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Senoir 21-2 > RA > Flashcards

RA Flashcards

1
Q

What is the most common inflammatory arthritis

A

RA

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2
Q

What Abs are prevelant in RA

A

Circulating autoantibodies, either rheumatoid factor (RF), anticyclic citrullinated peptide antibodies (ACPAs), or both, occur in approximately in 70% of patients.

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3
Q

What is the hallmark of inflammatory arthritis and RA

A

Hallmark of inflammatory arthritis and RA

Worse in AM or after prolonged periods of rest

Lasts for hours and improved with activity

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4
Q

What part of the body is usually spared by RA

A

Thoracic, lumbar and sacral spine

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5
Q

Progression of RA throughout the body

A

MCP, PIP and MTP initially then

Wrists, knees, elbows, ankles, hips and shoulders (roughly that order)

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6
Q

Common deformities is RA

A

Ulnar deviation of the MCP joints

Boutonnière deformity

Swan neck deformity

Subluxation of the toes at the MTP -> ulcers on top of the toes

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7
Q

Where does RA effect the spine

A

C1-C2 usually leading to minor subluxation

Risk spinal cord injury with intubation or other neck manipulation
C-spine series must be part of preoperative evaluation

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8
Q

What is Feltys Syndrome (triad)

A

RA + Splenomegaly + Leukopenia (usually neutropenia <2000)

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9
Q

What are the hematologist manifestations of RA

A

Anemia

Increased risk of lymphoma (Non-Hodgikn’s Lymphoma)

Leukocytosis

Eosinophilia

Thrombocytosis when RA is active

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10
Q

While a pt with RA AND SJS have postive Anti RO or Anti La Abs

A

Usually no

Secondary SJS

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11
Q

What is the most specific Ab for RA

A

Anti-CCP antibodies: present 60-70%

Rheumatoid Factor: present ~50% at presentation

ANA: + ~30%

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12
Q

How often should RA pts be imaged

A

Obtain at onset and at regular intervals q 1+ yrs to monitor

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13
Q

What is the increased risk for RA pts following joint replacement surgery

A

Spontaneous septic arthritis is common

often due to Staphylococcus aureus or Streptococcus species

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14
Q

What is the 4/7 criteria for RA

A

Must be present for at least 6 weeks

  • morning stiffness
  • Arthritis of three joint areas
  • Arthritis of the hands
  • symmetric arthritis
  • rheumatoid nodules
  • serum RF
  • postive rads findings
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15
Q

What is the 2010 criteria to Dx RA

A

Presence of synovitis in at least one joint

Absence of an alternative diagnosis better explaining the synovitis

Total score of at least 6 (of a possible 9) from the individual scores in four domains. The highest score achieved in a given domain is used for this calculation

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16
Q

What is Feltys Syndrome

A

A “complication” of RA affecting up to 3% of patients.
Not a separate disease process

30% of patients with Felty have large granular lymphocyte syndrome (an indolent leukemia)

Increased bacterial infections and non-healing ulcers related to leukopenia

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17
Q

What is the approach to using NSAIDs for RA

A

Analgesic and anti-inflammatory properties

  • Do NOT alter disease outcomes
  • Do NOT use as sole therapy for RA

Consider GI prophylaxis with PPI especially in older patients (>65yo)

Consider pts at risk for cardiovascular dz

18
Q

What is the approach to using steroids in RA pts

A

DMARDs take 2-6 months to reach maximal effect.

Used as “Bridge” to DMARD therapy, suppress inflammation

Low-dose therapy probably OK for most patients
-Typically 5-10mg prednisone daily while titrating DMARD to effect

19
Q

What must pts receive prior to initiation of DMARs

A

Prior to DMARDS patients should receive recommended vaccinations.

Live vaccines contraindicated once biologic DMARDS started

20
Q

What is the standard of care DMARD for RA

A

Methotrexate

Also anchor drug in successful combinations of synthetic DMARDs
Biologic DMARDS also more effective when used with methotrexate.

21
Q

What should be taken with Methotrexate to recude ADE

A

Oral Folate

22
Q

What is the monitoring timeframe for methotrexate

A

Monitor CBC, BMP, LFT, serum creatinine every 12 weeks. (every 2-4 weeks during initiation of therapy).

Check screening hepatitis panel before starting

23
Q

ADE of Methotrexate

A

Contraindicated: Hep B or Hep C, ongoing ETOH use, renal impairment
-Check screening hepatitis panel before starting

Adverse effects: Bone marrow suppression and development of pneumonitis

24
Q

What is the ADE of Hydroxychlorquine

A

Retinal toxicity—uncommon, but serious

Increased risk over time—cumulative dose

Initial eye exam and annual eye exams after 5 yrs of tx

25
Q

What are the 5 Synthetic DMARDS

A 
Methotrexate 
Hydroxychlorquine 
Sulfasalazine 
Leflunomide 
Minocycline
26
Q

What is important about using Leflunomide

A

It’s very similar to methotrexate with a longer half life

women need blood tests drawn prior to pregnancy even if stopped med years prior

Use cholestyramine to eliminate leflunomide if woman is considering to become pregnant

27
Q

If a woman is considering becoming pregnant and is on Leflunomide

What Rx must be given

A

Use cholestyramine to eliminate leflunomide if woman is considering to become pregnant

28
Q

What is the ADE of Minocycline

A

Long term therapy (over 2 years) may lead to cutaneous hyperpigmentation.

29
Q

How must biological DMARDs be administered ?

A

Must be given SubQ or as IV infusions

30
Q

MOA of RITUXIMAB

A

Depletes CD20+ B cells

31
Q

MOA of abatacept

A

Inhibit T cell costimulation

32
Q

MOA of Tocilizumab

A

Block the receptor for interlukin 6

33
Q

What is the screening and w/u prior to using a biological DMARD

A

Screen for latent TB
(Active TB or Untreated latent TB is an absolute contraindication to use of biologic DMARDs)

Screen for HEP B and C

34
Q

What are the C/I for Biolgical DMARDs

A

Anti TNF agents contraindicated with NYHA Class III or IV CHF or EF <50%

Solid malignancy or non-melanoma skin cancer treated within 5 years

A history of treated skin melanoma

History of treated lymphoproliferative malignancy

35
Q

Should two biologics be used at the same time

A

No!

Combine Biologics with methotrexate for improved efficacy

36
Q

TNF-A inhibitors

A

End in -mab except for Etanercept

37
Q

If a pt is taking anti-TNF Tx what is the increased RSK with RA

A

Infections including septic arthritis

38
Q

What is the role of the PCM in the tx of RA

A

Consider phone consultation first to initiate therapy until patient is seen

Test for TB, Hepatitis B, C, HIV etc

Immunizations prior to immunosuppression (pneumococcal, flu)

Bridge communication between Rheumatologist and PCM

39
Q

When treating a pt with RA

AGGRESSIVELY treat all CVD
Think about bone loss and prevent OA
Remember the pt is at an increased risk of lymphoma

A
40
Q

What are the prominent extra articular manifestations of RA

A

Extra-articular manifestations: pleural effusions, pulmonary nodules and interstitial fibrosis, subcutaneous nodules, pericarditis, secondary Sjogren syndrome, vasculitis

Senoir 21-2 (77 decks)

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