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PR3154 > OA / RA > Flashcards

OA / RA Flashcards

1
Q

[RA] What are the risk factors associated with JAK inhibitors?

A

(1) CVS
- 65 yo
- Smoking
- Obesity
- Diabetes mellitus
- Hypertension
(2) Malignancy
(3) Thromboembolic events
- HI, MF, blood clotting disorders
- Use of CRC / HRT
- Undergoing major surgery
- Immobility

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2
Q

[RA] Side effects of bDMARDs / tsDMARDs

A
  • hyperlipidaemia
  • Pulmonary toxicity -> esp. w/ interstitial disease
  • GI perforation (esp. w/ IL-6 inhibitors and JAKi)
  • Thrombosis (esp. w/ IL-6 inhibitors and JAKi)
  • Autoimmune disease (eg. SLE)
  • Myelosuppression
  • Infections
  • Injection site reaction
  • Hepatic -> raised aminotransferases
  • Malignancy risk
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3
Q

[RA] Side effects of Methotrexate

A

[GI] N / D, anorexia, stomatitis, mouth/GI ulcer;
[Liver] raised transaminases, cirrhosis;
[Lungs] fibrosis;
[Haem] myelosuppression, folic acid antagonist;
[Derm] photosensitive, TENS, SJS.

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4
Q

[RA] Pre-screening before starting DMARDs

A

(1) Infections
- TB
- Hep B or C
(2) Vaccinations
- Pneumococcal
- Influenza
- Hep B
- Varicella zoster / Herpes zoster
(3) Monitoring
- CBC: differential whites and platelet count
- LFT (alt, ast, albumin, bilirubin)
- Lipids
- SCr

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5
Q

[RA] List 3 poor prognosis factors for RA.

A
  • Persistent moderate / high disease activity
  • High acute phase reactant levels
  • High swollen joint count
  • Presence of RF / ACPA (esp. at high levels)
  • Presence of early erosions
  • Failure of >= 2 DMARDs
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6
Q

[RA] Suggest 3 non-pharmacological interventions for RA.

A
  • Patient education (misconceptions, expectations);
  • Psychosocial interventions (eg. CBT);
  • REST inflamed joint (using splints) –> but should not rest due to fatigue –> lead to sedentary lifestyle;
  • Physical activity (eg. swimming)
  • PT/OT referral
  • Nutritional & dietary counselling (anorexia, poor dietary intake, weight mgmt, reducing inflammation, reducing ASCVD risk)
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7
Q

[RA] what exercises should OA vs RA patient do?

A

OA (30 min x3 / week)
- Strengthening (body mobility exercises)
- neuromuscular training
- Low-impact aerobic (eg. walking, aquatic aerobics)
- mind-body (eg. Tai Chi)

RA
- range of motion exercises (aquatic exercises)
- increase muscle strength (eg. elastic bands, dumbbells)
- Aerobic exercises (swimming, running, cycling)
- AVOID high-intensity, weight-bearing exercises

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8
Q

[OA] Suggest 3 non-pharmacological interventions for OA.

A
  • Patient education (self-efficacy and self-management, misconceptions, expectations);
  • Physical activity (eg. tai chi, elastic bands)
  • Weight management
  • use of Cane –> support themselves
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9
Q

Criteria for diagnosis of RA

A

1) Early morning stiffness x >= 1hr x >= 6 wks
2) Swelling of >= 3 joints x >= 6 wks
3) Swelling of wrist / MCP / PIP joints
4) Rheumatoid nodules
5) +ve RF or anti-CCP tests
6) Radiographic changes

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10
Q

DDx between OA and RA

A

OA
- early morning stiffness < 30 min
- usually weight-bearing joints
- DIP / PIP are affected more often
- No systemic symptoms

RA
- +ve RF or anti-CCP results
- worse after rest
- PIP / MCP / wrist are affected more
often
- worse with rest
- symmetrical presentation
- has systemic Sx

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11
Q

List 5 systemic Sx experienced by RA patients.

A
  • Generalized aching / stiffness
  • Fatigue
  • Fever
  • Weight loss
  • Depression

Extra-articular complications
- Sjogren’s
- CAD, pericarditis, myocarditis, AF, HF
- Anaemia, Felty’s Syndrome
- Rheumatoid nodules
- Rheumatoid vasculitis

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12
Q

Red Flags for Joint Pain are:

A

1) Infection - systemic sx like Fever
2) Trauma -> fractures, dislocation
3) Malignancy-related causes

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13
Q

Risk Factors for OA are:

A

Genetic predisposition;
Anatomic factors (aka “bow-legged);
Joint injury (from sports, surgery);
Obesity;
Aging;
Gender
Occupation

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14
Q

How does inflammation occur in OA?

A

Formation of cartillage “shards” -> inflammation and pathologic changes in joint capsules & synovium -> effusion and synovial thickening.

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15
Q

How does pain occur in OA?

A

1) activation of nociceptive nerve endings
- mechanical irritant
- chemical irritant
2) distension of synovial capsule
- increased joint fluid
- microfracture
- periosteal irritation
- ligament, synovium or meniscus damage

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16
Q

Describe the 3 stages of OA.

