Arthritis Flashcards
Rheumatoid arthritis is symmetrical. True/false?
True
Women are how many more times likely to develop RA than men?
Three times
UK prevalence of RA in % is?
1%
Which haplotype is associated with RA?
HLA-DR4
Name two triggers of RA
- Smoking
- Stress
The main structure affected in RA is the…
Synovium
C1/C2 vertebral joint is rich in synovium. True/false?
True
C1/C2 are the only vertebra readily affected by RA. True/false?
True - other areas don’t have as much synovium
Pure RA involves cartilage degeneration. True/false?
False - no cartilage
Osteoarthritis involves synovium. True/false?
False - only cartilage is involved in pure OA
Both B and T cells are involved in RA. True/false?
True
RA always has autoantibodies present. True/false?
False - seronegative RA exists
In RA, which cells are over stimulated to progressively resorb the bone?
Osteoclast
Early RA is defined as that which has…
Two years of onset of RA symptoms
What is the therapeutic window to begin RA medication and ensure good outcomes?
3 months
Having negative antibody screen rules out RA. True/false?
False - seronegative RA
The three most commonly affected joints in RA are….
PIP, MCP and MTPs
Trigger finger is a type of
Tenosynovitis
Palindromic rheumatism is continual/episodic
Episodic
Rheumatoid Factor is which class of antibody?
IgM
Rheumatoid Factor is present in which % of patients?
20-50%
Rheumatoid Factor is how specific for RA?
70-80%
Anti-Cyclic Citrullinated Peptide is how specific for RA?
90-99%
Patients can be RF negative and anti-CCP positive. True/false?
True
The current classification system for RA is the…
2010 ACR/ EULAR classification
Which % of RA diagnosis is clinical and history (as opposed to investigation)?
90%
In RA, early morning stiffness typically lasts…
> 30 minutes
In OA, early-morning stiffness typically lasts
<30 minutes
Inflammatory markers are always raised in RA. True/false?
False
Plain X-rays are a useful form of diagnosing early RA. True/false?
False - no signs
Treatment changes of RA can be monitored with which investigation?
USS
What’s the gold-standard imaging standard for RA?
MRI
MRI can distinguish X from Y, making it useful in differential of R.A?
X = Synovitis Y = Synovial effusion
A DAS28 of <2.6 is considered to be
Remission
A DAS28 of >5.1. indicates
Active disease
Upon diagnosis of RA, DMARDs should be immediately commenced. True/false?
False - initial step with aspirin/NSAIDs, then add steroids, then trial DMARD
Patients on DMARD should be measured how often?
6 weeks DAS score taken
If more than 5 joints are involved, intra-articular steroid injection is recommended. True/false?
False - 5 is limit
Which drug must be co-prescribed with methotrexate?
Folic acid
Parenteral methotrexate has a risk of pneumonitis. True/false?
True
Which criteria is needed to move up treatment in RA?
DAS28>5.1 on 2 occasions at least 4 weeks apart
What investigations are important before commencing anti-TNF drugs?
Screen for latent TB, hepB/C, HIV, VZV
Describe late-stage RA signs of the hand (3)
- Boutonniere
- Ulnar deviation
- Swan-necking
IPEX Syndrome is caused by a mutation in which gene? What does this gene do?
FOXP3
Develops regulatory T-cells
HLA-B27 is associated with which disease?
Ankylosing spondylitis
RA is which type of hypersensitivity?
Type 4
SLE is which type of hypersensitivity disease?
Type 3
All _____ cells express MHC class I on their membrane.
Nucleated
ANA is useful in making RA diagnosis. True/false?
False
Which cartilage type covers the surface of bone in synovial joints?
Hyaline
Proteoglycans in hyaline cartilage are hydrophilic/phobic?
Philic
Joint healing is done with which type of cartilage? Why is this “worse”?
Replacement is fibrocartilage, which has a greater friction and is less wear resistant
The underlying pathology in osteochondritis dessicans is…
Loss of blood supply. Bone +/- cartilage can shear off.
Cartilage regeneration can be done in all cases of OA. True/false?
False - only applicable in osteochondritis dessicans
Cartilage regeneration surgery is possible in the patello-femoral joint. True/false?
False
Partial knee replacement has higher or lower fail rate than TKR?
Higher
What’s the average expectancy of a TKR?
15-20 years
What’s the risk of deep infection in TKR replacement?
1%
Paracetamol is a pure analgesic with very little anti-inflammatory property. True/false?
True
Example NSAIDs used in arthritis (3)
- Ibuprofen
- Naproxen
- Diclofenac
Side-effects of NSAIDs (3)
- Peptic ulceration
- Dyspepsia
- Oesophagitis
COX-2 is commonly targeted by which class of drug?
NSAID
DMARDs have analgesic properties. True/false?
False - pure anti-inflammatories
DMARDs should be started how soon after a RA diagnosis?
Within 3 months
Step 1 treatment option for RA is (2)
Non-opioid analgesic (such as aspirin, paracetamol or NSAID) +/- adjuvant
Step 2 treatment option for pain in RA Is
Weak opioid for mild to moderate pain (e.g. codeine) +/- non-opioid
Step 3 treatment option for RA pain is…
Strong opioid for moderate to severe pain (e.g. morphine) +/- non-opioid
Which DMARDs have the “least” toxicity profile?
1) Methotrexate
2) Sulfasalazine
What’s the MoA of methotrexate?
Unknown - only known it is a folate antagonist
Side effects of methotrexate include (3)
1) Lecopenia
2) Hepatitis
3) Later, cirrhosis
How long should methotrexate be stopped prior to conception? Why?
