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Yr 4 - CCC > MSK: Osteoarthritis & Rheumatoid Arthritis > Flashcards

MSK: Osteoarthritis & Rheumatoid Arthritis Flashcards

1
Q

Where does osteoarthritis (OA) occur?

A

Synovial joints

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2
Q

Commonly affected joints in OA?

A
  • Hips
  • Knees
  • DIP joints in hands
  • Carpometacarpal (CMC) joint at the base of the thumb
  • Lumbar spine
  • Cervical spine (cervical spondylosis)
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3
Q

Risk factors for OA?

A
  • Female
  • Obesity
  • Occupation
  • Trauma
  • FH
  • Age
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4
Q

The four key x-ray changes in osteoarthritis can be remembered with the “LOSS” mnemonic.

What are they?

A

L - loss of joint space

O - osteophytes (bone spurs)

S - subarticular sclerosis (increased density of the bone along the joint line)

S - subchondral cysts (fluid-filled holes in the bone)

May be called degenerative change

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5
Q

Xrays vs symptoms in OA?

A

X-ray changes do not necessarily correlate with symptoms. A patient might have significant signs on an x-ray but minimal symptoms, or the reverse.

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6
Q

Presentation of OA?

A
  • Joint pain & stiffness
  • Bulky, bony enlargement of the joint
  • Restricted range of motion
  • Crepitus on movement
  • Effusions (fluid) around the joint
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7
Q

Describe the pain and stiffness in OA?

A

Better in morning and worse with activity and at end of day.

Morning stiffness lasts for less than 30 minutes.

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8
Q

If morning stiffness lasts for longer than 30 minutes, what condition does it indicate?

A

Rheumatoid arthritis

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9
Q

Give some hand signs seen in OA

A
  • Heberden’s nodes
  • Bouchard’s nodes
  • Squaring at the base of the thumb (CMC joint)
  • Weak grip
  • Reduced range of motion
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10
Q

What joint do Herbeden’s nodes affect?

A

DIP joints

(Herb goes far)

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11
Q

What joint do Bouchard’s nodes affect?

A

PIP joints

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12
Q

TIP - referred pain in OA

A

Patients may present with referred pain, particularly in the adjacent joints. For example, consider osteoarthritis in the hip in patients presenting with lower back or knee pain.

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13
Q

When can a diagnosis of OA be made WITHOUT investigations?

What 3 features are needed?

A

1) Over 45 y/o
2) Typical pain associated with activity
3) Has no morning stiffness (or stiffness lasting under 30 minutes)

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14
Q

Non-pharmacological management of OA?

A

1) Therapeutic exercise to improve strength and function and reduce pain

2) Weight loss if overweight, to reduce the load on the joint

3) Occupational therapy to support activities and function (e.g., walking aids and adaptations to the home)

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15
Q

What is 1st line pharmacological management in OA?

A

NSAIDs

1st line usually topical (e.g. knee OA)

Oral where suitable

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16
Q

What must oral NSAIDs be prescribed with in OA?

A

co-prescribed with a proton pump inhibitor for gastroprotection

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17
Q

Pharmacological management options in OA?

A

1) NSAIDs (topical or oral)
2) Intra-articular steroid injections –> may temporarily improve symptoms
3) Joint replacement –> severe cases (most commonly knee and hip)

Weak opiates and paracetamol are only recommended for short-term, infrequent use.

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18
Q

Are strong opiates recommended in OA?

A

NO

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19
Q

Potential adverse effects of NSAIDs?

A

1) GI side effects e.g. gastritis and peptic ulcers (leading to upper gastrointestinal bleeding)

2) Renal e.g. AKI (e.g., acute tubular necrosis) and CKD

3) CVS side effects e.g. s hypertension, heart failure, myocardial infarction and stroke

4) Exacerbating asthma

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20
Q

Impact of NSAIDs on asthma?

A

Can exacerbate it

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21
Q

Is the WHO pain ladder useful in chronic pain?

A

No

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22
Q

How can NSAIDs cause HTN?

A

Block prostaglandins (prostaglandins cause vasodilation) –> use very cautiously with a history of high blood pressure

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23
Q

What is rheumatoid arthritis (RA)?

A

An autoimmune condition that causes chronic inflammation in the SYNOVIAL LINING (synovitis) of the joints, tendon sheaths and bursa. It is a type of inflammatory arthritis.

