ORTHO 224 Rheumatoid Arthritis Flashcards
Rheumatoid arthritis
Chronic systemic inflammatory disorder primarily affecting the synovium due to autoantibodies against IgG and CCP
What is the pathology behind RA?
There is synovial inflammation leading to hyperplasia with inflammatory and vascular infiltration = Pannus formation
This causes damage to the underlying cartilage by blocking the normal route of nutrition for the joint
What are the major cell types in the Pannus of RA?
T-lymphocytes and macrophages
What leads to deformities in RA?
bone exposure and erosions
How does RA present?
Slow symmetrical progression of a peripheral monoarthritis - usually between 30-50 years of age
More common in females than males
What are the early indications of RA?
pain and stiffness in the small hand and foot joints - worse in the morning
fatigue is a very common complaint
eventual restriction in movement
What can you see in RA hands?
ulnar deviation at the MCP joints fixed flexion (boutanniere?) or fixed extension (swan neck deformity)
What can you see in RA shoulder?
mimic of rotator cuff tendonitis
What can happen in RA feet?
swelling of MTP joints, broader feet and hammer toes with flat medial arch
What extra articular features can you have in RA?
nodules, vasculitis, lung (effusion/fibrosis/bronchiectasis), Heart (pericarditis, valvular disease); eyes (episcleritis/keratoconjunctivitis); Neuro (entrapment neuropathies); Haem (anaemia, thrombocytosis)
What are the 5 steps of treatment for RA?
Analgesia NSAIDS Corticosteroids DMARDs Biological agents
What NSAIDs are commonly used in RA?
ibuprofen, diclofenac and naproxen
What DMARD’s are used in RA?
methotrexate (+folic acid) : oral/subcut, once a week
sulfasalazine: daily, oral
leflunomide: daily, oral, a pyrimidine synthesis inhibitor
What are the monoclonal ab drugs used in RA?
infliximab - (chimeric)
adalimumab (human)
certolizumab (humanized)
entacerecept (fusion protein) - acts on soluble receptor protein
What is rituximab
A new cytokine modulate = lysis of CD20 B cells
= significant improvement in RF+ve RA
What is a vasculitis?
Inflammation within or through a vessel wall leading to impairment of blood flow and sometimes damage to vessel integrity = haemorrhage and organ infarct
What is Polymyalgia Rheumatica?
Sudden onset of severe pain and stiffness in the neck, shoulders, hip and lumbar spine
Worse in the morning and improves with activity
Between 50-60years
Malaise, weight loss
ESR >60 and raised CRP
Dramatic response to small dose corticosteroid
Describe Giant Cell Arteritis
Vasculitis commonly accompanying PMR
Affects large vessels - arch of aorta & branches
severe headaches, jaw claudication, fatigue, visual disturbances
Can lead to MI, stroke, blindness and tissue necrosis
Tx with high dose prednisolone
Describe Wegners Granulomatosis
Destructive vasculitis involving midline structures (ELK)
ENT, lungs and kidneys but also: skin and eyes
ENT most common presentation: sinusitis, otitis media, discharge
Lungs: Haemoptysis, SOB, pleuritis
Associated with ANCA antibodies
Describe polyarteritis nodosa
Rare condition
Middle aged men
multi-system vasculitis
aneurysm formation in medium sized vessels
constitutional symptoms, mononeuritis multiplex, HTN, GI infarct/necrosis, testicular pain, haematuria
How generally do you treat a vasculitis?
Inducing remission: steroids, cyclophosphamide, biologics
Maintain remission: azathioprine, methotrexate, mycophenolate, biologics
Monitor
Describe SLE?
Connective tissue disease
F>M (9:1) between 20&40 years
arthralgia, rash, constitutional sx, ulcers, myalgia, raynauds and a whole HOST of problems
ANA/ANF if -ve rule out SLE
dsDNA ab’s specific for SLE but only in 50%
variety of other ab’s
Manage: hydoxycloroquine for joints, steroids for severe systemic disease and iv cyclophosphamide for renal/late stage
Describe scleroderma
Connective tissue disease
hard skin, localised or systemic
CREST syndrome: Calcinosis, Raynauds, Eosophagus, sclerodactyly, telengectasia
Vascular complications
