Gout, rheumatoid arthritis and osteoarthritis [completed] Flashcards
What is gout?
Increases levels of plasma uric acid leading to the deposit of monosodium urate crystals in joints and tissues.
Split into secondary and primary.
What age group is gout more likely in?
Those over 45
Is gout more common in males or females?
Males
What are some risk factors for Gout?
Diet (Red meat and seafood)
Obesity
Alcohol Intake
Genetic predisposition
What medicines can cause secondary gout?
Thiazide and loop diuretics, ciclosporin, levodopa
Gout can be secondary to what other medical conditions?
Renal disease
Diabetes
Hypertension
Dislipidaemia
What joints does gout primarily affect?
Joints in the extremities usually the BIG TOE - lower temperatures in the extremities allow urate to precipitate from plasma.
What are the clinical features of gout?
Acute attack in extremities - most commonly in big toe then ankles and knees
Very painful, hot, red and shiny
Development of tophi
Fever, elevated ESR and prodromal symptoms (nausea, change in mood, loss of appetite)
What are tophi?
bumps of yellow urate under the skin
can take years to develop
How is gout diagnosed?
Gout should be suspected in anyone with:
Rapid onset of overnight pain with redness and swelling in toe knuckles (metatarsophalnageal joints)
Serum urate should be measured:
Urate levels of 360micromol/L or 6mg/L = very likely to be gout
If urate is below this then repeat the test at least 2 weeks after flare has settled.
What else can be used to diagnose gout?
Joint aspiration and microscopy of synovial fluid
x-ray
Ultrasound
CT
How is an acute attack of gout treated?
NSAID, colchicine or a SHORT COURSE of an oral corticosteroid.
What should you do if an NSAID or colchicine are unsuitable or ineffective in a gout flare?
Intramuscular or intraarticular corticosteroid injection
When can Canakinumab (IL-1 inhibitor) be given during a gout flare?
On referral to a rheumatologist, when NSAIDs, colchicine and corticosteroids and unsuitable or ineffective
What non drug advice can be given to patient to manage a gout flareup?
Applying ice packs to the affected area may help to alleviate pain alongside taking prescribed medicine.
How soon after an acute attack should urate lowering therapies be started?
2 to 4 weeks after flare has settled.
Who should a urate lowering therapy be offered to?
multiple or troublesome flares
CKD stages 3-5
People on diuretic therapies
If person has tophi
If person has chronic gouty arthritis
What are the two first line ULTs?
Allopurinol or febuxostat
In people who have gout and major CVD which ULT should be offered?
Allopurinol
What is second line treatment if the first ULT is not tolerated or ineffective?
Swap to the other ULT
The usual target serum urate in people starting ULTs is 360micromol/L or 6mg/dL. When would this target be even lower?
If person has tophi or chronic gouty arthritis.
What should be offered alongside starting a low-dose ULT and why?
Colchicine until target serum urate levels have been reached - as ULTs can sometimes cause acute attacks.
If colchicine is not suitable then consider LOW DOSE NSAID or LOW DOSE ORAL CORTICOSTEROID
If prescribing NSAIDs for gout what else may need to be given?
PPI for gastroprotection
What should a patient do if they experience a rash whilst taking allopurinol?
Stop taking it immediately and let their doctor know - may be Stevens-Johnson syndrome
What can be done if the rash from allopurinol is only mild?
It can be gradually reintroduced but should be stopped if rash recurs
If patient has a prior history of hypersensitivity to allopurinol there is also a risk of….
rash and hypersensitivity to febuxostat. Stop taking if these symptoms occur.
How often should a person taking a ULT have their serum urate checked?
every year
If a person is on allopurinol or febuxostat should they stop taking it during attacks?
No
What self care-advice can be offered to patients with gout?
- Limiting purine intake (seafood, red meat, pork)
- No more than 14 units of alcohol a week
- Drink a lot of water
- Lower BMI
What is rheumatoid arthritis?
An overreaction of the immune system causing the release of inflammatory cells within a joint –> releases cytokines which causes activity of proteolytic enzymes and destruction of bone and catilage
Who is at risk of rheumatoid arthritis?
