Arthritis Flashcards
What is osteoarthritis
- ‘wear and tear’ associated with increasing age
- occurs in the synovial joints and is a result of a combination of genetic factors, overuse and injury
- imbalance between the cartilage being worn down and the chondrocytes repairing it
What are the risk factors for osteoarthritis
- Increasing age
- obesity
- Occupation
- Trauma
- Female
- FH
What changes can be seen on X-ray in osteoarthritis
L – Loss of Joint Space
O – Osteophytes
S – Subarticular Sclerosis (increased density of the bone along the joint line)
S – Subchondral Cysts (fluid filled holes in the bone, aka geodes)
(don’t necessarily correlate with symptoms)
Which joints are commonly affected in osteoarthritis
Hips Knees Sacro-iliac joints Distal-interphalangeal joints in the hands (DIPs) The MCP joint at the base of the thumb Wrist Cervical spine
What is the presentation of osteoarthritis
- Pain & Stiffness worsened by activity
- deformities
- Instability
- Reduction in joint movement
What hand signs can be seen in osteoarthritis
- Haberdens nodes (in the DIP joints)
- Bouchards nodes (in the PIP joints)
- Squaring at the base of the thumb at the carpo-
metacarpal joint - Weak grip
- Reduced range of motion
How to diagnose osteoarthritis
Diagnosis can be made without any investigations if:
- > 45 years
- typical activity related pain
- no morning stiffness or stiffness lasting > 30 min
What is the management of osteoarthritis
- Patient education - lifestyle advice
- Basic medications
- Intra-articular injections
- Joint replacements
What lifestyle advice can be given to patients with osteoarthritis
- weight loss: reduces load on joint
- Physiotherapy
- occupational therapy
- Orthotics
What is the basic medication ladder used in osteoarthritis
- paracetamol + topical NSAIDs or topical capsaicin
- NSAID + PPI (omeprazole) (only if intermittent)
- Consider opiates e.g. codeine or opiates (careful RE. dependence, not useful in chronic pain)
What is rheumatoid arthritis
- Autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa
- usually develops in middle age but can be any time
What type of arthritis is osteoarthritis
asymmtrical oligoarthritis
What type of arthritis is Rheumatoid arthritis
Symmetrical distal poly-arthritis
Risk factors for Rheumatoid arthritis
- Female > men
- FH
- HLA DR4
- HLA DR1
Which antibodies should you screen for if suspected RA
- Anti-CCP: often pre-date the development of rheumatoid arthritis
- Rheumatoid factor: 70% of patients
What is the presentation of RA
- Pain: Improves on activity
- Swelling
- Stiffness: >30 minutes
- Onset can be rapid or over years
- Fatigue
Weight loss
Flu like illness
Muscles aches and weakness
What is Palindromic Rheumatism
- self limiting short episodes of inflammatory arthritis
- joint pain, stiffness and swelling typically affecting only a few joints
- episodes only last 1-2 days and then completely resolve. - positive Abs may progress to full RA
What joints are commonly affected by RA
Proximal Interphalangeal Joints (PIP) joints Metacarpophalangeal (MCP) joints Wrist and ankle Metatarsophalangeal joints Cervical spine (Large joints CAN be affected)
What signs can be seen in the hands in RA
Z shaped deformity to the thumb
Swan neck deformity
Boutonnieres deformity
Ulnar deviation of the fingers at the knuckle (MCP joints)
What is a swan neck deformitiy
hyperextended PIP with flexed DIP
What is Boutonnieres deformity
- hyperextended DIP with flexed PIP
- tear in the central slip of the extensor components of the fingers.
What extra-articular manifestations may you see in RA
Pulmonary fibrosis with pulmonary nodules (Caplan’s syndrome) Bronchiolitis obliterans Felty’s syndrome Secondary Sjogren’s Syndrome (AKA sicca syndrome) Anaemia of chronic disease Cardiovascular disease Episcleritis and scleritis Rheumatoid nodules Lymphadenopathy Carpel tunnel syndrome Amyloidosis
What is Felty’s Syndrome
RA, neutropenia and splenomegaly
What is Bronchiolitis obliterans
inflammation causing small airway destruction
What investigations should you complete if suspecting RA
- Check rheumatoid factor
- If RF negative, check anti-CCP antibodies
- Inflammatory markers: CRP and ESR
- X-ray of hands and feet
- Ultrasound scan of the joints can be used to evaluate and confirm synovitis
What X ray findings may you see in RA
Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions
When to refer a suspected RA
- any adult with persistent synovitis, even if they have negative rheumatoid factor, anti-CCP antibodies and inflammatory markers.
