RA Flashcards
What is the most common inflammatory arthritis
RA
What Abs are prevelant in RA
Circulating autoantibodies, either rheumatoid factor (RF), anticyclic citrullinated peptide antibodies (ACPAs), or both, occur in approximately in 70% of patients.
What is the hallmark of inflammatory arthritis and RA
Hallmark of inflammatory arthritis and RA
Worse in AM or after prolonged periods of rest
Lasts for hours and improved with activity
What part of the body is usually spared by RA
Thoracic, lumbar and sacral spine
Progression of RA throughout the body
MCP, PIP and MTP initially then
Wrists, knees, elbows, ankles, hips and shoulders (roughly that order)
Common deformities is RA
Ulnar deviation of the MCP joints
Boutonnière deformity
Swan neck deformity
Subluxation of the toes at the MTP -> ulcers on top of the toes
Where does RA effect the spine
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
What is Feltys Syndrome (triad)
RA + Splenomegaly + Leukopenia (usually neutropenia <2000)
What are the hematologist manifestations of RA
Anemia
Increased risk of lymphoma (Non-Hodgikn’s Lymphoma)
Leukocytosis
Eosinophilia
Thrombocytosis when RA is active
While a pt with RA AND SJS have postive Anti RO or Anti La Abs
Usually no
Secondary SJS
What is the most specific Ab for RA
Anti-CCP antibodies: present 60-70%
Rheumatoid Factor: present ~50% at presentation
ANA: + ~30%
How often should RA pts be imaged
Obtain at onset and at regular intervals q 1+ yrs to monitor
What is the increased risk for RA pts following joint replacement surgery
Spontaneous septic arthritis is common
often due to Staphylococcus aureus or Streptococcus species
What is the 4/7 criteria for RA
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
What is the 2010 criteria to Dx RA
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
What is Feltys Syndrome
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
What is the approach to using NSAIDs for RA
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
What is the approach to using steroids in RA pts
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
What must pts receive prior to initiation of DMARs
Prior to DMARDS patients should receive recommended vaccinations.
Live vaccines contraindicated once biologic DMARDS started
What is the standard of care DMARD for RA
Methotrexate
Also anchor drug in successful combinations of synthetic DMARDs
Biologic DMARDS also more effective when used with methotrexate.
What should be taken with Methotrexate to recude ADE
Oral Folate
What is the monitoring timeframe for methotrexate
Monitor CBC, BMP, LFT, serum creatinine every 12 weeks. (every 2-4 weeks during initiation of therapy).
Check screening hepatitis panel before starting
ADE of Methotrexate
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
What is the ADE of Hydroxychlorquine
Retinal toxicity—uncommon, but serious
Increased risk over time—cumulative dose
Initial eye exam and annual eye exams after 5 yrs of tx
What are the 5 Synthetic DMARDS
Methotrexate Hydroxychlorquine Sulfasalazine Leflunomide Minocycline
What is important about using Leflunomide
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
If a woman is considering becoming pregnant and is on Leflunomide
What Rx must be given
Use cholestyramine to eliminate leflunomide if woman is considering to become pregnant
What is the ADE of Minocycline
Long term therapy (over 2 years) may lead to cutaneous hyperpigmentation.
How must biological DMARDs be administered ?
Must be given SubQ or as IV infusions
MOA of RITUXIMAB
Depletes CD20+ B cells
MOA of abatacept
Inhibit T cell costimulation
MOA of Tocilizumab
Block the receptor for interlukin 6
What is the screening and w/u prior to using a biological DMARD
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
What are the C/I for Biolgical DMARDs
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
Should two biologics be used at the same time
No!
Combine Biologics with methotrexate for improved efficacy
TNF-A inhibitors
End in -mab except for Etanercept
If a pt is taking anti-TNF Tx what is the increased RSK with RA
Infections including septic arthritis
What is the role of the PCM in the tx of RA
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
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
What are the prominent extra articular manifestations of RA
Extra-articular manifestations: pleural effusions, pulmonary nodules and interstitial fibrosis, subcutaneous nodules, pericarditis, secondary Sjogren syndrome, vasculitis