Females
Peak age is people in 40s to 50s but can occur in children (juvenile)
Genetics - HLA-DR4 gene
Smoking is a risk factor
What are some clinical features of rheumatoid arthritis?
Joint pain
Swelling
Lasts longer than 6 weeks
Symmetrical
Stiffness in the morning > 30 minutes
Fever, weight loss, fatigue and depression, depression
Rheumatoid nodules/deformity
Raised CRP and ESR
Raised rheumatoid factor (60-70%) but NOT DEFINITIVE
What is swan neck?
Deformity in the hands due to RA causing twisting of the fingers and joints
What joint may be spared in RA in the hands?
Distal joints - first knuckles in finger
How can RA be diagnosed/what baseline test ?
FBC - signs of anaemia
CRP or ESR - inflammatory markers BUT NOT DEFINITIVE
U & Es - will be affected by treatment
LFTs - may have increases in ALP and GGT
Rheumatoid Factor - only 60-70% of patients BUT NOT DEFINITIVE
Specific antibodies
- anti CCP: more sensitive and specific than RF
- Antinuclear antibodies
Imaging (looking for synovitis or if lungs affected)
What kind of anaemia is commonly seen in rheumatoid arthritis?
Normochromic normocytic - RBC still the same size and colour
How can we differentiate between iron deficiency anaemia and anaemia of chronic disease?
Serum ferritin is normal/high in chronic disease
Serum transferrin is normal/low in chronic disease
Total iron binding capacity is LOW in chronic disease
What is the role of hepsidin in anaemia of chronic disease?
Chronic inflammation –> more IL-4 released –> more hepsidin released from liver
–> less iron absorbed from gut –> reduction in release of iron stores in body
What is the aim of treatment in RA?
“treat to target strategy”
- Treating active RA with the aim of achieving remission or low disease activity.
How should disease activity/remission be measured in adults with active RA?
DAS28
Measure CRP
What is the first line treatment for RA?
monotherapy with a conventional DMARD such as methotrexate, sulfasalazine, leflunomide.
If these are not suitable consider hydroxychloroquine.
Escalate dose as tolerated and monitor response.
When should monotherapy with a cDMARD be started after onset of RA?
As soon as possible and ideally within the 3 months
What can be given as short term bridging treatment when starting a cDMARD for RA?
glucocovrticosteroids - oral, IM or intra-articular
If treatment target is not achieved with monotherapy and dose escalation, what is given next?
combination cDMARDS
What is given in active RA when disease has responded inadequately to combination of cDMARDs? (DAS score = 5.1+)
Biological DMARDS: sarilumab, adalimumab, etanercept, infliximab
+/- methotrexate
What is the aim of patient access schemes?
Manufacturers agree on a discount with NHS - biological DMARDs given at a lower cost AS THIS IS A CRITERIA FOR STARTING PATIENTS ON BIO DMARD
What is the criteria for treatment with a biological DMARD to be continued?
moderate response after 6 months of treatment (EULAR)
If a biological DMARD with or without methotrexate is ineffective, what may be given?
Rituximab and methotrexate
If rituximab and methotrexate is ineffective, what may be given?
methotrexate + sarilumab or tocilizumab
What is given for symptom control in rheumatoid arthritis?
NSAIDs (with PPI)
glucocorticoids during flare ups
What needs to be considered when choosing a DMARD?
Patient preference
Co-morbidity
Tolerance - although most DMARDs are similar in efficacy, methotrexate and sulfasalazine are better tolerated
What is the DAS-28 score?
Disease activity score
Looks at how many joints affected by RA, ESR, CRP and how patients day to day activities are affected.
What is the 28 for in DAS-28?
The number of joints that are looked at
What does a score of 5.1 on the DAS-28 suggest?
Severe RA - if patient is on cDMARD combination and score is 5.1 may be eligible for a biological DMARD
What is the HAQ used for in RA?
Health assessment questionnaire:
- looks at effect of RA on day to day activities and to what extent - without any difficulty, some difficulty, much difficulty, cannot do at all
What should be done after 6 months of starting therapy with a biological DMARD?
