Inflammatory Arthropathies Flashcards
what is rheumatoid arthritis
autoimmune condition (type IV) that is inflammation in synovial membrane or articular cartilage
what joints are more commonly affected in RA
small joints of hands, feet and wrist - MCP (knuckles), PIPs (bendy bit) and wrist DIPs are not!
what joints can be affected as disease progresses in RA
larger joints such as knees, elbows and shoulders
what is prevalence of RA
can affect both sexes but women affected 3x more commonly than men any age but peaks 35-50
what is changes during acute phase of RA
pannus formation (inflammatory granulation tissue) and hyperplastic / reactive synovium
what is changes during chronic phase of RA
fibrosis and deformity
what is pathogenesis of RA
immune response initiated against synovium inflammatory pannus forms which then attacks and denudes articular cartilage leading to joint destruction tendon ruptures and soft tissue damage can occur leading to joint instability and subluxation
what causes RA
genetics rheumatoid factor (rheumatoid IgM) and auto antibody against Fc IgG anti CCP HLA-DR4 smoking post partum and breast feeding
what are the symptoms of RA
pain joint swelling morning stiffness fever leukocytosis malaise anorexia hyperfibrinogenemia
how is RA diagnosed
history and examination inflammatory markers (CRP, ESR, plasma viscosity) autoantibodies (not always reliable) X rays - pertiarticular osteopenia and swelling, periarticular erosion can occur later US - may be useful in detecting synovial inflammation if doubt MRI poor grip strength measured by squeeze test
how is RA severity measured
DAS28 score
DAS28 score for active RA
>5.1
DAS28 score for moderate RA
3.2-5.1
DAS28 score for low RA
2.6-3.2
DAS28 score for remission RA
<2.6
what are the DMARDs that used to treat RA
methotrexate sulfasalazine hydrocychlorquinine leflunomide gold, penicillamine, ciclosporin A
1st line treatment in RA
NSAIDs + steroids + DMARRD (methotrexate - start at 15mg/week and work up, max dose is 25mg/week)
2nd and 3rd line treatment in RA
add DMARD 2 and 3
what RA drugs are not safe in pregnancy
methotrexate sulfasalazine is safe :)
why do DMARDs need regular monitoring
bone marrow suppression, infection, liver function derangement, pneumonitis (methotrexate)
when should sulfasalazine be avoided
septrin allergy and G6DP
when are biological agents (anti TNF, CD 20 B cells, IL6, IL17, 12, 23) used in RA
failed to respond to 2 DMARDs including methotrecate and DAS28 >5.1 on 2 occasions 4 weeks apart
surgery can be performed for RA but this is increasingly less common. What surgeries?
synovectomy joint replacement joint excision tendon transfers arthrodesis (fusion) cervical spine stabilisation
what are the complications of RA
joint damage and deformities - swan antalo-axial subluxation - misalignment of 1st and 2nd cervical vertebrae rheumatoid nodules lung = pleural effusions, interstitial fibrosis and pulmonary nodules CV morbidity increased ocular involvement - keratoconjunctivitis sicca, episcleritis, uveitis and nodular scleritis which may lead to sceromalacia do screening for osteoporosis tendon rupture - tendon transfer and synovectomy to prevent future rupture
what is ankylosing spondylitis
chronic inflammatory disease of the spine and sacroiliac joints which can lead to eventual fusion of the intervertebral joints and S1 joints
what is prevalence of ank spond
males more commonly affected (3:1) age of onset = 20-40 yo
what % of ank spond are HLA-B27 positive
90%
what other conditions are associated with HLA-B27
reactive arthritis, crohns and uveitis
what conditions are associated with ank spond
anterior uveitis, aortosis, pulmonary fibrosis and amyloidosis
what are symptoms of ank spond
spinal pain and morning stiffness
what happens as time progresses in ank spond
loss of spinal movement and development of question mark spine with loss of lumbar lordosis and increased thoracic kyphosis may also develop hip or knee arthritis
why is ank spond known as “A” disease
axial arthritis anterior uveitis aortic regurgitation apical fibrosis amyloidosis / IgA nephropathy achilles tendonitis plantar fasciitis
how is lumbar spine flexion measured
schobers test measure 5cm below posterior superior iliac crests and 10cm above whilst patient upright then asking them to bend forward and remeasure distance normal = should extend beyond 20cm
what is shown on xray in ank spond
may show sclerosis and fusion of sacroiliac joints and bony spurs from vertebral bodies known as syndesmophytes which can bridge intervertebral disc resulting in fusion producing bamboo spine
what may an MRI detect in ank spond
earlier features such as bone marrow oedema and enthesitis of spinal ligaments
how is ank spond diagnosed
