Arthritis Flashcards
‘Symmetrical inflammatory arthritis affecting the peripheral joints’ is what?
Rheumatoid arthritis
What problems occur if RA is left untreated?
Deformities, joint damage and loss of function
As well as the joints, RA can also cause inflammation in organs. True or false?
True
Which sex is more likely to suffer from RA? By how many times?
Women are 3 times more commonly affected than men
What age group does RA affect?
Any age group
What is RA known as when it occurs in under 16s?
Juvenile idiopathic arthritis
RA is an autoimmune disease. True or false?
True
HLA-DR4 mediates which condition?
Rheumatoid arthritis
What are some potential triggers for RA?
Smoking, stress, infections
The presence of antibodies in RA has what effect on the prognosis?
Generally implies a worse prognosis
What is the main structure affected by RA?
The synovium
Which two areas does synovium line?
Inside of synovial joint capsules and tendon sheaths
Which disease only affects joints which have synovium?
Rheumatoid arthritis
Where in the spine can RA affect? Why?
C1 and C2, only spinal joints with synovium
What causes the joint destruction in RA?
Inflammatory cytokines
RA can cause joint fusion. True or false?
True
Which biologic agent works by depleting B cells?
Retuximab
In RA, T cells cause macrophage activation to release what 3 things?
TNF alpha, IL-1 and IL-6
Rheumatoid factor is released by what type of cell?
B cells
Infliximab and adalimumab work by inhibiting what?
TNF alpha
Tocilizumab works by inhibiting what?
IL-6 receptor
On x-rays for RA, it often looks like bits of bone have been eaten off (erosion)- what causes this to happen?
Osteoclast activity
What do osteoblasts do?
Lay down bone
What do osteoclasts do?
Resorb bone (remove cells by gradual breakdown)
Which condition spares the DIP joints?
Rheumatoid arthritis
Early RA is defined as when since symptoms began?
Less than 2 years
What is the therapeutic window of opportunity for better outcomes in RA?
The first 3 months since symptom onset
What causes morning stiffness for more than 30 mins?
Rheumatoid arthritis
Rheumatoid arthritis is usually asymmetrical. True or false?
False- it is usually symmetrical, though it can present in one joint before the other
Will you see radiographic changes in early RA?
No
What are the two main inflammatory markers?
CRP and PV
Apart from autoantibodies and inflammatory markers, what else could be seen in routine blood tests of an RA patient?
Anaemia and raised platelets
What types of imaging can be used for RA? Which is the gold standard?
X-rays
Ultrasound
MRI (gold standard)
Compressing the MCP and MTP joints will be painful in what condition?
Rheumatoid arthritis
What two auto-antibodies are associated with RA?
Rheumatoid factor (IgM) Anti-CCP
Anti-CCP antibody is associated with which condition?
Rheumatoid arthritis
If a patient does not have the specific antibody, could they still have RA if the clinical signs were there?
Yes
What is tenosynovitis?
Tendon sheath inflammation
What is damage to the flexor tendons of the hand known as?
Trigger finger
Carpal tunnel is the compression of which nerve? Which fingers does this supply?
Median nerve- supplies the middle 3 fingers
What is palindromic rheumatism?
Rheumatoid arthritis which comes and goes
Can RA have systemic symptoms?
Yes
When should x-rays be done for RA?
Whenever a patient presents- it is standard to do an x-ray of the hands and feet, even if there are no symptoms there
Early rheumatoid will show what on an x-ray?
Nothing
What scoring system is used to assess RA?
DAS28
What parts of the body are missed out of the DAS28 system?
Feet and ankles
What DAS28 score is indicative of severe, active disease?
> 5.1
What DAS28 score is indicative of remission?
< 2.6
A DAS28 score of 3.2-5.1 indicates what?
Moderate disease
A DAS28 score of 2.6-3.2 indicates what?
Low disease activity
What group of drugs are the main treatment for RA?
DMARDs
What can be used as adjunctive therapy for RA?
NSAIDs and steroids
Can steroids be used as sole therapy?
No
Oral steroids can be stopped suddenly. True or false?