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24
Q

What does inflammation of the tendons in RA increase the risk of?

A

Tendon rupture

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25
Q

Does RA typically affect joints asymmetrically or symmetrically across body?

What about OA?

A

RA –> symmetrically (this is called symmetrical polyarthritis)

OA –> asymetrically

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26
Q

Is RA more common in men or women?

A

Women (2-3x)

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27
Q

Risk factors for RA?

A
  • Middle age
  • Smoking
  • Obesity
  • FH
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28
Q

What is the most common gene associated with rheumatoid arthritis?

A

HLA DR4

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29
Q

The disease course varies between patients, from mild and remitting to severe and progressive.

Positive antibodies can predict worse disease.

What Abs may be seen in RA?

A

1) Rheumatoid factor (RF)

2) Anti-cyclic citrullinated peptide antibodies (anti-CCP antibodies)

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30
Q

What % of RA is RF present in?

A

Rheumatoid factor (RF) is an autoantibody present in around 70% of RA patients.

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31
Q

What does RF target in RA?

What does this cause?

A

It targets the Fc portion of the immunoglobulin G (IgG) –> this causes immune system activation against the patient’s own IgG, resulting in systemic inflammation.

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32
Q

What type of immunoglobulin is RF normally?

A

IgM

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33
Q

Are RF autoantibodies or anti-CCP antibodies more sensitive and specific for RA?

A

Anti-CCP

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34
Q

What % of RA are anti-CCP antibodies present in?

A

They are positive in around 80% of patients with rheumatoid arthritis.

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35
Q

Which antibodies can pre-date the development of rheumatoid arthritis (i.e. may indicate that a patient will develop the condition at some point)?

A

Anti-CCP

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36
Q

Presentation of RA?

A

Speed of onset can vary from rapid (e.g., overnight) to gradual (e.g., over months).

Joint symptoms:
1) Pain
2) Stiffness
3) Swelling

Systemic symptoms:
- Fatigue
- Weight loss
- Flu-like illness
- Muscles aches and weakness

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37
Q

Describe the stiffness seen in RA

A

Typically worse in morning (lasts >30 minutes) and improves with activity

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38
Q

What 4 joints does RA typically affect?

A

Rheumatoid arthritis typically causes symmetrical distal polyarthritis affecting the small joints of the hands and feet:

1) Metacarpophalangeal (MCP) joints
2) Proximal interphalangeal (PIP) joints
3) Wrist
4) Metatarsophalangeal (MTP) joints (in the foot)

N.B. Large joints such as the ankle, knee, hips, and shoulders can also be affected. It can affect the cervical spine (but not the lumbar spine).

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39
Q

On palpation of joints in RA, what may they feel like?

A

1) Tenderness
2) Synovial thickening - ‘boggy’ feeling

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40
Q

Does OA or RA typically affect the distal interphalangeal joints?

A

OA (Herberden’s nodes)

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41
Q

Does OA or RA affect the lumbar spine?

A

OA

42
Q

What is palindromic rheumatism?

A

Involves self-limiting episodes of inflammatory arthritis, with pain, stiffness and swelling typically affecting only a few joints.

43
Q

How long do symptoms of palindromic rheumatism last?

A

Days, then completely resolve

44
Q

How do joints appear between episodes of palindromic rheumatism?

A

Joints appear normal between episodes.

45
Q

What may indicate that palindromic rheumatism will progress to RA?

A

Rheumatoid factor or anti-CCP antibodie

46
Q

In patients with advanced RA, what hand signs can be seen?

A

1) Z-shaped deformity to the thumb

2) Swan neck deformity (hyperextended PIP and flexed DIP)

3) Boutonniere deformity (hyperextended DIP and flexed PIP)

4) Ulnar deviation of the fingers at the MCP joints

47
Q

What is swan neck deformity?

A

hyperextended PIP and flexed DIP

48
Q

What is Boutonniere deformity?

A

hyperextended DIP and flexed PIP

49
Q

What causes Boutonniere deformity?

A

A tear in the central slip of the extensor components at the proximal interphalangeal (PIP) joint.

Extra info:
The central slip connects to the middle phalanx at the PIP, and the lateral bands go around the PIP and connect to the distal phalanx.

When the patient tries to straighten their finger, the lateral bands pull on the distal phalanx, causing the distal interphalangeal (DIP) joint to hyperextend and the PIP joint to flex.