in patients with >3 months back pain: sacroiliitis on imaging AND >/=1 SpA feature or HLA-B27 positive AND >/=2 SpA features
what are these “SpA features”
inflammatory back pain arthritis enthesitis (heel) uveitis dactylitis psoriasis crohns / colitis good response to NSAIDs family history of SpA HLA-B27 elevated CRP
what is the treatment of ank spond
physio and exercise NSAIDs anti-TNF (target TNF that causes inflammation) DMARDs do not have impact but may be used if there is peripheral joint inflammation secukinuman (anti-IL17) is newest licensed agent
why is surgery not really used in ank spond
as it is reserved for hip and knee arthritis kyphoplasty to straighten out spine is controversial and carries risk
what is psoriatic arthritis
arthritis which occurs in up to 30% of people with psoriasis or family member who does (10-15% patients can have PsA without psoriasis) HLA-B27 associated
what is the pattern of arthritis in psoriatic arthritis
usually an asymmetric oligoarthritis (affecting 4 or more joints) but may also affect hands in similar pattern to RA
what are symptoms of psoriatic arthritis
sacroiliitis (often asymmetric) spondylitis (inflammation of spine) dactylitis (digits) enthesis (where tendon or ligaments insert into bone) = eg achilles tendonitis nail changes - pitting and onycholysis (lifting of nail from bed)
how is psoriatic arthritis diagnosed
history, exam, bloods, xrays
what is shown in bloods in psoriatic arthritis
inflammatory parameters (raised) negative RF
what is shown on Xray in psoriatic arthritis
marginal erosions “pencil in cup” deformity osteolysis enthesitis
how is psoriatic arthritis treated
similarly to RA with DMARDs - usually methotrexate
what is given to those who do not respond to standard treatment in psoriatic arthritis
anti-TNF
what can be considered in larger joints which are severely affected by psoriatic arthritis
joint replacement DIP fusion can occasionally help in affected DIP joints
what is the really aggressive and destructive form of psoriatic arthritis which can develop
5% have particularly aggressive and destructive form of condition known as arthritis mutilans
what is enteropathic arthritis
inflammatory arthritis involving peripheral joints and sometimes spine which occurs in patients with IBD
how many of IBD patients develop enteropathic arthritis
10%
what are symptoms of enteropathic arthritis
large joint asymmetrical oligoarthritis 20% of crohns patients have sacroiliitis loose watery stool weight loss, low grade fever eye involvement (uveitis) skin involvement (pyoderma gangrenosum) enthesitis (achilles tendonitis, plantar fasciitis, lateral epicondylitis) oral-apthous ulcers
how is enteropathic arthritis diagnosed
endoscopy with biopsy = ulceration / colitis raised inflammatory markers xray or MRI showing sacroilitis USS showing synovitis / tenosynovitis
how it enteropathic arthritis treated
finding medication to manage both underlying condition and arthritis
what is not a good idea in enteropathic arthritis as it may exacerbate IBD
NSAIDs
what medications are given in enteropathic arthritis
paracetomal or cocodamol DMARDs (methotrexate, sulfasalazine, azathioprine) anti-TNF licensed for both crohns and inflammatory arthritis
what are examples of anti TNF used in enteropathic arthritis
infliximab adalimumab
what is reactive arthritis
arthritis which occurs in response to infection
what infections most commonly cause reactive arthritis
GU (chalmydia, neisseria) GI (salmonella, campylobacter)
how does it cause reactive arthritis
infection triggers autoimmune arthropathy
is reactive arthritis HLAB27 positive
yes
what joints are affected in reactive arthritis
large joints eg knee become inflamed 1-3 weeks following infection asymmetrical mono arthritis or oligoarthritis
some patients with reactive arthritis have Reiter’s syndrome, what three conditions is this a triad of
urethritis uveitis or conjunctivitis arthritis
what are other symptoms of reactive arthritis
enthesitis mucocutaneous lesions ocular lesions (conjunctivitis, iritis) visceral manifestations (mild renal disease, carditis)
what mucocutaneous lesions can be present in reactive arthritis
keratodema blenorrhagica circinate balanitis painless oral ulcers hyperkeratotic nails
how is reactive arthritis diagnosed
history, exam, bloods, joint fluid analysis to rule out infection, xray of affected joint and opthalmology opinion
what shows up in bloods in reactive arthritis
inflammatory parameters (ESR, CRP, PV) can do HLA B27 but rarely necessary
how is reactive arthritis treated
mostly self limiting - resolve in 6 months treatment aimed at underlying cause and symptomatic relief including IA and IM steroids
can reactive arthritis become chronic
yeah, 12-20% do occasionally require DMARDs if so
