Arthritis - Part 1- Exam 2 Flashcards
_____ is the MC form of joint disease mainly affecting ____ populations. 90% of all patients will have radiographic evidence of arthritis in weight bearing joints by age ____
Osteoarthritis (OA)
aging
90% by age 40
What are risk factors for arthritis?
Age
Obesity
Genetics
Anatomical factors including joint shape and alignment
Joint Injury
Competitive contact sports
Jobs requiring frequent bending and carrying
Gender
OA of the hands and knees is more common in _____
more common in women
What does the pathogenesis of OA involve?
degeneration of cartilage and hypertrophy of bone in the articular margins
What are hypertrophy of bone in the articular margins called?
Osteophytes
What does OA result from?
Results from altered mechanics within the joint from repeated trauma or gait abnormalities
inflammation
loss of estrogen
Why do osteophytes develop in the articular margins?
develop at the side of bone because of increased pressure
What is the timing for OA? How does it progress?
Onset of symptoms is insidious, damage usually occurs over many years
typically progresses from symptomatic pain, to physical findings, to loss of function
**What makes OA pain worse? **What makes it better?
**patients will have pain on motion of the affected joint that is made worse by activity or weight bearing and relieved by rest
**What makes RA pain worse? What makes it better?
**RA pain gets worse with rest (think severe AM stiffness) and getter with activity
What 2 findings are common with OA?
usually have some decreased ROM and may have crepitus over the knee
What are Heberden nodes and Bouchard nodes?
bony enlargement of DIP= Heberden nodes
bony enlargement of PIP = Bouchard nodes
Which is more common in RA, Heberden or Bouchard nodes? Which one indicate more severe arthritis?
Bouchard nodes indicate more severe arthritis and are more typically seen in RA
Will OA cause an increase in ESR? What will the synovial fluid analysis reveal?
OA does not cause an elevation in ESR
Synovial fluid analysis is noninflammatory
**Draw the synovial fluid analysis chart
What will xrays show in a pt with OA?
May show narrowing of the joint space, osteophyte formation and lipping of marginal bone, and thickened, subchondral bone
What is the tx for OA?
braces/compression sleeves
regular exercise programs
weight loss
NSAIDs (oral and topical)
What are the 2 topical forms of NSAIDs? What are the preferred oral NSAIDs?
Voltaren gel (Now OTC) / Pennsaid
meloxicam (Mobic) 7.5mg - 15mg PO daily
because it is long acting and you only have to take
Can topical NSAIDs be used in combination with Coumadin?
YES! safe to use with coumadin
What are the risk factors for NSAIDs toxicity?
Risk factors include long-term use
higher NSAID dose
concomitant corticosteroids or anticoagulants
RA
hx of PUD
alcoholism or age > 70
What are the risk factors for NSAIDs induced renal toxicity?
Risk factors include age > 60
history of CKD
heart failure
ascites
diuretic use
What PO NSAID are safe to use in combo with coumadin?
celebrex
What are the sx/injectable options for OA?
Intra-articular Steroids
Hyaluronic acid
joint replacement
When is surgery indicated for OA?
Indicated for patients with severe OA that restricts walking or causes pain at rest
What is the underlying reason that hyaluronic acid injections works as tx for OA? How long do they last for?
series of injections into the joint → increasing the viscosity of the synovial fluid, which helps lubricate, cushion and reduce pain in the joint
increase in effectiveness over the course of four weeks, reaching a peak at eight weeks
Where is natural hyaluronic acid obtained from?
vitreous solution of roosters and bovine
What is the underlying dz process in gout?
Gout is a metabolic disease associated with abnormal amounts of urates in the body
Hyperuricemia (serum uric acid level > 6.8 mg/dL) is due to overproduction or underexcretion of uric acid, or both
What are the 2 classifications of gout?
Primary gout
secondary gout
Is gout usually one joint or many? What is considered hyperuricemia? What joint is most commonly affected by gout?
usually monoarticular
serum uric acid level > 6.8 mg/dL)
MTP joint of the great toe
______ gout has a heritable component and affects genes whose products regulate urate handling by the kidney. What are the MC pt population?
