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MDD > Inflammatory Arthritis > Flashcards

Inflammatory Arthritis Flashcards

1
Q

what are types of inflammatory arthritis?

A

Connective tissue disease

Crystal (Gout, Pseudogout)

Spondyloarthropathies (Psoriatic, Ankylosing spondylitis, Reactive, Enteropthic)

Rheumatoid

Septic

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2
Q

what is rheumatoid arthritis described as

A

symmetrical small joint chronic inflammatory polyarthritis

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3
Q

what joints are most commonly affected in rheumatoid arthritis

A 
MTP - 90%
Ankle - 80%
Knee - 80%
MCP + PIP - 90%
Wrists - 80%
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4
Q

what are some radiological features of rheumatoid arthritis

A

Degree of osetopenia –more transparent bones

Erosive change – small holes around joint space

Joing space narrowing

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5
Q

what are the extra articular features of rheumatoid arthritis

A 
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
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6
Q

what does having rheumatic nodules imply

A

the patient is seropositive (RF)

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7
Q

what is the most common extra articular pathology in rheumatoid arthritis

A

lung nodules

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8
Q

what is Felty’s syndrome

A

neutropenia, splenomegaly and anaemia due to RA

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9
Q

what is RA associated atlantio-axial subluxation

A

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

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10
Q

what is the presentation of RA associated atlantio-axial subluxation

A

Presents with localised pain and deformity, as well as cervical radiculopathy

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11
Q

how do you diagnose atlantio-axial subluxation

A

XR - APO, Lat, odontoid pegs

MRI

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12
Q

how do you manage atlantio-axial subluxation

A

Surgical decompression of the spine

Stabilise involved segments of spine

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13
Q

what is a spondyloarthropathy

A

seronegative inflammation of the enthesis of joints (insertion of tendon into bone)

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14
Q

what are extra articular features of spondyloarthropathies

A

Acihilles tendon inflammation

Palmoplantar psoriasis

Dactylitis – digit/toe inflammation

Iritis

Psoraitic nail changes
Bowie lines
Subungal hyperkeratosis
Onicholysis

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15
Q

what are radiographic features of spondyloarthropathies

A

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

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16
Q

what is the triad of reactive arthritis

A

Urethritis

Conjunctivitis

Arthritis – usually a monoarthritis

17
Q

what causes reactive arthritis

A

gram negative bacterial organisms - usually STI and bowel organisms

18
Q

what is the usual history for reactive arthritis

A

bowel/STI 4 weeks previously, then onset of reactive arthritis triad

19
Q

what is the treatment for reactive arthritis

A

self limiting - no Abx indicated

lasts for about 3 months

20
Q

what investigations should be done for ?inflammatory arthritis

A

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)

21
Q

what inflammation score is used for ankylosing spondylitis

A

BASDAI

22
Q

what inflammation score is used for psoriatic arthritis

A

DAS 66/68

23
Q

what are the medical management options for inflammatory arthritis

A

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

24
Q

what bloods needs to be assessed during DMARD therapy for inflammatory arthritis and how often is it done

A

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)

25
Q

what values must be normal before starting a DMARD

A

FBC
BP
CXR
Renal function

26
Q

methotrexate side effects

A

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`

27
Q

sulfasalazine side effects

A

Nausea

GI upset

Increased risk of infection

Blood disorders

Mood changes - Increases risk of suicidal thoughts

Can stain urine, contact lenses and teeth orange!

28
Q

what is the main complication in hydroxychloroquine use and what is done to prevent this

A

macular degeneration

check VA before starting and regular optician review every year required

29
Q

what are some contraindications to intraarticular injection

A

Non consent

Hypersensitivity

Infections in the joint

Bacteraemia

Fractures/unstable joints

Artificial joints

Diabetes

Pregnancy

Bleeding disorders

Anticoagulation medication/disorders

Psoriasis

30
Q

what is the criteria for biologic use in rheumatoid arthritis

A

DAS-28 score >5.1

must have trialled at least 2 DMARDs with one being methotrexate up to 20mg

31
Q

what are contraindications to biologics

A

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

32
Q

what is screened for before commencing biologic use

A

CXR for infection/fibrosis/Tb

Hepatitis screen

HIV screen

Tb screen

Immunisations

Bloods

33
Q

what are side effects of biologics

A

Nausea

Blocked/runny nose

Indigestion

Injection site reaction

Incresed risk of infection

Drug induced lupus

Increased risk of cancers (theoretical)

34
Q

what are the 4 main categories of biologics and give an example

A

Anti-TNF - infliximab/etanercept

anti-CD20 - rituximab

Tcell co stimulator inhibitor - abatacept

IL6 antagonist - tocilizumab

35
Q

how long is DMARD treatment for an inflammatory arthritis

A

lifelong

MDD (22 decks)

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