- Urgent if:
- small joints of hands and feet affected
- multiple joints or symptoms have been present >3mo
What is the diagnostic criteria for RA
Patients are scored based on:
- joints that are involved (more and smaller joints score higher)
- Serology (rheumatoid factor and anti-CCP)
- Inflammatory markers (ESR and CRP)
- Duration of symptoms (more or less than 6 weeks)
Scores >6 indicates a diagnosis of RA
What is the DAS28 Score
Disease Activity Score. It is based on the assessment for 28 joints and points are given for:
- Swollen joints
- Tender joints
- ESR/CRP result
- monitoring disease activity and response to treatment.
Who has a worse prognosis for RA
Younger onset Male More joints and organs affected Presence of RF and anti-CCP Erosions seen on xray
What is the Management of RA
- Start treatment ASAP - better outcomes
- MDT involvement
- Short course steroids at first presentation & in flares
- NSAIDs/COX2 inhibitors + PPI
- DMARDS
What is DMARD therapy
- First line is monotherapy with methotrexate, leflunomide or sulfasalazine
- 2 of the above
- Methotrexate + biologics (TNF inhibitor)
What happens with patients with RA in pregnancy
- Symptoms often improve in pregnancy: ?natural increase in steroid hormone production?
- DMARDs: Sulfasalazine or hydroxychloroquine ONLY
What is the aim of biological therapies in RA
- Lead to immunosuppression to prevent the development of auto-antibodies
- Include:
- Anti-TNF (adalimumab, infliximab, etanercept_
- Anti-CD20 (rituximab)
What is the problem with biological therapies
- Increase risk of infection
- Can lead to reactivation of dormant hepatitis B and TB
How does methotrexate work?
- interfering with the metabolism of folate and suppressing certain components of the immune system.
How is methotrexate taken
- It is taken by injection or tablet once a week
- Folic acid 5mg is also prescribed once a week to be taken on a different day to the methotrexate.
What are the common side effects of taking methorexate
- Mouth ulcers and mucositis
- Liver toxicity
- Pulmonary fibrosis
- Bone marrow suppression and leukopenia
- teratogenic ( avoid pregnancy within 3 months of taking it, woman AND men)
What is sulfasalazine
- works as an immunosuppressive and anti-inflammatory medications
- mechanism is not clear but ? folate metabolism
- appears to be safe in pregnancy however women need adequate folic acid supplementation.
Key side effects of sulfasalazine
Temporary male infertility (reduced sperm count)
Bone marrow suppression
What is Hydroxychloroquine
- traditionally an anti-malarial medication
- acts as an immunosuppressive medication
- It is thought to be safe in pregnancy.
What are the key side effects of Hydroxychloroquine
Nightmares
Reduced visual acuity (macular toxicity)
Liver toxicity
Skin pigmentation
What is rituximab
- monoclonal antibody that targets the CD20 protein on the surface of B cells
- causes destruction of B cells
- immunosuppression for autoimmune conditions such as rheumatoid arthritis and cancers relating to B cells.
Key side effects of rituximab
Vulnerability to severe infections and sepsis Night sweats Thrombocytopenia (low platelets) Peripheral neuropathy Liver and lung toxicity
what is psoriatic arthritis
- inflammatory arthritis associated with psoriasis
- Can vary in severity
- occurs in 10-20% of patients occurs in 10-20% of patients with psoriasis and usually occurs within 10 years of developing the skin changes within 10 years of skin changes
- seronegative spondyloarthropathy
What signs may you see in psoriatic arthritis
Plaques of psoriasis on the skin Pitting of the nails Onycholysis Dactylitis Enthesitis Eye disease (conjunctivitis and anterior uveitis) Aortitis (inflammation of the aorta) Amyloidosis
What is onycholysis
separation of the nail from the nail bed
What is Dactylitis
inflammation of the full finger
What is Enthesitis
- inflammation of the entheses, which are the points of insertion of tendons into bone
- plantar fasciitis and achilles tendonitis.
How do you diagnose psoriatic arthritis
patients with psoriasis complete the PEST (Psoriasis Epidemiological Screening Tool) l to screen for psoriatic arthritis
- several questions asking about joint pain, swelling, a history of arthritis and nail pitting.