50
Q

What is atlantoaxial subluxation?

A

Occurs in the cervical spine when the odontoid peg of the axis (C2) shifts within the atlas (C1).

51
Q

Cause of atlantoaxial subluxation?

A

Synovitis and damage to the ligaments around the odontoid peg of the axis (C2) allow it to shift within the atlas (C1).

52
Q

Complications of Atlantoaxial subluxation?

A

This is an EMERGENCY - can cause spinal cord compression

53
Q

What scan can be done to visualise atlantoaxial subluxation?

A

MRI

54
Q

What 3 pulmonary manifestations can be seen in RA?

A

1) Pulmonary fibrosis

2) Bronchiolitis obliterans (small airway destruction and airflow obstruction in the lungs)

3) Caplan syndrome (pulmonary nodules in patients with rheumatoid arthritis exposed to coal, silica or asbestos dust)

55
Q

What is Caplan syndrome?

A

When pulmonary nodules form in patients with rheumatoid arthritis exposed to coal, silica or asbestos dust)

56
Q

Give some extra-articular manifestations of rheumatoid arthritis

A

1) Pulmonary fibrosis

2) Felty’s syndrome

3) Sjögren’s syndrome

4) Anaemia of chronic disease

5) Cardiovascular disease

6) Eye manifestations

7) Rheumatoid nodules (firm, painless lumps under the skin, typically on the elbows and fingers)

8) Lymphadenopathy

9) Carpel tunnel syndrome

10) Amyloidosis

11) Bronchiolitis obliterans

12) Caplan syndrome

57
Q

What is Felty’s syndrome a triad of?

A

1) rheumatoid arthritis
2) neutropenia
3) splenomegaly

58
Q

What is Sjögren’s syndrome?

A

1) RA
2) Dry eyes
3) Dry mouth

59
Q

What are rheumatoid nodules?

A

Firm, painless lumps under the skin, typically on the elbows and fingers

60
Q

What are some eye manifestations of RA?

A

1) Dry eye syndrome (keratoconjunctivitis sicca)
2) Episcleritis
3) Scleritis
4) Keratitis
5) Cataracts
6) Retinopathy

61
Q

Cataracts in RA is a side effect of what drug treatment?

A

Steroids

62
Q

Retinopathy in RA of what drug treatment?

A

hydroxychloroquine

63
Q

what investigations can be done in suspected RA?

A

1) RF
2) Anti-CCP antibodies
3) Inflammatory markers e.g. CRP and ESR
4) Xrays of hands and feet for bone changes
5) US or MRI can be used to detect synovitis (useful when clinical findings are unclear)

64
Q

What is diagnosis of RA based on?

A

clinical findings and blood results

65
Q

What criteria can be used to make RA diagnosis?

A

The American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria

66
Q

What xray changes may be seen in RA?

A

1) Periarticular osteopenia
2) Boney erosions
3) Soft tissue swelling
4) Joint destruction and deformity (in more advanced disease)

67
Q

Which questionnaire measures functional ability in RA?

What can this be used for?

A

The Health Assessment Questionnaire (HAQ)

Can be used to assess response to treatment

68
Q

What 2 scoring systems can be used in RA?

A

1) The Health Assessment Questionnaire (HAQ)

2) The Disease Activity Score 28 Joints (DAS28)

69
Q

The Disease Activity Score 28 Joints (DAS28) involves assessing 28 joints.

What gets points?

A

1) Swollen joints
2) Tender joints
3) The ESR or CRP result

70
Q

What 2 things are used to measure success of RA treatment?

A

1) CRP

2) DAS28

71
Q

Pharmacological management of RA?

A

1) Short-term steroids (oral or intramuscular)

2) Conventional disease-modifying anti-rheumatic drugs (cDMARDs) and biologic DMARDs

3) NSAIDs (helpful for pain relief but have associated risks and side effects)

72
Q

When would short terms steroids be used in RA?

A

1) initial presentation
2) when initiating a new treatment
3) during flares to settle the inflammation and control symptoms quickly

73
Q

What are the 3 treatment options with dmards in RA?

A

1) Monotherapy with methotrexate, leflunomide or sulfasalazine

2) Combination treatment with multiple cDMARDs

3) Biologic therapies (usually alongside methotrexate)

74
Q

What are the 4 most common DMARDs used in RA?

