Inflammatory Arthritis Flashcards
what are types of inflammatory arthritis?
Connective tissue disease
Crystal (Gout, Pseudogout)
Spondyloarthropathies (Psoriatic, Ankylosing spondylitis, Reactive, Enteropthic)
Rheumatoid
Septic
what is rheumatoid arthritis described as
symmetrical small joint chronic inflammatory polyarthritis
what joints are most commonly affected in rheumatoid arthritis
MTP - 90% Ankle - 80% Knee - 80% MCP + PIP - 90% Wrists - 80%
what are some radiological features of rheumatoid arthritis
Degree of osetopenia –more transparent bones
Erosive change – small holes around joint space
Joing space narrowing
what are the extra articular features of rheumatoid arthritis
Nodules Pleural effusions Scleritis/episcleritis Vasculitis Lung nodules entrapment neuropathies glove and stocking sensory loss dry eyes nephrotic syndrome due to amyloidosis of the kidneys Feltys syndrome normocytic normochromic anaemia reynauds
what does having rheumatic nodules imply
the patient is seropositive (RF)
what is the most common extra articular pathology in rheumatoid arthritis
lung nodules
what is Felty’s syndrome
neutropenia, splenomegaly and anaemia due to RA
what is RA associated atlantio-axial subluxation
Atlanto-axial instability occurs in 50-80% of patients with RA of the cervical spine
This is because the transverse and apical ligaments are destroyed
what is the presentation of RA associated atlantio-axial subluxation
Presents with localised pain and deformity, as well as cervical radiculopathy
how do you diagnose atlantio-axial subluxation
XR - APO, Lat, odontoid pegs
MRI
how do you manage atlantio-axial subluxation
Surgical decompression of the spine
Stabilise involved segments of spine
what is a spondyloarthropathy
seronegative inflammation of the enthesis of joints (insertion of tendon into bone)
what are extra articular features of spondyloarthropathies
Acihilles tendon inflammation
Palmoplantar psoriasis
Dactylitis – digit/toe inflammation
Iritis
Psoraitic nail changes
Bowie lines
Subungal hyperkeratosis
Onicholysis
what are radiographic features of spondyloarthropathies
Variable
From one joint to a fully symmetrical small joint polyarthritis
Mimics some tendinopathies
Psoriatic arthritis tends to affect distal interphalangeal joints (as does OA) which tends to be a differentiating factor between that and RA
Sacroiliac joint
Decrease joint space in joint
Increased opacity
Effusion of the joint space
what is the triad of reactive arthritis
Urethritis
Conjunctivitis
Arthritis – usually a monoarthritis
what causes reactive arthritis
gram negative bacterial organisms - usually STI and bowel organisms
what is the usual history for reactive arthritis
bowel/STI 4 weeks previously, then onset of reactive arthritis triad
what is the treatment for reactive arthritis
self limiting - no Abx indicated
lasts for about 3 months
what investigations should be done for ?inflammatory arthritis
History + Examination
Bloods
FBC (raised platelets/WCC, microcytic/normocytic anaemia)
CRP (raised)
ESR (raised)
U + E (mainly for baseline renal function for medications)
RF
20-30% of +ve do not have RA
Anti-CCP
60-70% sensitivity (less than RA)
More specific for RA – majority of +ve tests have RA
Similar to RA in that the presence indicates worse prognosis
HLA-B27? (+ve = higher risk for ankylosing spondylitis)
ANA (like the ‘check engine light for the immune system)
Full infectious screen
Serum uric acid
USS
Identifies early inflammation
X-ray
Check for Tb for methotrexate starting
Aspirate
Polarised light microscopy to check for crystals
Inflammation Scores (e.g. DAS28)
what inflammation score is used for ankylosing spondylitis
BASDAI
what inflammation score is used for psoriatic arthritis
DAS 66/68
what are the medical management options for inflammatory arthritis
Analgesia
NSAIDS mostly but opiates may be used
DMARDS
methotrexate 1st line
sulfasalazine 2nd line
leflunomide/hydroxychloroquinine/penecillamine/azathioprine also used
Steroids
used to bridge gap between DMARDS commencing and working (8 weeks)
Biologics
what bloods needs to be assessed during DMARD therapy for inflammatory arthritis and how often is it done
FBC, creatinine and LFT done every 2 weeks
brackets = worrying
WCC (<3.5)
Neutrophils (<2)
Renal function (worsened)
Hb (fall)
Platelets (<100)
ALT/ALP (raised)
what values must be normal before starting a DMARD
FBC
BP
CXR
Renal function
methotrexate side effects
Nausea
GI upset
Mouth ulcers increased risk of infection
Hair loss
Blood disorders
Pulmonary toxicity
Causes a pneumonitis – not fibrosis
Liver toxicity
Bleeding
Recurrent infection
Persistent nausea
Blood disorders`
sulfasalazine side effects
Nausea
GI upset
Increased risk of infection
Blood disorders
Mood changes - Increases risk of suicidal thoughts
Can stain urine, contact lenses and teeth orange!
what is the main complication in hydroxychloroquine use and what is done to prevent this
macular degeneration
check VA before starting and regular optician review every year required
what are some contraindications to intraarticular injection
Non consent
Hypersensitivity
Infections in the joint
Bacteraemia
Fractures/unstable joints
Artificial joints
Diabetes
Pregnancy
Bleeding disorders
Anticoagulation medication/disorders
Psoriasis
what is the criteria for biologic use in rheumatoid arthritis
DAS-28 score >5.1
must have trialled at least 2 DMARDs with one being methotrexate up to 20mg
what are contraindications to biologics
Cancer
History of Tb
Pregnancy
Leg ulcers
Active infection
Septic arthritis
Heart failure grade 3 or more
History or family history of demyelination
PUVA cumulative dose >1000j + ciclosporin
Interstitial lung disease
what is screened for before commencing biologic use
CXR for infection/fibrosis/Tb
Hepatitis screen
HIV screen
Tb screen
Immunisations
Bloods
what are side effects of biologics
Nausea
Blocked/runny nose
Indigestion
Injection site reaction
Incresed risk of infection
Drug induced lupus
Increased risk of cancers (theoretical)
what are the 4 main categories of biologics and give an example
Anti-TNF - infliximab/etanercept
anti-CD20 - rituximab
Tcell co stimulator inhibitor - abatacept
IL6 antagonist - tocilizumab
how long is DMARD treatment for an inflammatory arthritis
lifelong