False- patients must be taken off oral steroids by gradually reducing the dose
What is the first line DMARD?
Methotrexate
What is a good second line DMARD (especially in pregnancy)?
Sulphasalazine
What should always be started together with a DMARD? Why is this?
Steroids- because DMARDs take a few months to start to work, the steroid controls the inflammation in the meantime
Why are patients on DMARDs monitored?
Bone marrow suppression- low WCC
Why should patients on methotrexate be told to look out for a dry cough or dyspnoea?
It can cause pneumonitis
What advice would you give to young women starting methotrexate?
Use contraception- you cannot get pregnant on this drug
When can you give a biologic drug in RA?
If there has been a failure to respond to at least two DMARDs, and a DAS28 score of > 5.1
Should methotrexate be co-prescribed with a biologic?
Yes
What are 2 major risk factors of biologics?
- Immunosuppression
- Risk of reactivation of TB (patients should be screened)
What is the most common form of arthritis?
Osteoarthritis
Which arthritis is progressive and degenerative?
Osteoarthritis
What are 3 features of osteoarthritis?
- Gradual thinning of cartilage
- Loss of joint space
- Formation of bony spurs
When does osteoarthritis typically set in?
Around aged 40
Cartilage consists mainly of which type of collagen fibres?
Type II
What type of pain is found in osteoarthritis?
Mechanical pain
When is OA pain better and worse?
Worse on activity and by the end of the day
Better with rest
What type of arthritis causes crepitus?
Osteoarthritis
What type of arthritis causes morning stiffness for < 30 mins?
Osteoarthritis
‘One of the most common ares to be affected is the. neck’ describes what condition?
Osteoarthritis
What are Heberden’s nodes?
Bony enlargements in OA seen at the DIPs
What are Bouchard’s nodes?
Bony enlargements in OA seen at the PIPs
What will the affected areas of OA feel like?
Hard and lumpy
What is a Baker’s cyst?
An effusion in the knee spreads into the popliteal fossa and bulges out
What can a Baker’s cyst be misdiagnosed as?
DVT
What can lumbar spine OA cause if it impinges on the spinal cord?
Spinal stenosis
Osteoarthritis is more common in which gender?
Females
What are 5 risk factors for OA?
- Occupation
- Hobbies
- Previous Injury
- Obesity
- Co-morbidities
How do inflammatory markers come back usually in OA?
Normal
What are 4 typical x-ray changes of OA?
- Loss of joint space
- Subchondral sclerosis
- Bony cysts
- Osteophytes
What are the primary affected joints of the hands in OA?
DIPs and CMCs
What are some options of pharmacological treatment for OA?
NSAIDs and analgesia
What are some non-pharmalogical treatments for OA?
Physiotherapy, weight loss, education, footwear
Will drugs reverse or cure the symptoms of OA?
No
What crystal arthropathy is associated with monosodium rate crystals?
Gout
What crystal arthropathy is associated with calcium pyrophosphate dihidrate (CPPD) crystals?
Pseudogout
How long do attacks of gout usually last?
2 weeks
Is gout an inflammatory arthritis?
Yes
Which sex is gout most common in?
Men
Which arthropathy is most common in men?
Gout
What are risk factors for gout?
Red meat, shellfish, alcohol
What conditions can cause increased cell turnover (which increases purines)?
Psoriasis, infections, extreme diets
What defines hyperuricaemia?
Serum uric acid > 7mg/dL
What does hyperuricaemia mean in terms of having gout?
Does not mean you will definitely have gout- though it does increase the risk
What are some ‘overproduction’ causes of gout?
Genetic, high cell turnover, overconsumption of purine rich foods
What are some ‘under-excretion’ causes of gout?
Renal insufficiency, starvation, thyroid problems, drugs and alcohol
When is the best time to measure serum urate?
2 weeks following an acute attack
What are 3 different differentials of gout?
- Septic arthritis
- Trauma
- Seronegative arthritis e.g. psoriatic
Can gout become chronic after repeated acute attacks?
Yes
What medication is often associated with chronic polyarticular gout?
