Inflammatory Arthritis Flashcards
What is the effect of smoking on rheumatoid arthritis?
reduces prognosis
less responsive to treatment
what is rheumatoid arthritis?
a chronic inflammatory disease of the joints- symmetrical polyarthritis
What is the main pathology behind rheumatoid arthritis?
- autoantibodies (usually) causing inflammation of the synovium
- synovium proliferates and releases cytokines into synovial space
- cytokines eat into cartilage and bones causing progressive joint destruction
what are the main 4 symptoms of rheumatoid arthritis?
joint pain stiffness joint swelling general (eg malaise, fatigue) \+ any extra-articular features
what are the main 3 clinical signs of rheumatoid arthritis?
(boggy) swelling
tenderness
reduced range of movement
why can rheumatoid arthritis result in dry eyes?
inflammation and then fibrosis of the lacrimal gland causing reduced tear production
why can rhuematoid arthritis result in a dry mouth?
inflammation and then fibrosis of the salivary gland causing reduced saliva production
compare pulmonary fibrosis caused by rheumatoid arthritis to idiopathic pulmonary fibrosis?
pulmonary fibrosis caused by rheumatoid arthritis is much less aggressive
what cytokine produced in the rheumatoid arthritis process causes osteoporosis?
IL-6
what are the 2 main antibodies involved in rheumatoid arthritis?
anti-CCP
Rheumatoid Factor
(not everyone has both or any of these)
what is the best radiological investigation for rheumatoid arthritis?
ultrasound
what is the main treatment used for rheumatoid arthritis?
methotrexate
what are the 4 biologics that have achieved major impact in rheumatoid arthritis?
- anti-TNF (infliximab)
- B cell depletion (rituximab)
- disruption of T cell co-stimulation (abatacept)
- IL-1 inhibiaiton (anankira) or IL-6 inhibition (tocilizumab)
What is soft tissue rheumatism?
pain caused by inflammation/damage to ligaments, tendons, muscles or nerve near a joint rather than the bone or cartilage
(pain is very localised)
how many joints are affected in polyarthritis?
4+
how does rheumatoid arthritis increase CV risk?
pro-inflammatory conditions increase risk of atheroma
What are spondyloarthropathies?
a family of inflammatory arthritides characterised by involvement of both spine and peripheral joints
what HLA type do genetically predisposed individuals to ankylosing spondylitis commonly have?
HLA B27
what are the 4 disease subgroups of spondyloarthropathies?
ie 4 inflammatory arthritides that can have spinal involvement
ankylosing spondylitis
psoriatic arthritis
reactiv arthritis
enteropathic arthritis
compare mechanical back pain to inflammatory back pain in terms of response to activity?
mechanical back pain: worsened by activity
inflammatory back pain: better with activity
what is an enthesis?
a sit of insertion of a tendon, ligament or articular capsule into the bone
what is enthesitis?
inflammation of an insertion site on a bone
what is dactylitis?
inflamamtion of entire digit
sausage digits
what is the most common type of juvenile inflammatory arthritis?
oligoarticular arthritis
what is the location and distrubution of oligoarticular arthritis?
large limbs in an asymmetrical pattern
what is ankylosing spondylitis?
a chronic systemic inflammatory disorder that primarily affects the spine
(a spondyloarthropathy)
what joint involvement is the hallmark of ankylosing spondylitis?
sacroiliac joint involvement
–> sacroilits
in ankylosing spondylitis, peripheral arthritis is uncommon, but if this were to happen, what joints would typically be affected?
big joints
eg shoulder and hip
who tends to get ankylosing spondylitis?
men in early adulthood
what does exercise do to the pain felt in ankylosing spondylitis?
relieves pain
because ankylosing spondylitis is an inflammatory condition
Ankylosing spondylitis is known as the ‘A’ disease- what are the 7 ‘A’ features?
Axial arthritis Anterior uveitis Aortic regurgitation Apical lung fibrosis Amyloidosis Achilles tendinitis plAntar fasciitis
what test is good for assessing flexion of the lumbar spine?
schober’s test
what are the main differences between ankylosing spondylitis spine and osteoarthritis spine?