- A high score triggers a referral to a rheumatologist.
What Xray changes may you see in psoriatic arthritis
- Periostitis
- Ankylosis
- Osteolysis is destruction of bone
- Dactylitis is inflammation of the whole digit and appears on the xray as soft tissue swelling
- Pencil-in-cup appearance
What is periostitis
is inflammation of the periosteum causing a thickened and irregular outline of the bone
What is ankylosis
is where bones joining together causing joint stiffening
What is the ‘pencil-in-cup’ appearance
- central erosions of the bone beside the joints and this causes the appearance of one bone in the joint being hollow and looking like a cup whilst the other is narrow and sits in the cup.
What is the management of psoriatic arthritis
- NSAIDs for pain
- DMARDS (methotrexate, leflunomide or sulfasalazine)
- Anti-TNF medications (etanercept, infliximab or adalimumab)
- Ustekinumab is last line (after anti-TNF medications) and is a monoclonal antibody that targets interleukin 12 and 23
What is Ankylosing Spondylitis
- inflammatory condition mainly affecting the spine that causes progressive stiffness and pain
- seronegative spondyloarthropathy
- Inflammation can lead to fusion of the spine and SI joints
Which conditions are part of the seronegative spondyloarthropathy group
- Psoriatic arthrtitis
- Ankylosing spondylitis
- reactive arthritis
Which gene may be involved in ankylosing spondylitis
HLA B27 gene (90%)
which joints are mainly involved in ank spond
- sacroiliac joints
- joints of the vertebral column
Typical presentation of ank spond
- young adult male, late 20s
- dev of symptoms >3 months
- Lower back pain & stiffness
- Sacroilliac back pain
- Worse on rest, improves with movement
- Pain worse at night and may wake patient
- Stiffness >30 minutes
What other features can indicate ank spond
- Anterior uveitis
- Weight loss, fatigue
- Chest pain related to costovertebral and costosternal joints
- Enthesitis
- Restrictive lung disease: restricted chest wall movement
- Pulmonary fibrosis at the upper lobes 1% of AS patients
- IBD
What is Schober’s test
- Assess’ spine mobility
- L5/dimples of venous, mark 10cm above, 5m below then patient bends forwards
- If distance between dots is <20cm indicates reduction in movement of lumbar spine
What investigations should you complete if suspecting ank spond
- Inflammatory markers (CRP and ESR)
- HLA B27 genetic test
- Xray of the spine and sacrum
- MRI of the spine can show bone marrow oedema early in the disease before there are any xray changes
What may you see on XRAY in a patient with ank spond
- ‘Bamboo spine’
- Squaring of the vertebral bodies
- Subchondral sclerosis and erosions
- Syndesmophytes
- Ossification of the ligaments, discs and joints.
- Fusion of the facet, sacroiliac and costovertebral joints
What are syndesmophytes
areas of bone growth where the ligaments insert into the bone. They occur related to the ligaments supporting the intervertebral joints.
What medications are used in Ank spond
- NSAIDs
- Steroids can be use during flares to control symptoms.
- Anti-TNF medications
- Secukinumab is a monoclonal antibody against interleukin-17. only if response to above inadequate.
What other management other than medications should be given to patients with ank spond
Physiotherapy Exercise and mobilisation Avoid smoking Bisphosphonates to treat osteoporosis Treatment of complications
What is reactive arthritis (Reiters Syndrome)
- synovitis occurs in the joints as a reaction to a recent infective trigger
- Acute monoarthritis
- seronegative spondyloarthropathy
- link with the HLA B27 gene
What is the presentation of Reactive arthritis
- Warm, tender, swollen joint
- Following infection
- RULE OUT SEPTIC ARTHRITIS
What type of infection does reactive arthritis tend to follow
- gastroenteritis
- Chlamydia
What other common associations are there with reactive arthritis
- Can’t see, can’t pee, can’y climb a tree
- Bilateral conjunctivitis (non-infective)
- Anterior uveitis
- Circinate balanitis is dermatitis of the head of the penis
What is the management of reactive arthritis
- NSAIDs
- Steroid injections into the affected joints
- Systemic steroids (multiple joints)
- Most resolve within 6 months and don’t recur.
- Recurrent: may require DMARDs or anti-TNF medications.