Redo DAS-28 and compare to before starting. if less than <0.6 difference there has not been an improvement?
What are some key counselling points for methotrexate?
7.5mg Taken ONCE A WEEK
- common side effects: nausea, loss of appetite, hair loss
- red flags: jaundice, signs of infection, pulmonary toxicity, oedema, urine changes, bleeding
- SUN SENSITIVITY - use spa 30 and try to stay out of the sun
- Monitoring: RBC, liver, kidney function every 2-3 months
- Folic acid may be needed taken on a different day to methotrexate
- over 2 days late with dose speak to doctor
What are some key counselling points for sulfasalazine?
- started on 1 500mg tablet od
- Sulfasalazine can turn urine orange but this is harmless
- common side effects: Gi disturbances, dizziness, headaches, changes in taste
- red flags: lung, kidney toxicity, infections, chest pain
- Monitoring: regular FBC, LFT and kidney
What are some counselling points for azathioprine?
- Usual dose is 1-3mg a day
- Monitoring: regular FBC, LFT and kidney at least once a week for first 8 weeks
- Sun senstivity - SPF 30 and avoid if possible
- Risk of infections
- speak to doctor or pharmacist if over 2 doses missed
- Call 111 if you take too much
- Nausea is a common side effect
- Red flags: vomiting, diarrhoea, kidney problems, hypotension, bleeding or bruising
What are some key counselling points for ciclosporin?
1.5 mg/kg twice daily if taken alone
- Speak to a doctor if you take too much
- FBC, LIVER AND KIDNEY every 3 months
- Risk of infection (may need preventative treatment if near someone with chickenpox), metallic taste, tremor
What should not be given OTC if a person is on methotrexate?
NSAIDS
Self-care advice for RA?
Yearly flu and pneumococcal vaccines
Healthy balanced diet
Low impact, non-contact exercises such as swimming, cycling or aqua aerobics.
National Rheumatoid Arthritis Society local support groups
What is osteoarthritis?
It is when there is a quicker breakdown than production in the joints leading to the loss of cartilage around a joint. Bone outgrowths occur at joint margins and joints harden - deformity of joints
What are the risk factors for Osteoarthritis?
Age (more common in older people)
Obesity (biggest modifiable risk factor)
Genetic component (especially in females and if in hands)
Trauma or injury
Why is obesity a risk factor in OA?
Weight puts more strain on the joints
What are the clinical features of osteoarthritis?
Pain that increases with activity, movement and loading of a joint
Pain may radiate beyond the joint
Stiffness in the morning but gets better after 30 mins (after moving)
Joints are deformed
Most likely to affect hands
How is OA diagnosed?
Clinically / imaging not needed
What are the core treatments in OA?
Therapeutic exercise and weight management
What exercise should be considered in managing osteoarthritis?
muscle strengthening and general aerobic fitness. Aim to keep mobile and use joints as often as possible instead of allowing seizing up.
What should patients be advised when starting exercise for OA?
May cause pain/discomfort but will help joint pain and function in long term
What effect will weight management have on OA?
improve quality of life
improve physical function
reduce pain
Any weight loss is likely to be beneficial
What else should patients be provided alongside exercise and weight management in OA?
Information and support - should be accessible to the patient and should be signposted to other resources
What adjunct therapy may people with OA benefit from?
DEVICES
- walking aids if lower limbs affected
Manual therapy/physio
- for hip and knee
What non-drug treatments should NOT be offered to people with OA?
acupuncture
dry needling electrotherapy
routine use of insoles, braces tape and splints or supports
What pharmacological management can be offered alongside non-pharmacological treatment in OA?
offer topical NSAID if knee is affected and consider for other joints
Use an oral NSAID if topical is ineffective or unsuitable (give PPI or h2 antagonist as well)
Intra-articular corticosteroids may be considered if medication is ineffective or unsuitable or to support exercise.
What medications should not be offered to patients with OA?
- routine paracetamol or weak opioids unless used infrequently or others are ineffective
- glucosamine
- strong opioids
- intra-articular hyaluronan injections
