Arthritis Part 1 Flashcards
MC form of joint disease
Mainly a disease of aging
Osteoarthritis
90% of pts will have radiographic evidence of arthritis in wt bearing joints by what age?
40
RF for osteoarthritis
- age
- obesity
- genetics
- anatomical factors
- joint injury
- contact sport
- jobs requiring bending or carrying
- gender
T/F: OA of the hands and knees are MC in men
F - women
pathophys/causes of OA
- degeneration of cartilage and hypertrophy of bone in articular margins (osteophytes)
- altered mechanics within joint (trauma, gait abnmlities)
- inflammation
- loss of estrogen
s/s of OA
- insidious onset
- pain on motion, worse by activity or wt bearing and relieved by rest
- reduced ROM; Crepitus over the knee
- No systemic manifestations
- Mild Joint effusion and other articular signs of inflammation
Bony enlargements of the DIP and PIP are occasionally prominent in OA, what are the terms for these enlargements?
- DIP - Heberden nodes
- PIP - Bouchard nodes
w/u for OA? Findings?
- ESP NOT elevated
- SF analysis - noninflammatory
- XR - narrowing of joint space, osteophyte formation and lipping of marginal bone, and thickened, subchondral bone; bone cysts possible
mgmt for OA
- assistive devices, joint protection
- exercising, losing wt
- acetaminophen, NSAIDs (voltaren/pennsaid, meloxicam)
- intra-articular steroids
- hyaluronic acid
- surgery
MC serious SE of NSAID toxicity
GI toxicity, such as gastric ulceration, perforation and GI bleeding
RF for NSAID toxicity
long-term use, higher NSAID dose, concomitant corticosteroids or anticoagulants, RA, hx of PUD, alcoholism or age > 70
what medication can reduce risk of serious GI effects from NSAIDs when treating OA?
PPIs (omeprazole)
should be used in high-risk pts
ALL NSAIDs can cause ____ toxicity?
RF?
- renal
- age > 60, h/o CKD, HF, ascites, and diuretic use
inc viscosity of synovial fluid = lubricate, cushion and reduce pain in joint
A last resort before surgery and provides symptomatic relief
inc in effectiveness over the course of 4 wks, reaching a peak at 8 wks
which tx for OA?
hyaluronic acid
when is surgery indicated for OA?
severe OA that restricts walking or causes pain at rest
metabolic disease associated with abnormal amounts of urates
Characterized by a recurring arthritis, usually monoarticular
gout
90% of primary gout are what pt demographic?
men >30 y/o
- a characteristic nodular deposit of monosodium urate crystals with an associated FB reaction
- found in cartilage, subcutaneous and periarticular tissues, tendon, bone, kidneys
- seen in chronic or recurrent gout
tophus
- sudden onset and frequently nocturnal
- Precipitated by alc, changes in meds that affect urate metabolism, fasting for procedures
- Joint is swollen and exquisitely tender and the overlying skin tense, warm, and dusky red
gout
what is podagra?
manifestation of gout, in which uric acid crystallizes and settles in one or more joints. - MC MTP joint of big toe
Chronic tophi may be found in what locations?
the external ears, feet, olecranon and prepatellar bursae, and hands
w/u for gout
- serum uric acid
- CBC - inc WBC
- Joint fluid analysis - sodium urate crystals
- XR
joint fluid analysis shows needle-like and negatively birefringent with light microscopy
dx?
gout - sodium urate crystals
late XR finding of gout?
punched-out erosions with an overhanging rim of cortical bone (“rat bite”)
mgmt for asx Hyperuricemia
- Should not be treated, unless arthritis, renal calculi or tophi become apparent
- avoid high purine foods?
mgmt of acute gout attack
- NSAIDs - naproxen
- colchicine
- CS (best if NSAIDs are CI) - methylprednisone/prednisone; TAC injection if monoarticular
- +/- urate-lowering tx
- change diet - avoid excessive alc, purine foods, drink a lot of water
- avoid hyperuremic meds
possible MOA of colchicine?
SE?
- Interfere with inflammasome complex present in neutrophils and monocytes preventing activation of IL-1
- GI upset, gout flare, DIC, neuromuscular dz
hyperurcemic meds?
- thiazide
- loops
- niacin
indications for Urate-lowering Therapy when treating gout?
