inflammatory arthritis Flashcards
Non inflammatory synovial fluid analysis
- fluid
- wbc count
- % PMN
- crystals
- clear
- <2K
- 50%
- no
Inflam/crystals synovial fluid analysis
- fluid
- wbc count
- % PMN
- crystals
- cloudy
- 2k-50K
- > 50%
- (-) birefringent is gout , + birefringent is CPPD
Septic arthritis
- fluid
- wbc count
- % PMN
- crystals
- cloudy/pus
- > 50 K ( bact) , 10-30K ( fungal/mycobact)
- > 75%` ( bact infect)
- +/- ( crystals can co exist )
sero positive chronic inflam arthritis
(SSS-RPDM)
sjogren
slceorderma
systemic lupus erythematous
rheumatoid arthristis
polymyositis
dermatomyositis
mixed connective tissue disease
sero neg chronic inflammatory arthritis (PEAR)
- Psoriatric arthritis
- enteropathic arthritis ( IBD)
- ankylosing arthritis
- reactive arthritis
and the undifferentiated
rheumathoid arththritis diagnosis
ACR/EULAR Classification of RA Score ≥ 6 is Definite RA
A) Joint involvement 0= 1 large joint
1= 2-10 large joints
2= 1-3 sml jts
3= 4-10 sml jts
5= >10 joints, at least 1 small
B) Serology
0 = 2 = 3 =
RF, CCP neg
RF or CCP low positive high positive
C) Acute Phase Reactants
0 = ESR, CRP normal | Abnormal = 1
D) Duration of symptoms
0 = <6wk | 1 = ≥6 week
most common joints in RA , symmetricla or assym ?
symmetrical
small joints
polyarthritis
MCP
PIP
Wrist
which serology has the most sensitivity in RA
anti ccp
95% specificity,can precede arthritis
predicts more erosive disease (in association with smoking = major RF)
XR finding in rheumatoid arthritis
periarticular osteopenia
joint space narrowing
marginal erosions
what’s caplan’s syndrome ?
rheumatoid pneumoconiosis
rare heme conditions in RA ? what’s the triad of sx
Felty syndrome ( ++ prone to infection)
Triad
- sero + RA
- splenomegaly
- neutropenia
lymphoproliferative conditions in RA related to what
EBV or MTX related
what’s one of the earliest sign of RA ?
carpal tunnel syndrome
what’s a lifethreatening presentation in RA
c1-c2 instability/subluxation
other RA extra articular manifestations
- Rheumatoid nodules
- Vasculitis – variable vessel involvement
- Often occurs in “burnt out” disease
- Scleritis/Episcleritis, corneal melt
- Sicca symptoms (dry eyes, dry mouth)
- Raynaud’s phenomenon
- Neutrophilic dermatoses
(eg) Sweet’s Syndrome, Pyoderma gangrenosum
cardiac vs RA
Pericarditis (+/- effusion), myocarditis
* Coronary artery disease (2X risk)
lung vs RA
- Interstitial lung disease (NSIP, UIP)
** Usually anti-CCP positive - Pleural effusion (sterile exudate with low glucose)
- Pulmonary nodules
- Bronchiolitis obliterans
- Caplan’s syndrome: rheumatoid pneumoconiosis
hematology vs RA
- Anemia, reactive thrombocytosis
- Felty’s syndrome (rare)
- Seropositive RA + splenomegaly + neutropenia
- Lymphoproliferative conditions
-May be EBV related or MTX related
neuro msk signs in RA
- Carpel tunnel ( early)
- C1-C2 instability -luxation = loife threatening
random other extra articular manifestations in RA
- Rheumatoid nodules
- Vasculitis – variable vessel involvement
- Often occurs in “burnt out” disease
- Scleritis/Episcleritis, corneal melt
- Sicca symptoms (dry eyes, dry mouth)
- Raynaud’s phenomenon
- Neutrophilic dermatoses
(eg) Sweet’s Syndrome, Pyoderma gangrenosum
contraindications to mtx ?
- Pregnancy / breastfeeding /
childbearing potential (without
contraception) - Known ILD
- Known advanced liver disease
- Pre-existing bone marrow
failure/severe cytopenias - Active severe infection
which type of dmard s ritux ?
biologic
anti cd20
which small molecules/targeted synthetic dmard increases the risk of HZ ?
JAKi
Aprelimast
initially what did post marketing studies show with tofacinitis vs tnf i
- Large post-marketing safety study revealed increased risk of all-cause mortality, MACE, VTE & cancer in tofacitinib vs TNFi (patients had RA, age >50 with >1 CV risk factor)
- FDA issued black box warning Sep 2021 against all JAK inhibitors for all indications (approved if failed/intolerant to >1 anti-TNF)
RELATION Study – Tofa vs TNFi, similar risk of MACE. Tofa not associated with increased risk of cancer excluding NMSC
tx for RA managemnet
- bridge
- steroids < 3 months, nsaid, analgesics - long term tx ( disease modifiying)
- start usually with mtx unless low disease actitvity (go with hydrochloro)
- if that doesn’t work, add tnf inhib with mtx
- if that doesn’t work change to biologic or small molecule if not at target
when is tnf contraindicated ?
