OA and RA Flashcards
What are some of the causes of OA?
May be primary or secondary to mechanical, metabolic, hormonal, avascular necrosis or previous stress
What are the signs on physical examination for OA?
-Reduced range of movement and pain at extremes of joint movement
- Periarticular tenderness
- Crepitus
- Bony swelling and deformity due to osteophyte formation (hypertrophy of subchondral bone)
o In fingers this leads to Heberden’s nodes of the DIPs and Bouchard’s nodes of the PIPs. There may also be squaring of the first MCP
What investigations should be done for OA?
Plain film x ray
Blood tests for crp/ESR to rule out inflammation
Joint aspiration to rule out gout/septic arthritis
What is the management for OA?
Conservative: -exercise, weight loss -Building up muscle -hot and cold packs Pharmacological: -Paracetamol/NSAIDs -Intrarticular steroid injections Surgery: -Arthroscopy -Partial or full replacement
Which population group is RA most common in?
Middle-aged females
What is the pathophysiology of RA?
Autoimmune attack of the synovial membrane leads to cell proliferation and villous hypertrophy.
There is increased volume and cellularity of the synovial fluid. This causes osteopenia of the surrounding bone and atrophy of the muscles
What are the extra-articular features of RA?
Subcutaneous nodules Pulmonary - pleural thickenings and effusions Neuropathy - from nerve entrapment Anaemia of chronic disease Ocular - Scleritis and Episcleritis Renal - membranous glomerulonephritis Cardiac - pericarditis
What are the main signs seen in the hands for RA?
o Swan neck deformity; where there is flexion of the DIP and hyperextension of the PIP
o Boutonnière deformity; where there is hyperflexion of the PIP and extension of the DIP
o Z thumb
o Subluxation of the MCP joints o Radial deviation of the wrist
o Ulnar deviation of the fingers
o Extensor tendon rupture (can mimic radial nerve palsy) due to ulnar subluxation
What are the OA hand changes
Herberden’s (DIP) and Bouchard’s (PIP) nodes
What investigative criteria are used for RA? What do they include?
EULAR 2010 ACR criteria >6 Joints involved Serology - RF and CCP Symptom duration - more than 6 weeks Acute phase reactants - CRP and ESR
How is RA disease activity measured? What 4 things does it include?
DAS-28
- Joint swelling
- Joint tenderness
- Patient subjective view of their health over the past week
- Objective measure of inflammation, usually ESR
How is RA managed?
There should be physical therapy for all patients
Most patients are prescribed a regular analgesic such as NSAIDS + PPI
In flares or new patients a short term course of steroids can be used
DMARDs should be considered in all patients e.g. methotrexate
Patients are usually commenced on triple therapy of Methotrexate, a steroid and another DMARD
Biological therapies can be used when a trial of 2 DMARDs have failed and the DAS-28 score is >5.2
What are the 4 DMARDs?
Methotrexate
Sulphasalazine
Hydroxychloroquine
Leflunomide
Wht is sjogrens syndrome?
It is a slowly progressive inflammatory disease of the exocrine glands, particularly the salivary and lacrial glands
How do sjogren’s patients typically present?
They present with dryness of muscosal membranes including mouth, eyes and genitals
It can also cause a polyarthritis, lung, kidney and liver involvement
What investgations should be done for sjogrens?
Anti-Ro and anti-La antibodies are characteristic of Sjögren’s
What is the management of sjogren’s?
Mainly symptomatic management as there is no real treatment
When should septic arthritis be considered?`
In any single hot swollen joint
What are the risk factors for spetic arthritis?
Pre-existing joint disease (esp RA) Diabetes Immunosuppressed Chronic renal failure Increased age
What are the investigations for spetic arthritis?
Urgent joint aspiration and culture
Blood cultures are essential prior to antibiotics
What is the management of septic arthritis?
If in doubt start empirical antibiotics until sensitivities are known
Start antibiotics according to trust guidelines e.g. flucloxacillin
Continue antibiotics for prolonged period e.g. 2 weeks IV then consider 2-4 weeks PO
Consider orthopaedic review for joint wash out
How long do DMARDs take to start working?
6-12 weeks
What is the most dangerous side effect of DMARDs?
Immunosupression, especially with methotrexate
This can cause a pancytopenia and increase susceeptibility to infection, require regular FBC and LFT monitoring
What are the main side effects of methotrexate?
Pneumonitis
Hepatotoxicity
Oral ulcers
Teratogenic
What are the main side effects of sulfasalazine?
Rash
Reduced sperm count
oral ulcers
GI upset
What are the side effects of Leflunomide?
Teratogenic
oral ulcers
hepatotoxicity
What are the side effects of hydroxychloroquine?
Retinopathy
Annual eye screening required
What are the requirements to start biological agents?
Must have trialed 2 DMARDs
What are some of the side effects of biologic agents?
Immunosupression
Reactivation of TB
Worsening heart failure