A

Stage 1: predictable sharp pain w/ mechanical insult.
Stage 2: more constant pain, w/ unpredictable episodes of stiffness.
Stage 3: Constant dull/aching pain, punctuated by episodes of often unpredictable intense, exhausting pain.

17
Q

Criteria for diagnosis of OA

A

NICE guidelines - without imaging:
1) >= 45 yo
2) Activity-related joint pain
3) Morning stiffness <= 30 min

18
Q

What are the goals of therapy for RA?

A

1) Achieve remission or low disease activity.
- >= 6 mo
- Boolean 2.0 criteria (tender and swollen joint count, CRP <= 1 mg/dL, PGA <= 2cm)
2) Functional improvement
3) Stop disease progression
4) Prevent joint damage
5) Control pain

19
Q

What are the goals of therapy for OA?

A

1) Relieve pain (and inflammation if any) - via pharmacological means
2) Improve / preserve range of motion & joint function - via non-pharmacological means
3) Improve QoL

20
Q

Pharmacological Treatment protocol for RA is:

A

1) Methotrexate - 1st line
- + PO glucocorticoids (3mo) / IA glucocorticoid q3 mo (max 3 times a year for same joint)
- if contraindicated -> use sulfasalazine, leflunomide or hydroxychloroquine

If no improvement after 3 mo, or did not hit remission after 6 mo:
2) consider adding bDMARD / tsDMARD.
- consider risk factors for tofacitinib
- consider poor prognostic factors
3) Switch bDMARD / tsDMARD

21
Q

Monitoring parameters for Leflunomide are:

A

FBC
LFT (AST, ALT, albuminu, billirubin)

22
Q

Monitoring parameters for Methotrexate are:

A

FBC
LFT (AST, ALT, albuminu, billirubin)
SCr

23
Q

Monitoring parameters for Sulfasalazine are:

A

FBC

24
Q

Monitoring parameters for Hydroxychloroquine are:

A

Eye exam (ophthalmoscopy)

25
Q

In which DMARD will G6PD patients have a higher risk of anaemia?

A

Sulfasalazine
Hydroxychloroquine

Other forms of anaemia:
Tofacitinib
TNF alpha blockers

26
Q

Which DMARD has teratogenic effects?

A

Methotrexate
Leflunomide

27
Q

Pharmacological Treatment for OA is:

A

1) Topical NSAIDs -> most feasible for knee
2) Oral NSAIDs -> dangers of toxicity, + PPI prophylaxis.
3) PO paracetamol / Tramadol
- used when contraindicated for NSAIDs
4) IA glucocorticoid injections (4-6 wks)
- consider contraindications of Infection, Fracture and joint instability and joint osteoporosis at site.

28
Q

[Side Effects] Oral NSAIDs

A

[GI]
- N, dyspepsia, anorexia, abdo. pain
- GI bleed, ulceration, perforation
[CVS - for diclofenac and coxibs] MI, stroke, vascular death risks in patients w/ CHF, IHD or PAD if NSAID is used long term.
[Renal] AKI
[Hypersensitivity]
- Allergic rxn -> avoid all NSAIDs and coxibs if anaphylaxis is involved.
- Pseudoallergic rxn -> coxibs may be used w/ caution.

[Others]
- Skin reactions: more likely w/ -oxicam, sulindac, diflunisal
- Hypertension
- Platelet: stop NSAIDs 3 days before surgery (1 wk for aspirin)
- [CNS] drowsiness, dizziness, headaches, tinnitus.

29
Q

What are red flags for NSAID use suggesting severe GI complications / bleeding?

A
  • Fatigue
  • Severe dyspepsia
  • Signs of GI bleeding (melena)
  • unexplained blood loss anaemia
  • Iron deficiency
30
Q

What are risk factors for Renal toxicity with NSAID use?

A
  • CKD (max <5-7d) -> not to use at all if eGFR < 15)
  • Aminoglycosides, amphotericin B, radiocontrast material
  • Triple Whammy: Diuretics, ACEi/ARB
  • Volume depletion (emesis, diarrhea, sepsis, haemorrhage)
  • Effective arterial volume depletion (HF, nephrotic syndrome, cirrhosis)
  • Severe hyper-Ca
  • Renal artery stenosis

(!) To monitor SCr and Electrolytes.

31
Q

[RA] what are poor prognostic factors in RA?

A
  • Persistent moderate / high disease activity
  • High Acute Phase Reactant levels
  • high Swollen Joint count
  • Presence of RF / ACPA
  • Presence of early erosions
  • Failure of >= 2 DMARDs
32
Q

what are the Contraindications for short-term IA glucocorticoid use?

A

Infection: periarticular infection, septic arthritis;
Fracture: periarticular;
Joint: instability, juxtaarticular osteoporosis

33
Q

When should Duloxetine be used in OA?

A

Moderate-to-severe symptoms +
contraindication / inadequate response to NSAIDS.

Has SNRI side effects: Drowsy, Insomnia, Dizziness, Stomach upset, Changes in sexual dysfunction.

34
Q

How should patients maximise the effectiveness of joint replacement?

A

Postoperative rehabilitation

35
Q

When is joint replacement in OA Contraindicated?

A
  • Active infection
  • Chronic lower extremity ischaemia
  • Skeletal immaturity

PR3154 (10 decks)

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