Primary gout
90% of patients with primary gout are men > 30 yrs old
_____ gout is related to acquired causes of hyperuricemia
secondary gout
What are some common causes of gout? What is a super important history question?
alcohol
excessive dietary purine ingestion
fasting for medical procedure
fructose
diuretics
cyclosporine or tacrolimus
levodopa
any new medications recently?
What is the characteristic lesion of gouty arthritis? What is it composed of?
tophus: a nodular deposit of monosodium urate crystals with an associated foreign body reaction
Name some common places tophi can be found? How common are uric acid kidney stones in a pt with gout?
Tophi are found in cartilage, subcutaneous and periarticular tissues, tendon, bone, kidneys
Uric acid kidney stones are present in 10% of patients with gout
How will gouty arthritis present? Besides the great toe, what additional joints are commonly affected?
is sudden onset and frequently nocturnal, usually just one joint but if more than one, will be asymmetrical
Feet, knees and ankles
What 2 joints are rarely affected in gouty arthritis? What happens as the attack progresses? What will the affected joint look like?
Hips and shoulders
pain intensifies
Joint is swollen and exquisitely tender and the overlying skin tense, warm, and dusky red
Where are some common locations to have chronic tophi?
external ears, feet, olecranon and prepatellar bursae, and hands
Does uric acid always have to be elevated in a gout attack?
No! will be elevated in 95% of patients but a single uric acid can be normal in 25% of cases
**What will the joint fluid analysis show in a gout attack?
Joint fluid analysis demonstrating sodium urate crystals (needle-like and negatively birefringent with light microscopy) is diagnostic
What is a late xray finding in gouty arthritis?
Later, radiographs demonstrate punched-out erosions with an overhanging rim of cortical bone (“rat bite”)
will be normal early
Do you need to treat asymptomatic hyperuricemia?
NO! Should not be treated, unless arthritis, renal calculi or tophi become apparent
What are some food that have high purine content?
anchovies
herring
kidney
liver
mackerel
meat extracts
mincemeats
mussels
sardines
yeast
beer
whiskey
What is the tx for an acute gouty attack?
NSAIDs for 5-10 days (naproxen or indomethacin)
colchicine 1.2mg
corticosteroids for pt who cannot take NSAIDs
_____ MOA Mechanism unknown - thought to Interfere with inflammasome complex present in neutrophils and monocytes preventing activation of interleukin-1beta (IL-1), which is thought to mediate some gout symptoms
Colchicine
What are the SEs of cochicine? What are the monitoring parameters?
GI effects (diarrhea, nausea, cramping, abdominal pain, vomiting)
CBC, renal and hepatic function tests
______ Often give dramatic symptomatic relief in acute episodes of gout and will control most attacks and are most useful for patients with contraindications to NSAIDs. Can also try ______, if monoarticular
Corticosteroids
intra-articular injection of triamcinolone is very effective
Triamcinolone vs Methylprednisolone, which is more likely to lead to bursitis
Triamcinolone has a higher likelihood of crystalizing and lead to bursitis
What are some pt education points that will help manage gout between attacks?
Avoid excessive alcohol consumption
Avoid foods with high purine content
High water intake
avoid thiazide and loop diuretics
avoid niacin
_____ is used as an urate-lowering therapy for gout as management in between attacks. When is it indicated? What is the serum acid level goal?
allopurinol
Indicated for frequent acute arthritis (2 or more per yr), tophaceous deposits, or CKD (stage 2 or worse)
below 6 mg/dL
_____ MOA lowers plasma uric acid level by blocking the xanthine oxidase, the enzyme responsible for the conversion of hypoxanthine to xanthine to uric acid. What drug class?