Diuretics
What will blood tests for gout show?
Raised inflammatory markers and WCC
What will x rays for gout show in chronic vs acute attacks?
Acute- normal
Chronic- erosions, osteophytes, joint destruction
What is the gold standard test for gout?
Joint aspirate
Needle shaped crystals with negative birefringence relates to what?
Gout
How do you manage an acute attack of gout?
NSAIDs, colchicine, steroids
What are 3 lifestyle recommendations for gout?
- Lose weight
- Restrict risk factors
- Fluids
What is used for gout prophylaxis and when should it be started?
Allopurinol- 2-4 weeks after an acute attack
start low, go slow
What is the target serum rate in gout?
< 0.3 mmol/l
What can also be known as CPPD?
Pseudogout
Pseudogout is more common in who?
Older population
What is the only way to tell the difference between gout and pseudogout?
Joint aspirate
Rhomboid shaped crystals with a weakly positive birefringence relates to what disease?
Pseudogout
Is it possible to have both gout and pseudo gout?
Yes
Should allopurinol be given for pseudo gout?
No
What is caused by hydroxyapatite crystals?
Milwaukee shoulder
What has a similar presentation to Milwaukee shoulder?
Septic arthritis
Milwaukee shoulder causes an acute rapid deterioration, most common in females around ? years?
50-60
Hydroxyapatite crystals will be detected under microscopy. True or false?
False- but an alizarin stain shows red clumps
Does paracetamol cause any renal impairment?
No
Is paracetamol safe in pregnancy?
Yes
What are 2 examples of atypical analgesics?
Amitriptyline and gabapentin
Should NSAIDs be used long term?
No
Naproxen is what type of drug?
NSAID
Do NSAIDs cause renal impairment?
Yes
When is it important to not give NSAIDs?
In patients with asthma
Celecoxib is what type of drug?
COX2 inhibitor (a type of NSAID)
What is the benefit of COX2 inhibitors?
No risk of peptic ulceration
What is the disadvantage of COX2 inhibitors? For this reason, who should they be given to?
They greatly increase CV risk- should only be given to patients with no other risk factors for this
When should DMARDs be started?
Within 3 months of symptoms starting
What are two reasons for blood tests on patients on methotrexate?
- Low WCC
- Liver damage
What supplement must be given to patients on methotrexate?
Folic acid
What are 4 rheumatological uses for methotrexate?
- Rheumatoid
- Psoriatic
- Connective tissue diseases
- Vasculitis
Does the teratogenic effect of methotrexate apply to males?
Yes
If a patient with RA was to develop a cough and SOB soon after diagnosis, what is this likely to be?
Pneumonitis
If a patient with RA was to develop a cough and SOB a long time after diagnosis, what is this likely to be?
RA associated pulmonary fibrosis
What other DMARD is often used in combination with methotrexate?
Sulphasalazine
What DMARD can cause reduced sperm count? Is it reversible?
Sulphasalazine- yes
What DMARD can cause Stevens Johnsons Syndrome?
Sulphasalazine
What is a teratogenic DMARD that is not methotrexate?
Leflunomide
What DMARD should you move patients toil methotrexate is causing too many side effects?
Leflunomide
Does hydroychloroquine have any effect in joint damage?
No
What DMARD can cause irreversible retinopathy?
Hydroxychloroquine
How are biologics given?
Subcutaneous injection
What 3 diseases are anti-TNF agents used for?
- RA
- Psoriatic
- Ankylosing spondylitis
Biologics have been said to increase risk of cancer. What kind specifically?
Melanoma
What type of drug used for RA exacerbates heart failure?
ANti-TNF biologics
What medications should be given alongside steroids?
Calcium and vitamin D
What drug should be used in gout patients who cannot tolerate allopurinol?
Febuxostat
Allopurinol and febuxostat are what type of drugs?
Xanthine oxidase inhibitors
What does xanthine oxidase do?
Changes purines into uric acid
When should febuxostat be used with caution?
Ischaemic heart disease
What other rheumatological condition can occur as a side effect of allopurinol?
Vasculitis
What can allopurinol and methotrexate combined cause?