AS- bone density reduced in late disease fusion of vertebrae syndesmophytes no subchondral sclerosis or cysts
OA- normal bone density reduced joint space but no fusion osteophytes subchondral sclerosis and cysts
what is a syndesmophyte?
a bony growth originating inside a ligament
what is the treatment of ankylosing spondylitis?
physiotherapy and home exercises NSAIDs immunosuppressants (but only if peripheral involvement) biologics steroids
What is psoriatic arthritis?
an inflammatory arthritis associated with psoriasis
is rheumatoid factor present in psoriatic arthritis?
no
what are the 5 main presentations of psoriatic arthritis?
- sacroilitis (spondyloarthropathy)
- nail involvement (pitting, onycholysis, hyperkeratosis)
- dactlitis
- enthesitis
- extra-artcicular features (eg eye disease)
what are the 5 clinical subgroups of psoriatic arthritis?
- confined to DIP joints in hands and feet
- symmetrical polyarthritis (similar to RA)
- spinal involvement
- asymmetrical oligoarthriis
- arthritis mutilans
what is the treatment of psoriatic arthritis?
physiotherapy NSAIDs steroids joint injections immunosuppresants biologics
What is reactive arthritis?
an infection induced systemic illness characterised by inflammatory synovitis from which micro-organisms cannot be cultures
how long after infection does reactive arthritis symptoms present?
1-4 weeks
what are the 2 classes of infection which most commonly cause reactive arthritis?
urogenital
enterogenic
what HLA type can predispose to reactive arthritis?
HLA B27
who tends to get reactive arthritis?
20-40 y/o
male and females
what is reiter’s syndrome?
a form of reactive arthritis with a triad of classical symptoms:
- UTI
- conjuntivits/uveitis/iris
- arthritis
what is the treatent of reactive arthritis?
physiotherapy NSAIDs steroids antibiotics for underlying infection immunosuppressants if chronic (most resolve spontaneously within 6 months)
what condition is enteropathic arthritis associated with?
inflammatory bowel disease
typically Crohn’s
what happens to the enteropathic arthritis symptoms during a flare up of IBD?
joint pain and stiffness becomes worse
what is the treatment of enteropathic arthritis?
treat underlying inflammatory bowel disease
+
normal analgesia eg paracetamol, cc-codamol
why are NSAIDs not a good idea to use in enteropathic arthritis?
may exacerbate the inflammatory bowel disease
what does arthropathy mean?
disease of a joint
what does arthralgia mean?
pain in a joint
what does arthritis mean?
inflammation of a joint
what are the 4 subtypes of inflammatory arthropathy?
seropositive
seronegative
infectious
crystal deposition
are spondyloarthropathies seropositive or seronegative?
seronegative
is SLE seropostive or seronegative inflammatory arthritis?
seropositive inflammatory arthritis
is enteropathic arthritis seropositive or seronegative inflammatory arthritis?
seronegative inflammatory arthritis
is ankylosing spondylitis seropositive or seronegative inflammatory arthritis?
seronegative
is Sjogren’s syndrome seropositve or seronegative inflammatory arthritis?
seropositive
is reactive arthritis seropositive or seronegative inflammatory arthritis?
seronegative
is rheumatoid arthritis seropositive or seronegative inflammatory arthritis?
seropositive
is vasculitis seropositive or seronegative inflammatory arthritis?
seropositive
what are the main joints affected in rheumatoid arthritis?
small joints in hands and feet
as disease progresses: knees, shoulders, elbows and others
what does the synovium become after being attacked by auto-antibodies?
(inflammatory) pannus
which joints in the fingers are typically not involved in rheumatoid arthritis?
DIPs
which joints in the hands are typically involved in rheumatoid arthritis?
MCPs and PIPs
what important area of in the spine can be affected by rheumatoid arthritis? and what can this cause?
cervical spine causing atlanto-axial sublaxation
this can lead to cervical cord compression
where do rheumatoid nodules typically appear?
extensor surfaces or sites of frequent mechanical irritation
which is more specific for rheumatoid arthritis- anti-CCP or RF?
anti-CCP
when should a DMARD be commenced?
within 3 months of rheumatoid arthritis symptom onset
what short term treatments are used for rheumatoid arthritis? (ie for symptom relief)
simple analgesia NSAIDs intramuscular steroids intra-articular steroids oral steroids
when does a patient with rheumatoid arthritis become eligible for biologic therapy?
when disease doesn’t respond to standard DMARD therapy
what are the most commonly used biologics used in rheumatoid arthritis?
anti-TNF drugs
in advanced ankylosing spondylitis what shape changes in the spine occur?
loss of lumbar lordosis
increased thoracic kyphosis
what is a bamboo spine?
when the intervertebral discs in the spine fuse together
occurs in ankylosing spondylitis
what is the location and distribution of affected joints in enteropathic arthritis?
asymmetrical large joints (can involve spine)
What are the 2 major classes of drugs for inflammatory arthritis?
symptom relief
or
disease modifiers
what are the 2 major classes of drugs that are disease modifiers for the treatment of inflammatory arthritis?