Allopurinol
Xanthine oxidase inhibitors
____ occurs in 2% of starting allopurinol of cases, usually within the first few months of therapy. Describe it
Hypersensitivity
Most commonly presents as a rash that may progress to toxic epidermal necrolysis associated with vasculitis and hepatitis
______ have been reported during the early stages of allopurinol use. How do you combat this?
Acutegoutattacks
anti-inflammatory prophylaxis is generally recommended for 3 to 6 months to reduce the risk of gout attacks
aka prophylax with NSAID, steroid or colchine
What pt population should you NOT use febuxostat (Uloric) in?
pts with established CV dz due to higher rates of CV death when compared to allopurinol
When should febuxostat (Uloric) be used?
Febuxostat should only be used in patients who have an inadequate response to a maximally titrated dose of allopurinol, who are intolerant to allopurinol, or for whom treatment with allopurinol is not advisable
Is febuxostat or allopurinol more likely to cause kidney stones?
allopurinol is MORE likely to cause kidney stones than febuxostat
_____ MOA lowers serum uric acid levels by blocking the tubular reabsorption of filtered urate, thereby increasing uric acid excretion by the kidney. What is the serious adverse reaction?
Probenecid
aplastic anemia (think hem conditions)
When is probenecid used? When is it CI?
Acceptable alternative when xanthine oxidase inhibitor cannot be used OR in combination when the xanthine oxidase inhibitor fails to reach serum uric acid levels as monotherapy
CI: Should not be used in patients with creatinine clearance < 50 mL/min
What causes resorption/shrinkage of extensive tophi?
allopurinol or febuxostat so that requires maintaining a serum uric acid level below 6 mg/dL
_____ Calcium pyrophosphate deposition (CPPD) in fibrocartilage and hyaline cartilage can cause an acute crystal-induced arthritis
Pseudogout
What is chondrocalcinosis? What age range?
CPPD can also be an asymptomatic condition detected incidentally on radiographs
Calcium pyrophosphate deposition (CPPD)
Most often seen in patients > 60 yrs old
What is pseudogout characterized by? What 2 joints? What can you see on xrays?
Characterized by acute, recurrent arthritis involving large joints, most commonly the knees and wrists
Almost always accompanied by radiographic chondrocalcinosis= Calcium pyrophosphate deposition (CPPD)
**What will joint fluid analysis of pseudogout reveal?
**Joint fluid analysis demonstrates positive birefringent rhomboid-shaped crystals
What is the tx for pseudogout? _____ is more effective for prophylaxis
NSAIDs
colchicine: more effective for prophylaxis
Methylprednisolone injections
What is RA? What sex is MC? What are the peak onsets for both sexes?
RA is a chronic systemic inflammatory disease whose major manifestation is synovitis of multiple joints
3x more common in women
40s - 50s for females
60s - 80s for males
What is the pathologic findings in the joint for RA? What is the predominate feature?
include chronic synovitis with formation of a PANNUS, which erodes cartilage, bone, ligaments and tendons
synovitis!!
How will RA present? **What is the highlighted feature? What makes RA better?
Symmetrical swelling of multiple joints with tenderness and pain is characteristic
small joints of the hand/wrist are affected first
can wax and wane with periods of “flare ups”
**Stiffness persisting for >30 minutes to hours is prominent in the AM, and may recur after daytime inactivity
**gets better with activity
What are the MC sites of RA? What are the MC sites?
PIP joints of the fingers, MCP joints, wrists, knees, ankles (think small joints of the hands and wrist are usually affected first)
MTP joints are most common sites
What are 3 complications of RA?
Synovial cysts and rupture of tendons may
Boutonniere deformity and swan neck deformity
Where are common sites to see rheumatoid nodules? How common are they? What do nodules correlate with?