- Freq acute arthritis (>=2 per yr), tophaceous deposits, or CKD (stage 2 or worse)
- Min goal of serum uric acid < 6
Lower plasma uric acid level by blocking the final enzymatic steps in the production of uric acid
what med?
gout
Xanthine oxidase inhibitors
Allopurinol 1st line
SE of Allopurinol (Zyloprim)
- gout flare
- rash - can progress to toxic epidermal necrolysis assoc w/ vasculitis and hepatitis (rare)
Caution when using Uloric (febuxostat) in patients with what chronic condition?
CV disease - higher rate of CV death compared to allopurinol
Lower serum uric acid levels by blocking the tubular reabsorption of filtered urate, thereby increasing uric acid excretion by the kidney
Probenecid
SE of Probenecid
- Hem&onc: Anemia, aplastic anemia, hemolytic anemia (in G6PD deficiency), leukopenia
- Hepatic: necrosis
- Hypersensitivity
DDI probenecid
Acetaminophen
Resorption of extensive tophi requires maintaining a serum uric acid level below ?
6 mg/dL
mgmt for large tophi
surgery
what is pseudogout?
Calcium pyrophosphate deposition (CPPD) in fibrocartilage and hyaline cartilage can cause an acute crystal-induced arthritis
MC > 60 yrs old
acute, recurrent arthritis involving large joints, MC knees and wrists
Joint analysis shows positive birefringent rhomboid-shaped crystals
XR shows chondrocalcinosis
dx?
pseudogout
mgmt for pseudogout
- NSAIDs; colchicine
- CS - methylprednisone
- CS injections
a chronic systemic inflammatory disease whose major manifestation is synovitis of multiple joints
RA
RA MC in what pt demographic?
- female
- 40-50s (female); 60-80s (male)
pathologic findings in joints of RA
chronic synovitis with formation of a pannus, which erodes cartilage, bone, ligaments and tendons
- Symmetrical swelling of multiple joints with tenderness and pain
- Stiffness for a long period of time prominent in AM; may recur after daytime inactivity
- nodules over bony prominences
- PIP joints of fingers, MCP joints, wrists, knees, ankles, and MTP joints MC
- Synovial cysts and rupture of tendons possible
- deformities possible
dx?
RA
other RA manifestations besides MSK?
- HEENT: Dryness of eyes, mouth and other mucous membranes is found, esp in advanced disease
- Interstitial lung disease: cough and progressive dyspnea
- Pericarditis and pleural disease
- Felty syndrome – occurrence of splenomegaly and neutropenia, usually in the setting of severe, destructive arthritis
- Small vessel vasculitis: tiny hemorrhagic infarcts in the nail folds or finger pulps
w/u for RA
- Anti-CCP ab - most specific
- rheumatoid factor
- ESP & CRP
- CBC
- joint fluid analysis
- XR changes
mgmt for RA
- DMARDs + NSAIDs
- add TNFi if DMARD not enough - CS; TAC injections
Max amount of CS injections that can be done?
RA
4x a year
1st line DMARD?
MTX
SE of MTX
- teratogenic - preg test beforehand + contraceptives during
- gastric irritation, stomatitis
- panctyopenia
- hepatotoxicity w/ fibrosis and cirrhosis
is it ok to drink alc while on MTX?
no!
supplement MTX with?
folic acid 1 mg PO daily
SE of Hydroxychloroquine
cardiomyopathy
2nd line DMARD?
sulfasalazine
SE and CI of sulfasalzine
- Neutropenia and thrombocytopenia; hemolysis if G6PD def
- CI: ASA allergy
Check G6PD level beforehand; monitor w/ CBC q2-4 wks x 3 mo, then q 3 mo
what medication is freq added for RA patients who have not responded adequately to MTX?
TNF inhibitors
a soluble recombinant TNF receptor
Etanercept (Enbrel)
a chimeric monoclonal antibody
Infliximab (Remicade)
a human monoclonal antibody that binds to TNF
Adalimumab (Humira)
a human anti-TNF monoclonal antibody
Golimumab (Simponi)
a PEGylated monoclonal antibody TNF inhibitor
Certolizumab pegol (Cimzia)
which TNF inhibitor is IV infusions?
Infliximab (Remicade)
which TNF inhibitor requires more injections?
Etanercept (Enbrel) - dose 50 mg SQ qweek
which TNF inhibitor requires the least administation?
Golimumab (Simponi) - 50 mg subQ monthly