DMARDs (Disease Modifying Anti-Rheumatic Drugs
Biologics
what type of NSAIDs reduce the risk of peptic ulceration compared to typical NSAIDs?
COX-2 selective inhibitors
why should COX-2 inhibitors not be used in patients with high cardiovascular risk?
COX-2 inhibitors increase cardiovascular risk
more than COX-1 inhibitors
what is Step 1 in the WHO analgesic pathway?
non-opioid (eg paracetamol or NSAID)
+/- adjuvant (eg anti-convulsant or anti-depressant
what is Step 2 in the WHO analgesic pathway?
weak opioid (eg codeine)
+ non-opioid (eg paracetamol or NSAID)
+/- adjuvant (eg anti-convulsant or anti-depressant)
what is Step 3 in the WHO analgesic pathway?
strong opioid (eg morphine)
+ non-opioid (eg paracetamol or NSAID)
+/- adjuvant (eg anti-convulsant or anti-depressant)
if a DMARD is not enough, should you add another DMARD or switch DMARDs?
add another
what is the first choice DMARD in most patients?
methotrexate
how is methotrexate administered?
orally or subcutaneous injection
why is the subcutaneous injection of methotrexate sometimes preferred to the oral form?
less nausea
why must alcohol intake be limited when on a methotrexate?
because methotrexate already increases hepatitis/cirrhosis risk
can a patient on methotrexate try to conceive?
no
methotrexate is teratogenic
should be switched to sulfasalazine 3 months before conception
what are the first line biologics for inflammatory arthritis?
anti-TNF therapy
eg etanercept subcut, adalimumab subcut, certolizumab subcut, infliximab IV
why are methotrexate and anti-TNF therapy effective in combonation for inflammatory arthritis?
methotrexate suppresses the immune system so prevents the development of antibodies forming to neutralise the anti-TNF
why should patients about to receive anti-TNF therapy be screened for latent TB?
anti-TNF can break down the granulomas that were preventing latent TB infection spreading
what is a DAS score?
what does a high DAS score mean?
disease activity score
(for inflammatory arthritis)
the higher the score, the worse the disase progression is
is anti-TNF used in: rheumatoid arthritis? psoriatic arthritis? ankylosing spondylitis? connective tissue disease?
RA? yes
PA? yes
AS? yes
CTD? no
is Rituximab used in: rheumatoid arthritis? psoriatic arthritis? ankylosing spondylitis? connective tissue disease?
RA? yes
PA? no
AS? no
CTD? yes
what DAS28 scores shows rheumatoid disease remission?
what are the 4 main side effects of methotrexate?
DMARD
myelosuppression (bone marrow suppression)
liver cirrhosis
pneumonitis
teratogenicity
what are the 3 main side effects of sulfasalazine?
DMARD
rashes
(reversible) oligospermia
heinz body anaemia
what are the 3 main side effects of leflunomide? (DMARD)
liver impairment
interstitiual lung disease
hypertension
what are the 2 main side effects of hydroxychloroquine? (DMARD)
retinopathy
corneal deposits
what are the 6 main side effects of prednisolone?
cushingoid features muscle atrophy osteoporosis impaired glucose tolerance hypertension cataracts
what is the main side effect of gold? (DMARD)
proteinuria
what are the 2 main side effects of penicillamine? (DMARD)
porteinuria
exacerbation of myasthenia gravis
what are the 2 main side effects of etanercept? (biologic)
demyelination
reactivation of latent TB
what is the main side effect of infliximab? (biologic)
reactivation of latent TB
what is the main side effect of adalimumab? (biologic)
reactivation of latent TB
what is the main side effect of rituximab? (biologic)
infusion reactions
what nodes are found in RA- heberdens or bouchards?
bouchards
because PIP joints are affected but DIP joints are spared