Irreversible bone marrow suppression
What are another group of drugs which can be used for gout but are uncommon?
Uricosurics
You must come off methotrexate for how long before trying to conceive?
3 months
What are drug options for patients during pregnancy?
Sulphasalazine or biologics
RA gets worse in pregnancy. True or false?
False- it usually gets better, but there is often a flare up after birth
Are sponyloarthropathies inflammatory?
Yes
What makes individuals genetically predisposed to spondyloarthropathies?
Being HLA-B27 positive
Being from where makes you more likely to be HLA-B27 positive?
Northern countries
Being HLA-B27 + means you will definitely have one of the conditions it is associated with. True or false?
False
What are the 4 conditions that come under the spondyloarthropathies?
- Reactive arthritis
- Ankylosing spondylitis
- Psoriatic arthritis
- Enteropathic arthritis
When is inflammatory pain better/worse?
Worse with rest and better with activity
Do you get morning stiffness with inflammatory pain?
Yes
What area of the body is involved in sponydloarthropathies which is not involved in other kinds?
The spine and sacroiliac joints
What is enthesitis?
Inflammation at insertions of tendons into bones
What is dactylitis?
‘Sausage digits’- inflammation of an entire digit
Is peripheral arthritis common in ankolysing spondylitis?
No
When does AS usually occur? Which sex is it more common in?
Usually late teens or early adulthood, more common in males
What can happen to the vertebrae in AS, causing patients to have limited movement?
Fusion
What can happen to chest expansion in AS?
Reduced
What blood tests are important for AS?
Inflammatory markers
HLA-B27
What condition is Bamboo spine associated with?
Ankolysing spondylitis
Can an x-ray be normal in AS?
Yes, in early disease
What is the best test for AS?
MRI
How can you tell AS apart from osteoarthritis?
AS in inflammatory, OA is not
What will happen to bone density in AS?
Decreased
What will happen to bone density in OA?
Normal, maybe increased
Can you have psoriatic arthritis without psoriasis?
Yes (around 10%)
What are the findings with regards to rheumatoid nodules and factor in psoriatic arthritis?
Negative
What nail features can be seen in psoriatic arthritis?
Pitting and onycholysis
What happens in arthritis mutilans?
Lots of joint destruction very quickly
What disease may show erosions, osteolysis and enthesis on x-ray?
Psoriatic arthritis
Which biologic is particularly useful for psoriatic arthritis?
Secukinumab (anti- IL-17)
What cell mediates psoriatic arthritis?
T cells
What are some non-medical treatments for psoriatic arthritis?
Physiotherapy, occupational therapy, orthotics/chiropodists
What causes reactive arthritis to occur?
An infection of some sort
Is reactive arthritis inflammatory?
Yes (inflammatory synovitis)
Can microorganisms be cultured from reactive arthritis?
No
How soon after an infection do symptoms of reactive arthritis occur?
1-4 weeks
What are the commonest types of infection to cause reactive arthritis?
Urogenital, enterogenic
What age group and sex is reactive arthritis most common in?
20s-40s, with equal sex distribution
Are individuals who suffer from reactive arthritis HLA-B27 positive?
Yes
Reiter’s syndrome is a class of reactive arthritis made up of what 3 things?
- Urethritis
- Conjunctivitis/uveitis/iritis
- Arthritis
Is reactive arthritis symmetrical? How many joints tend to be affected?
No, usually 1 joint or can be up to 4
What should you do in reactive arthritis to rule out infection?
Joint fluid analysis
What are the main treatments involved in reactive arthritis?
NSAIDs and corticosteroids
When should you give DMARDs in reactive arthritis?
If resistant or chronic
Is it possible to develop chronic reactive arthritis?
Yes
What condition is enteropathic arthritis associated with?
IBD
What will be the relation between arthritis and IBD flare ups?
Arthritis will be worse during a flare up
What skin condition may be associated with enteropathic arthritis and IBD?
Pyoderma gangrenosum
What medication should you NOT give in enteropathic arthritis? Why?
NSAIDS- they can exacerbate IBD