Most commonly occur over bony prominences but also seen in the bursae and tendon sheaths
20% have nodules
Nodules correlate with the presence of rheumatoid factor in serum
What is Felty syndrome?
occurrence of splenomegaly and neutropenia, usually in the setting of severe, destructive arthritis
What 3 organ systems are also involved in RA?
ocular: dry eye (and other mucosal membranes)
lung: Interstitial lung disease
vascular: Small vessel vasculitis can develop and manifests as tiny hemorrhagic infarcts in the nail folds or finger pulps
_____ is the most specific blood test for RA. They are present in ____% of patients. ___ and ____ are typically elevated in proportion to disease activity
Anti-CCP antibodies
70-80%
ESR and CRP levels
Rheumatoid factor is only ___% sensitive in early disease
50%
can occur in other autoimmune disease and in chronic infections, including Hep C, syphilis, subacute bacterial endocarditis, and TB
_____ confirms the inflammatory nature of the rheumatoid arthritis. Why do you need to do this?
Joint fluid analysis
Needed to rule out superimposed septic arthritis, which is a common complication of RA
_____ are most specific for RA and may be normal in the first ___ of symptoms
Radiographic changes
6 months
Where do the earliest radiographic changes of RA occur? Where do later changes of RA happen?
Earliest radiographic changes occur in the hands or feet and consist of soft tissue swelling and juxta articular demineralization
changes of uniform joint space narrowing and erosions develop
What are the primary objectives in treating RA? How do you do this? What is the drug class of choice?
are reduction of inflammation and pain, preservation of function, and prevention of deformity
Early, aggressive intervention is necessary
Disease modifying antirheumatic drugs (DMARDs) should be started as soon as the diagnosis is made and then adjusted with the aim of suppressing disease activity
When are NSAIDs used in the treatment of RA?
NSAIDs provide some symptomatic relief but should not be used as monotherapy, use in combination with DMARDs
When are corticosteroids used in the tx of RA?
Low-dose corticosteroids produce a prompt anti-inflammatory effect and slow the rate of articular erosion
Often used as a bridge to reduce disease activity until the slower acting DMARDs take effect
______ may be helpful if one or two joints are the chief source of pain for RA. How many times a year?
Intra-articular triamcinolone injection
no more than 4 times a year
_____ is the initial DMARDs of choice for RA pts. How long does it take to see a benefit?
methotrexate
generally well-tolerated and provides a beneficial effect in 4 to 6 weeks
What are the adverse effects of methotrexate?
teratogenic: need pregnancy test at baseline with MANDATORY contraception
gastric irritation and stomatitis
pancytopenia
Hepatotoxicity with fibrosis and cirrhosis is a toxic effect that correlates with cumulative dose
What are the monitoring requirements for methotrexate? Should you drink alcohol?
monitor CBC and LFTs at least every 12 weeks
NO! because it already stressed out the liver
Must give _____ when prescribing anyone methotrexate.Why?
Folic Acid supplementation with 1mg PO daily
to decrease the SE profile of methotrexate
What are the SEs of hydroxychloroquine? What is needed before starting medication?
A predominantly restrictive or diastoliccardiomyopathypresenting as heart failure has been reported following long-term use of antimalarials for rheumatic diseases
CBC, LFTs, Renal FCN, Eye exam prior to starting medication
______ is a 2nd line medication in RA. What are the 2 possible SEs?
Sulfasalazine
neutropenia and thrombocytopenia
If you give Sulfasalazine to a pt with G6PD deficiency, what happens? When is it CI?
Causes hemolysis
so a G6PD level should be checked prior to initiating
Contraindicated in patients with ASA allergy
What are the monitoring requirements for a pt on sulfasalazine?
CBC should be obtained every 2 to 4 weeks for the first 3 months and then every 3 months
_____ are frequently added to the RA regimen of a pt who has not responded to methotrexate
TNF Inhibitors
Etanercept (Enbrel)
Infliximab (Remicade)
Adalimumab (Humira)
Golimumab (Simponi)
Certolizumab pegol (Cimzia)
What drug class?
TNF inhibitors
What is the broad overview for RA treatment?
combo of methotrexate with one of the TNF inhibitors
EARLY referral to a rheumatologist is essential for appropriate diagnosis and the introduction of effective therapy
Consider looking at this chart again
**Draw the synovial fluid analysis chart
Which chart does Mellert want us to know??
