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ClinMed Lab II > Case 1: RA > Flashcards

Case 1: RA Flashcards

1
Q

What is the most common form of chronic inflammatory arthritis that can result in joint damage and physical disability?

A

RA

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2
Q

T/F: RA is a systemic disease with a lot of extra-articular manifestations?

A

True

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3
Q

Risk factors for RA

A
  • Genetics
  • F >> M
  • Smoking
  • Peak incidence 25-55 (females of childbearing age)
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4
Q

Risk factors Genetics

A

HLA-DRB1 genes “shared epitope”

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5
Q

Risk factors Gender

A

Estrogen is a component of creating TNF (inflammatory response)

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6
Q

Pathophys: What tissue is the main target for RA autoimmune process?

A

Synovial tissues

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7
Q

Pathophys: What is a pannus formed from?

A
  • Synovial proliferation
  • Pannus invades & destroys bone and cartilage
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8
Q

Pathophys: What is the preclinical stage?

A
  • Breakdown of self-tolerance
  • RA and anti-CCP are detected years before manifestations of RA occur
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9
Q

Clinical Manifestations Joints

A
  • Insidious onset
  • Morning stiffness > 30 mins (also after prolonged inactivity)
  • Symmetric swelling
  • Many joints (tender/painful)
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10
Q

What are the joints that are most affected in RA?

A
  • PIP
  • MCP
  • MTP
  • (also wrists, ankles, knees)
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11
Q

Clinical Manifestations Hands

A
  • Ulnar deviation of MCP joints
  • Swan neck deformity
  • Boutonniere deformity
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12
Q

Describe a Swan neck deformity

A

Hyperextension of PIP, flexion of DIP

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13
Q

Describe a Boutonniere deformity

A

Flexion of PIP, extension of DIP

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14
Q

Clinical Manifestations General

A
  • Fatigue
  • Weight loss
  • Low grade fever
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15
Q

Clinical Manifestations Rheumatoid Nodules

A
  • 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
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16
Q

Clinical Manifestation Vasculitis

A
  • Attacking blood vessel
  • Anything from small lesions to large bruises
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17
Q

What is the most common ocular clinical manifestation?

A

Keratoconjunctivitis sicca (2/2 Sjogren syndrome, could also include xerostomia, dry eye)

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18
Q

What is the most common pulmonary clinical manifestation?

A

Pleuritis (arthritic CP, dyspnea)

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19
Q

Clinical Manifestations Cardiac

A
  • Chronic inflamm increasese risk for CV dz
  • Pericardial effusions
  • Pericarditis
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20
Q

Felty Syndrome Triad

A
  1. Splenomegaly
  2. Neutropenia
    1. could be asympto or have recurrent bacterial infxn
  3. RA
    1. seropositive, erosive, severe
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21
Q

SANTA?

A
  • Splenomegaly
  • Anemia
  • Neutropenia
  • Thrombocytopenia
  • Arthritis
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22
Q

What 4 specific labs should you order for RA?

A
  1. Anti-CCP
  2. RA(RF)
  3. ESR
  4. CRP
23
Q

What is the most specific bloodwork for RA?

A

Anti-CCP antibodies (95% specific)

24
Q

What percentage of RA patients are RF positive?

A

80%

25
Q

What percentage of RA patients are seronegative?

A

About 15%

26
Q

T/F: ESR/CRP will be normal in RA patients

A

False - elevated

27
Q

What else might you see on lab results for RA?

A
  • Mild anemia
  • Thrombocytosis
  • WBC nl/mild
  • Leukocytosis (platelets can be inc or dec)
28
Q

What might you see with the synovial fluid of a RA patient?

A
  • inflammatory effusion
  • Leukocytes (1500-25k)
  • PMNs predominate
29
Q

T/F: Radiographs in early stages of disease will likely be normal

A

True

30
Q

What will you see on radiographs initially?

A
  • Soft tissue swelling
  • Osteopenia around joint
  • Earliest changes show in wrists or feet
31
Q

What will you see on radiographs later in the RA dz process?

A
  • Joint space narrowing and erosions
  • MRI or U/S can be used
32
Q

American College of Rheumatology 2010 Classification Criteria Summary and Takeaways?

A
  • 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
33
Q

Criteria for the Dx of RA?

A
  • 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)
34
Q

What if a patient is seronegative? How do you Dx RA?

A

If seronegative - can still Dx RA if you have excluded other causes and all other characteristics are met

35
Q

What are the treatment goals for RA?

A
  • Control pain and inflammation
  • Preserve function
  • Prevent deformity
  • Early Dx and initiation of DMARDs (Dz Modifying Anti-Rhematic Drugs)!!
  • Rheumatologist involvement
    • infusions, multiple meds
36
Q

T/F: RA patients often just need monotherapy of DMARDs

A

False - often need combination of DMARDs

(MTX + TNH inhibitor) MC

37
Q

Pretreatment Screening

A
  • 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
38
Q

What medication is used for symptom relief but doesn’t alter the disease course of RA?

A

NSAIDs - all are about equal

(NOT for monotherapy)

39
Q

What medication is very helpful for both sx relief and slowing the rate of joint damage?

A

Corticosteroids

(NOT for monotherapy or long term use!)

40
Q

What medication is a good choice to use to bridge while starting a DMARD?

A

Corticosteroids

Start Prednisone 5-20mg QD (depending on severity)

Taper as soon as possible

41
Q

If the patient has sever RA what DMARD should be started?

A

Biologics (TNF Inhibitor):

  • Etanercept (Enbrel)
  • Infliximab (Remicade)
  • Adalimumab (Humira)
42
Q

What are some conventional DMARDs?

A
  • Methotrexate = MC
  • Sulfasalazine
  • Hydrocychloroquine
  • Leflunomide
43
Q

Starting dose for Methotrexate?

A

7.5mg PO weekly

Usually note improvement within 2-6 wks

44
Q

Contraindications for Methotrexate?

A
  • Pregnancy (teratogenic)
  • Liver dz
  • Heavy EtOH
  • Severe renal impairment
45
Q

Methotrexate S/E?

A
  • GI upset
  • Stomatitis
  • Need close monitoring: CBC (cytopenias) - watch for suppression of bone marrow
    • LFT’s for hepatotoxicity
46
Q

What should be given with every patient on Methotrexate?

A
  • Folic acid 1 mg PO QD OR
  • Leucovorin Ca+ 2.5-5mg weekly
  • To prevent hematologic and other S/E
47
Q

TNF Inhibitors

A
  • 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)
48
Q

What MUST you screen for prior to starting TNF Inhibitors?

A

Latent TB

49
Q

What is the TNF Inhibitor of choice?

A

Etanercept

50
Q

Follow Up

A
  • Assess sx and functional status at all visits
  • Monitor lab work for dz activity and potential toxicities of medication
  • Follow radiographs q 2 yrs
51
Q

Prognosis?

A
  • 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
52
Q

What are poor prognosis factors?

A
  • RF or anti-CCP positive
  • Extra-articular dz
  • Functional limitations
  • Erosions on radiograph
53
Q

What are the 4 categories for the scoring of RA?

A
  1. Joint involvement (tender/swollen)
  2. Serology
  3. Acute-phase reactant
  4. Duration of sx

ClinMed Lab II (12 decks)

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