OA / RA Flashcards
[RA] What are the risk factors associated with JAK inhibitors?
(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
[RA] Side effects of bDMARDs / tsDMARDs
- 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
[RA] Side effects of Methotrexate
[GI] N / D, anorexia, stomatitis, mouth/GI ulcer;
[Liver] raised transaminases, cirrhosis;
[Lungs] fibrosis;
[Haem] myelosuppression, folic acid antagonist;
[Derm] photosensitive, TENS, SJS.
[RA] Pre-screening before starting DMARDs
(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
[RA] List 3 poor prognosis factors for RA.
- 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
[RA] Suggest 3 non-pharmacological interventions for RA.
- 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)
[RA] what exercises should OA vs RA patient do?
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
[OA] Suggest 3 non-pharmacological interventions for OA.
- Patient education (self-efficacy and self-management, misconceptions, expectations);
- Physical activity (eg. tai chi, elastic bands)
- Weight management
- use of Cane –> support themselves
Criteria for diagnosis of RA
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
DDx between OA and RA
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
List 5 systemic Sx experienced by RA patients.
- 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
Red Flags for Joint Pain are:
1) Infection - systemic sx like Fever
2) Trauma -> fractures, dislocation
3) Malignancy-related causes
Risk Factors for OA are:
Genetic predisposition;
Anatomic factors (aka “bow-legged);
Joint injury (from sports, surgery);
Obesity;
Aging;
Gender
Occupation
How does inflammation occur in OA?
Formation of cartillage “shards” -> inflammation and pathologic changes in joint capsules & synovium -> effusion and synovial thickening.
How does pain occur in OA?
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
Describe the 3 stages of OA.
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.
Criteria for diagnosis of OA
NICE guidelines - without imaging:
1) >= 45 yo
2) Activity-related joint pain
3) Morning stiffness <= 30 min
What are the goals of therapy for RA?
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
What are the goals of therapy for OA?
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
Pharmacological Treatment protocol for RA is:
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
Monitoring parameters for Leflunomide are:
FBC
LFT (AST, ALT, albuminu, billirubin)
Monitoring parameters for Methotrexate are:
FBC
LFT (AST, ALT, albuminu, billirubin)
SCr
Monitoring parameters for Sulfasalazine are:
FBC
Monitoring parameters for Hydroxychloroquine are:
Eye exam (ophthalmoscopy)
In which DMARD will G6PD patients have a higher risk of anaemia?
Sulfasalazine
Hydroxychloroquine
Other forms of anaemia:
Tofacitinib
TNF alpha blockers
Which DMARD has teratogenic effects?
Methotrexate
Leflunomide
Pharmacological Treatment for OA is:
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.
[Side Effects] Oral NSAIDs
[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.
What are red flags for NSAID use suggesting severe GI complications / bleeding?
- Fatigue
- Severe dyspepsia
- Signs of GI bleeding (melena)
- unexplained blood loss anaemia
- Iron deficiency
What are risk factors for Renal toxicity with NSAID use?
- 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.
[RA] what are poor prognostic factors in RA?
- 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
what are the Contraindications for short-term IA glucocorticoid use?
Infection: periarticular infection, septic arthritis;
Fracture: periarticular;
Joint: instability, juxtaarticular osteoporosis
When should Duloxetine be used in OA?
Moderate-to-severe symptoms +
contraindication / inadequate response to NSAIDS.
Has SNRI side effects: Drowsy, Insomnia, Dizziness, Stomach upset, Changes in sexual dysfunction.
How should patients maximise the effectiveness of joint replacement?
Postoperative rehabilitation
When is joint replacement in OA Contraindicated?
- Active infection
- Chronic lower extremity ischaemia
- Skeletal immaturity