A

1) methotrexate
2) sulfasalazine
3) hydroxychloroquine
4) leflunomide

75
Q

What is the ‘mildest’ DMARD? When would it be used?

A

Hydroxychloroquine

May be used in mild disease and palindromic rheumatism.

76
Q

How can pregnancy affect RA?

A

Pregnancy can improve symptoms, but some pregnant women experience a symptom flare.

77
Q

What are the 2 safest DMARDs in pregnancy?

A

1) Hydroxychloroquine

2) Sulfasalazine

78
Q

What is required alongside sulfasalazine in pregnancy?

A

Extra folic acid

79
Q

Which 2 DMARDs are teratogenic?

A

1) methotrexate

2) leflunomide

80
Q

Biological therapies interact with the immune system to reduce inflammation in RA.

Examples:

A

1) Tumour necrosis factor (TNF) inhibitors (e.g., adalimumab, infliximab, etanercept, golimumab and certolizumab)

2) Anti-CD20 on B cells (e.g., rituximab)

3) Anti-interleukin-6 inhibitors (e.g., sarilumab and tocilizumab)

4) JAK inhibitors (e.g., upadacitinib, tofacitinib and baricitinib)

5) T-cell co-stimulation inhibitors (e.g., abatacept)

81
Q

What is TNF?

A

Tumour necrosis factor is a cytokine involved in stimulating inflammation. Blocking TNF reduces inflammation.

82
Q

Give 3 examples of TNF inhibitors

A

1) adalimumab
2) infliximab
3) etanercept

83
Q

What is rituximab?

A

a monoclonal antibody that targets the CD20 proteins on the surface of B cells

84
Q

Complications of biologics?

A

They cause immunosuppression, increasing the risk of infection, certain cancers (e.g., skin) and reactivation of latent TB.

85
Q

How often is methotrexate given in RA?

What is given with it?

A

Given 1x a week

Folic acid 5mg is taken once a week (on a different day to the methotrexate).

86
Q

What is important about giving folic acid with methotrexate?

A

Take on DIFFERENT day to methotrexate

87
Q

Side effects of methotrexate?

A

1) Mouth ulcers and mucositis

2) Liver toxicity

3) Bone marrow suppression and leukopenia (low white blood cells)

4) Teratogenic (harmful to pregnancy) and needs to be avoided before conception in both women and men

88
Q

What is Leflunomide? How does it work?

A

Leflunomide is an immunosuppressant medication that interferes with the production of pyrimidine (an important component of RNA and DNA)

89
Q

Which DMARD interferes with production of pyrimidine?

A

Leflunomide

90
Q

Side effects of Leflunomide?

A
  • Mouth ulcers and mucositis
  • Increased blood pressure
  • Liver toxicity
  • Bone marrow suppression and leukopenia (low white blood cells)
  • Teratogenic (harmful to pregnancy) and needs to be avoided before conception in both women and men
  • Peripheral neuropathy
91
Q

Which DMARD can cause peripheral neuropathy?

A

Leflunomide

92
Q

Side effects of sulfalazine?

A

1) Orange urine

2) Reversible male infertility (reduced sperm count and quality)

3) Bone marrow suppression

93
Q

Which RA drug can cause orange urine?

A

Sulfasalazine

94
Q

Which RA drug can cause reversible male infertility?

A

Sulfasalazine

95
Q

Side effects of Hydroxychloroquine?

A

1) Retinal toxicity (reduced visual acuity (macular toxicity)
2) Blue-grey skin pigmentation
3) Hair lightening (bleaching)

96
Q

Which RA drug can cause hair lightening (bleaching)?

A

Hydroxychloroquine

97
Q

Which RA drug can cause blue-grey skin pigmentation?

A

Hydroxychloroquine

98
Q

Which RA drug can cause retinal toxicity?

A

Hydroxychloroquine

99
Q

Which RA drugs can cause reactivation of tuberculosis?

A

Anti-TNF medications

100
Q

Side effects of RA drugs:

A

Methotrexate: Bone marrow suppression and leukopenia, and highly teratogenic

Leflunomide: Hypertension and peripheral neuropathy

Sulfasalazine: Orange urine and male infertility (reduces sperm count)

Hydroxychloroquine: Retinal toxicity, blue-grey skin pigmentation and hair bleaching

Anti-TNF medications: Reactivation of tuberculosis

Rituximab: Night sweats and thrombocytopenia

101
Q
A

Yr 4 - CCC (54 decks)

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