasalazine, Hydroxychloroquine (Plaquenil), Leflunomide, Methotrexate, Azathioprine, Cyclophosphamide, or Cyclosporine? Increased risk of lymphoma with long-term use.

Methotrexate

T/F Any autoimmune disease increases risk of lymphoma, with or without meds.

True

How often are checkups on Methotrexate?

At least every 8 weeks, but every 2-3 weeks at first. Concern for hepatotoxicity and bone marrow suppression.

T/F Methotrexate shows prevention or reduction of bone erosion.

False. New medication studies show that, but Methotrexate wasn't studied.

Is this a TNF inhibitor, Costimulation modulator, B cell depletion, IL-1 inhibitor, IL-6 inhibitor, or Janus/Jak kinase inhibitor? Remicade IV

TNF inhibitor

Is this a TNF inhibitor, Costimulation modulator, B cell depletion, IL-1 inhibitor, IL-6 inhibitor, or Janus/Jak kinase inhibitor? Embrel SC

TNF inhibitor

Is this a TNF inhibitor, Costimulation modulator, B cell depletion, IL-1 inhibitor, IL-6 inhibitor, or Janus/Jak kinase inhibitor? Humira SC

TNF inhibitor

``` Is this a TNF inhibitor, Costimulation modulator, B cell depletion, IL-1 inhibitor, IL-6 inhibitor, or Janus/Jak kinase inhibitor? Cimzia SC (2x/month) ```

TNF inhibitor

``` Is this a TNF inhibitor, Costimulation modulator, B cell depletion, IL-1 inhibitor, IL-6 inhibitor, or Janus/Jak kinase inhibitor? Simponi SC (1x/month) ```

TNF inhibitor

Is this a TNF inhibitor, Costimulation modulator, B cell depletion, IL-1 inhibitor, IL-6 inhibitor, or Janus/Jak kinase inhibitor? Orencia SC/IV

Costimulation modulator

Is this a TNF inhibitor, Costimulation modulator, B cell depletion, IL-1 inhibitor, IL-6 inhibitor, or Janus/Jak kinase inhibitor? Rituxan IV

B cell depletion

Is this a TNF inhibitor, Costimulation modulator, B cell depletion, IL-1 inhibitor, IL-6 inhibitor, or Janus/Jak kinase inhibitor? Anikinra SC

IL-1 inhibitor

Is this a TNF inhibitor, Costimulation modulator, B cell depletion, IL-1 inhibitor, IL-6 inhibitor, or Janus/Jak kinase inhibitor? Actemra SC/IV (q 4 weeks)

IL-6 inhibitor

Is this a TNF inhibitor, Costimulation modulator, B cell depletion, IL-1 inhibitor, IL-6 inhibitor, or Janus/Jak kinase inhibitor? Tofacitinib (Xeljanz) PO

Janus/Jak kinase inhibitor

Due to the synovitis, there is bone erosion, pain, joint swelling, and joint space narrowing. Which ones are caused by osteoclasts, synoviocytes, and chondrocytes?

Bone Erosion = Ostoclasts Pain = Synoviocytes Joint Swelling = Synoviocytes Joint Space Narrowing - Chondrocytes

For patients with inadequate response to Methotrexate, _____ are effective in controlling RA symptoms.

TNF inhibitors

T/F If patients fail Methotrexate, the next step are TNF inhibitors.

False. Try Methotrexate in combination with Plaquenil, Azathioprine, or Sulfasalazine first.

If there is bone erosion, need to use _____.

TNF inhibitors

With TNF inhibitors, _____, _____, and _____ are frequent sites of adverse effects. So frequent monitoring is needed.

Blood, liver, and kidneys

How often are patients monitored with anti TNF drugs?

Interval lab testing from 4-8 weeks. 12 weeks if no adverse effects after 1 year. Most need to be seen 3-6x/year.

T/F Treatment in RA should be monitored and changed based on disease activity.

True