Case 1: RA Flashcards
What is the most common form of chronic inflammatory arthritis that can result in joint damage and physical disability?
RA
T/F: RA is a systemic disease with a lot of extra-articular manifestations?
True
Risk factors for RA
- Genetics
- F >> M
- Smoking
- Peak incidence 25-55 (females of childbearing age)
Risk factors Genetics
HLA-DRB1 genes “shared epitope”
Risk factors Gender
Estrogen is a component of creating TNF (inflammatory response)
Pathophys: What tissue is the main target for RA autoimmune process?
Synovial tissues
Pathophys: What is a pannus formed from?
- Synovial proliferation
- Pannus invades & destroys bone and cartilage
Pathophys: What is the preclinical stage?
- Breakdown of self-tolerance
- RA and anti-CCP are detected years before manifestations of RA occur
Clinical Manifestations Joints
- Insidious onset
- Morning stiffness > 30 mins (also after prolonged inactivity)
- Symmetric swelling
- Many joints (tender/painful)
What are the joints that are most affected in RA?
- PIP
- MCP
- MTP
- (also wrists, ankles, knees)
Clinical Manifestations Hands
- Ulnar deviation of MCP joints
- Swan neck deformity
- Boutonniere deformity
Describe a Swan neck deformity
Hyperextension of PIP, flexion of DIP
Describe a Boutonniere deformity
Flexion of PIP, extension of DIP
Clinical Manifestations General
- Fatigue
- Weight loss
- Low grade fever
Clinical Manifestations Rheumatoid Nodules
- Almost only in those who are RF positive
- Often on extensor surfaces (forearms), over joints, pressure points
- Firm, non tender
- in lungs, sclerae, other tissues
Clinical Manifestation Vasculitis
- Attacking blood vessel
- Anything from small lesions to large bruises
What is the most common ocular clinical manifestation?
Keratoconjunctivitis sicca (2/2 Sjogren syndrome, could also include xerostomia, dry eye)
What is the most common pulmonary clinical manifestation?
Pleuritis (arthritic CP, dyspnea)
Clinical Manifestations Cardiac
- Chronic inflamm increasese risk for CV dz
- Pericardial effusions
- Pericarditis
Felty Syndrome Triad
- Splenomegaly
- Neutropenia
- could be asympto or have recurrent bacterial infxn
- RA
- seropositive, erosive, severe
SANTA?
- Splenomegaly
- Anemia
- Neutropenia
- Thrombocytopenia
- Arthritis
What 4 specific labs should you order for RA?
- Anti-CCP
- RA(RF)
- ESR
- CRP
What is the most specific bloodwork for RA?
Anti-CCP antibodies (95% specific)
What percentage of RA patients are RF positive?
80%
What percentage of RA patients are seronegative?
About 15%
T/F: ESR/CRP will be normal in RA patients
False - elevated
What else might you see on lab results for RA?
- Mild anemia
- Thrombocytosis
- WBC nl/mild
- Leukocytosis (platelets can be inc or dec)
What might you see with the synovial fluid of a RA patient?
- inflammatory effusion
- Leukocytes (1500-25k)
- PMNs predominate
T/F: Radiographs in early stages of disease will likely be normal
True
What will you see on radiographs initially?
- Soft tissue swelling
- Osteopenia around joint
- Earliest changes show in wrists or feet
What will you see on radiographs later in the RA dz process?
- Joint space narrowing and erosions
- MRI or U/S can be used
American College of Rheumatology 2010 Classification Criteria Summary and Takeaways?
- Must get a score of at least 6
- Get most points for involvement of small joints
- Do not need RF to make Dx
- Duration > 6 wks
Criteria for the Dx of RA?
- Inflammatory arthritis involving > 3 joints
- Positive RF and/or anti-CCP
- Elevated ESR and/or CRP
- Duration of > 6 wks
- Excluded other causes (osteomyelitis, SLE)
What if a patient is seronegative? How do you Dx RA?
If seronegative - can still Dx RA if you have excluded other causes and all other characteristics are met
What are the treatment goals for RA?
- Control pain and inflammation
- Preserve function
- Prevent deformity
- Early Dx and initiation of DMARDs (Dz Modifying Anti-Rhematic Drugs)!!
- Rheumatologist involvement
- infusions, multiple meds
T/F: RA patients often just need monotherapy of DMARDs
False - often need combination of DMARDs
(MTX + TNH inhibitor) MC
Pretreatment Screening
- Hep B & C
- Baseline CBC, Cr, LFTs, ESR, CRP
- Ophthalmic screening (eye toxicity)
- Hydroxycholorquine MC S/E
- Check for Latent TB
- R/O pregnancy
- Baseline radiographs
What medication is used for symptom relief but doesn’t alter the disease course of RA?
NSAIDs - all are about equal
(NOT for monotherapy)
What medication is very helpful for both sx relief and slowing the rate of joint damage?
Corticosteroids
(NOT for monotherapy or long term use!)
What medication is a good choice to use to bridge while starting a DMARD?
Corticosteroids
Start Prednisone 5-20mg QD (depending on severity)
Taper as soon as possible
If the patient has sever RA what DMARD should be started?
Biologics (TNF Inhibitor):
- Etanercept (Enbrel)
- Infliximab (Remicade)
- Adalimumab (Humira)
What are some conventional DMARDs?
- Methotrexate = MC
- Sulfasalazine
- Hydrocychloroquine
- Leflunomide
Starting dose for Methotrexate?
7.5mg PO weekly
Usually note improvement within 2-6 wks
Contraindications for Methotrexate?
- Pregnancy (teratogenic)
- Liver dz
- Heavy EtOH
- Severe renal impairment
Methotrexate S/E?
- GI upset
- Stomatitis
-
Need close monitoring: CBC (cytopenias) - watch for suppression of bone marrow
- LFT’s for hepatotoxicity
What should be given with every patient on Methotrexate?
- Folic acid 1 mg PO QD OR
- Leucovorin Ca+ 2.5-5mg weekly
- To prevent hematologic and other S/E
TNF Inhibitors
- REFER to Rheum
- SQ or IV (infusion)
- Expensive!!
- Well tolerated - low S/E
- Much higher risk of serious bacterial infxn
- granulomatous infxn (esp reactivation of TB)
What MUST you screen for prior to starting TNF Inhibitors?
Latent TB
What is the TNF Inhibitor of choice?
Etanercept
Follow Up
- Assess sx and functional status at all visits
- Monitor lab work for dz activity and potential toxicities of medication
- Follow radiographs q 2 yrs
Prognosis?
- Prior to MTX - very poor morbidity, mortality, and financial loss
- With successful tx: less deformity, joint SX, morbidity, mortality
- Pts will have dz flares
- Higher motality with RA attributed to CV dz from chronic inflammation
What are poor prognosis factors?
- RF or anti-CCP positive
- Extra-articular dz
- Functional limitations
- Erosions on radiograph
What are the 4 categories for the scoring of RA?
- Joint involvement (tender/swollen)
- Serology
- Acute-phase reactant
- Duration of sx