At least 3 months - it is highly teratogenic
Side-effects of sulfasalazine include (4)
1) Nausea
2) Rash/mouth ulcers (potentially Stevens-Johnson Syndrome)
3) Neutropenia
4) Oligospermia
Hydroxychloroquine has what effect on joint damage?
None
Hydroxychloroquine is used in which type of disease?
Connective tissue diseases (such as SLE, Sjorgen’s, RA)
Sodium aurothiomate is a type of what?
DMARD - not used any more due to BM suppression and kidney damage
Penicillinamine as a DMARD has which side-effects?
Same as gold - kidney damage,BM suppression
Which DMARDs require regular FBCs & LFTs?
Methotrexate and sulfasalazine
Biologic therapies are delivered via which route?
S/C
What are side-effects of biologics?
- Malignancy (especially skin cancer)
- Risk of infection (especially TB)
- Contraindicated in pulmonary fibrosis
Tocilizumab targets what?
IL-6
Abatacept targets what?
CTLA-4 (blocking T-cell activation)
Ustekinumab targets what?
IL-12 and IL-23 (involved in psoriatic arthritis)
What’s more common, sternoclavicular joint arthritis or AC joint arthritis?
AC joint
Symptoms of glenohumeral OA include (3)
1) Pain
2) Crepitus
3) Loss of ROM
Reverse geometry shoulder replacement is an alternative surgery which involves which muscle? What condition is it used for?
Deltoid & treatment of rotator cuff tear
OA is commonly polyarticular. True/false?
False - RA tends to be polyarticular
RA tends to involve the joint spaces narrowing early on. True/false?
False - OA has early narrowing
Which hand joints are commonly implicated in OA?
DIP + PIP
MCP joints are involved in OA/RA?
RA
What are the hand signs of OA?
1) Heberdens (DIP) nodes
2) Bouchard nodes (PIP)
Psoriatic arthritis can result in which sign on x-ray?
Pencil-in-cup
What % of rheumatoid arthritis presents as a monoarthritis?
30%
What common presentations are associated with RA?
Trigger finger, tenosynovitis, carpal tunnel, palindromic rheumatism
What is more specific, Rheumatoid Factor or anti-CCP?
Anti-CCP
Anti-CCP is only positive at symptom onset in RA, T/F?
False - it can be positive for years before symptoms
Anti-CCP is associated with smoking, T/F?
True
Anti-CCP will be high/low with disease severity, true or false?
True
Anti-CCP is a useful marker in judging treatment of RA. T/F?
False - will always be positive
Steroids can be used as a monotherapy in RA, T/F?
False - only as a bridge between flares
How many DMARDs can be given at once?
3 (plus steroids plus aspirin/NSAIDs)
List 2 anti-TNFalpha antibodies?
Infliximab, adaluminab
List 1 anti-TCR antibody
Abatacept
List 1 anti-Bcell antibody
Rituximab
Biologics are ONLY used if which criteria are met?
If patient fails to respond to 2 DMARDs (one of which is MTX) AND has a Das28 of >5.1 on at least 2 occasions 4 weeks apart.
T/F: Live vaccines can be given in biologic therapy?
False
C1-C2 subluxation is a complication of RA, T/F?
True - C1 and C2 are rich in synovium.
A young woman with rheumatoid arthritis mentions she is thinking of starting a family. Her current medication is MTX 15mg/weekly. What should she do about her medication/
Come off it and wait 3 months before trying to conceive. Replace with steroids + possibly another DMARD (?)
RA will improve in pregnancy
A 36 year old man has very sore joints despite treatment with MTX, SZS and hydroxychloroquine. His DAS28 is 5,88. He is commenced on a new therapy but later returns with cough, 2 stone weight loss, night sweats and fever. What has likely occured?
He likely has an underlying infection (e.g. TB) which has been reactivated by his anti-TNFalpha therapy.
A 42 year old female is commenced on aspirin, steroids and methotrexate for his rheumatoid arthritis. He has crackles at both lung bases. Which medication is likely responsible & condition?
Methotrexate - methorexate pneumonitis
Which NSAID is COX-2 selective? Why is using this advantageous?
Celecoxib.
It has a lower chance of giving peptic ulcer.
GI Side effects of NSAIDs
Dyspepsia, oesophagitis, gastritis, peptic ulcer, small/large bowel ulcer
Is renal impairment a side-effect of NSAID use?
Yes
Which lab results will DMARDs improve in patients with RA?
ESR, CRP
What are the side-effects of methotrexate? (5)
1) Leucopaenia/ thrombocytopenia
2) Hepatitis
3) Pneumonitis
4) Rash/ mouth ulcers (SJS)
5) Teratogenic
What are the side-effects of leflunomide?
Similar to MTX (low WBCs and PLTs, hepatitis, pneumonitis, teratogenic)
What are the side-effects of sulfasalazine? (4)
1) Rash/mouth ulcers (SJS)
2) Neutropenia
3) Reversible oligozoospermia
4) Hepatitis
What is the main side-effect of hydroxychloroquine?
Retinopathy
How much more effective is anti-TNF therapy than conventional DMARDs?
1.5x
How are anti-TNFs administered?
S/C
List some anti-TNF drugs (3)
1) Etanrecept
2) Adaluminab
3) Infliximab
What are the side-effects of anti-TNF drugs? 2
1) Risk of TB infection
2) Possible cancer (esp skin)
Contraindicated in certain situations e.g. pulmonary fibrosis, heart failure
Secukinab inhibits what?
IL-17
Tocilizumab inhibits what?
IL-6 (used in RA)
Abatacept inhibits what? What is it used in?
Activation of T-cells
Used in psoriatic arthritis
Is rituximab used in spondyloarthropathy?
No (only in RA and CTD)
RA hand signs
Boutinnere’s deformity, ulnar deviation, swan neck