History for inflammatory arthroses Flashcards
- Describe features of the history that help to distinguish an inflammatory from non-inflammatory arthritis - Demonstrate an understanding of the importance of extra-articular manifestations in systemic disease - Assess the impact of a disability (i.e. physical impairment) on activities of daily living (functional history)
What is a key feature of inflammatory arthritis? What does it indicate?
Early morning stiffness (EMS)
- improves with activity
- length of EMS indicative of disease activity (several hours = very active disease)
5 key features to think about when taking a history for RA:
- Onset of disease
- Subsequent course
- Extra-articular manifestations
- Management
- Current state
Questions regarding onset of disease: (3)
- Did the symptoms manifest suddenly or gradually (insidious)?
- How many joints are affected? (polyarticular, oligoarticular, monoarticular)
- Any associated systemic features? (fever, weight loss, fatigue)
What is the typical course of RA?
- typically flares & remissions, lasting weeks to months
- can also have chronic course with cumulative deformity
Does RA only affect small joints, like MCPs and PCPs?
No, can affect larger joints too.
- elbow, shoulder, hip, knee, etc.
5 extra-articular manifestations of RA & other AA diseases:
- eye diseases
- skin disease
- lung disease
- neurological disorders
- nodules
Which eye diseases are associated with AA disease? (2)
- sicca symptoms (dry eyes/mouth)
- inflammatory eye disease (uvetis, scleretis)
Which skin diseases are associated with AA disease? (3)
- leg ulcers (RA)
- psoriasis (psoriatic arthritis)
- malar or photosensitive rash (SLE)
Where can nodules appear in AA disease?
- subcutaneous
- in organs (heart, lungs)
What type of lung disease is common in pts with RA? What signs should we look out for?
Interstitial lung disease
- seen in RA, SLE & systemic sclerosis
- look for SOB & cough
Which neurological changes should we look out for in pts with AA disease?
Sensory and/or motor changes from involvement of nerves supplying upper/lower limbs.
Your patient has RA. What are the 4 main categories of management for RA?
- NSAIDs
- corticosteroids
- disease-modifying drugs
- surgical management
What are the two main categories of NSAIDs? What should you consider before prescribing them to your pt with RA?
- non-specific and selective (COX-2 specific)
- ask them if they have any history of peptic ulcer disease
Why should you ask about peptic ulcer disease before prescribing NSAIDs?
Non-specific NSAIDs (ibuprofen, naproxen, diclofenac, ketorolac) block PGE2 production
- PGE2 important for mucosal health and bicarbonate secretion in GI tract
- ∆ NSAIDs will worsen peptic ulcer disease
Where do corticosteroids fit in the treatment plan for RA?
- typically used in early treatment to control inflammation
- some pts remain on low-dose corticosteroids long-term
What should you ask your pt if they report having used corticosteroids for their treatment of RA?
- how long they have been using them and what dose
- if they’re experiencing effects of long-term corticosteroid use (diabetes, osteoporosis)
What are the 3 classes of disease-modifying anti-rheumatic drugs (DMARDs)?
- conventional synthetic DMARDs (csDMARDs)
- targeted synthetic DMARDs (tsDMARDs)
- biological DMARDs (bDMARDs)
4 examples of csDMARDs:
- methotrexate
- sulfasalazine
- leflunomide
- hydroxychloroquine
What’s the first-line DMARD for RA? What does it do?
Weekly dosage of methotrexate
- broad immunosuppressive action to mitigate disease progression
Are csDMARDs, tsDMARDs and bDMARDs equally plausible forms of therapy for RA?
No
- we always start treatment with csDMARDs
- if there is no response to any of these treatments, then we can try out a tsDMARD or bDMARD
Regardless of the DMARD being used, you should always ask the pt about…
Any side effects they’re experiencing from their treatment.
What is the final option for RA treatment (in eligible pts)?
Surgery
- typically joint replacement
How do we assess the current state of our pt with RA? (3)
- assess activity of disease (early morning stiffness good indicator)
- identifying joints affected
- acknowledge how disease is affecting their ADLs and instrumental ADLs