HF, if hx history of class III or 4 HF
if dvpt HF on tnfi –> switch to another agent
what’s a hydroxychloroquine side effect? what should you do annually ?
retinal toxicity
annual opthamological exam for retinal toxicity
when is sulfa contraindicated
with sulfa allergy
regarding hepatotoxicty, when do you hold mtx ?
when elevated LFTs > 2x ULN = hold the mtx and then resume at lower dose 1-2 weeks post normalization
pneumonitis, do you dose reduce or do you discontitnue mtx ?
discontinue
cytopenia, do you dose reduce o do you discontinue
depends on the severity
if mtx toxicity happens, what’s to keep in mind in terms of rescue therapy
- folinic acid rescue
- hydration
if have to use a biologics and have prior lymphoproliferattive malignancy, what can you use ?
rituximab
if have prior skin cancer, which dmards do we prefer and which do we avoid ?
cs DMards
avoid tnfi bcs increased risk of non melanoma skin cancer
if prior serious infection, which biologics to consider
csDmards
if you have latent tb, how long should you complete tx before thinking about startting biologics or tofacitinib ?
complete at least 1 month of tx
if active tb, how long do you have to wait before thinking about starting biologics or tofacitinib ?
complete full treatment
for which non live vaccine do you need to hold mtx 2 weeks post administration
influenza
ritux vs non live vaccine ? delay by how long ?
time all vaccines for when next RTX dose is due, then delay RTX for >2 weeks
what if you are on prednisone, how do you deal with non live vaccines
Give influenza vaccine; Defer other vaccines if on > 20 mg Prednisone until tapered
how long usually hold after admin of live atttenuated vaccines
usually 4 weeks post
rituximab - how long prior do you hold before live vaccine
IVIG - how long prior do you hold before live vaccine
JAKi : how long prior do you hold before live vaccine
6 months
8-11 months
1 week prior
meds to avoid pre pregnancy and how long to hold pre pregnancy.
- mtx : 1-3 months
- leflunomide : depennding on the level and if present, wash it out with cholestyramine
- taper pred <20
pregnancy safe RA meds
HQ is safe
SSZ
certolizumab ( large molecule and cant cross the placenta anyways)
no NSAID
low dose glucocorticoid is okay
postpartum meds
sulfasalazine okay for BF
avoid mtx and leflunomide during breast feeding
meds to avoid in male preconception
cyhclophosphamide and thalidomide
what’s EORA
elderly onset RA >65
what’s unique about EORA
- prsentation
- sero + ?
- small or large
- like PMR
- less likely sero +
- mostly large joints
type of rash noted in parvo b19 w viral arthritis ?
rerticular rash
what;s a another RA mimic with pitting edema, respondding well to pred and may be paraneoplastic
RS3PE : remiting seroneg symetrical synovitis with pitting edema
if accelerated nodulosis appears , what should be done ?
stop the offending drug aka mtx
which type of enteropathic IBD seroneg arthropathies correlates with bowel activity ?
type 1 ( oligo, usually large joints)
type 2 enteropathic seroneg arthropathies look like what ?
polyarthritis and independent of bowel
seronegative arthropathies clinical features
- SI joint/Axial involvement
- Peripheral joints
1.Asymmetric, large joint: AS, PsA, Reactive, IBD Type 1 (oligo, usually large joints, correlates with bowel activity)
2.Symmetric, small joint: PsA (DIP), IBD Type 2 (polyarthritis, independent of
bowel)
imaging featutres of seronegative arthropathies
- Peripheral X-rays: Erosions,
periosteal new bone formation, ankylosis - Spine X-ray: Syndesmophytes
- SI Joint X-ray: sclerosis, erosions, ankylosis - Can be symmetric in AS, asymmetric in PsA/IBD
- SI Joint MRI: Bone marrow edema
what medications to give in seronegative spondyloarthropathies axial disease
- nsaid
- tnf alpha inhibitors ( better for uveitis/ ibd) or il 17 ( psorias)
- jak inhib ( tofacitinib , upadacitinib)
what medications tog ive in seronegative spondyloparthropathies peripherla disease
- nsaids
- glucocorticoid ( avoid in PsA givne paradoxical worsening of psoriasis with taper)
- dmard : mtx, sulfasalazine ( lefluno, cyclosporine, apremilast in psa)
- biologics/small molecules ( tnf alpha, il17, il17-23, il23, jak i , ctla 4)
in peripheral seroneg, in what case would you avoid glucocorticoid ?
psa bcs paradoxical flare
which nsaid do we prefer in ibd when peripheral disease and why
celebrex, rest can trigger ibd flare
il17 should be avoided with who
IBD !
abatacept ( ctla-=4 ) best for who ?
PSA
can tnfi used in reactive arthritis ?
rarely
tb in reactive arthitis
no
timeline p[resentation of reactive arthritis and following what
ad 4 weeks
post gastro/urethritis
presentation usually of reactive arthritis ?
mono/oligo
LE
back pain, sacroilitis
culprit bacteria causing reactive arthritis
c trachomatis
yersinia
salmonella
shigella
campylobacter
eye issues with reactive arthritis ?
yes conjunctivity and uveitis
can;t see, can’t pee, can’t climb a tree = ?
reactive arthritis
