RA

Question 1

Prodromal effects of RA

Answer 1

Fatigue, weakness, low grade fever, joint pain, loss of appetite, stiffness and muscle aches

Question 2

Diagnostic criteria

Answer 2

Joint involvement
- most commonly hands, wrists, feet
- may involve: elbows, shoulders, Hip, knees, ankles
Serology
duration of symptoms
acute phase reactants

If patient has a score of 6 or more they will be diagnosed with RA

Question 3

Extra-articular manifestations of RA

Answer 3

Rheumatoid nodules - common in hands elbows and forearms - mainly seen in erosive disease
Cardiac - risk of CV mortality, pericarditis, conduction abnormalities
Vasculitis - inflammation of small superficial blood vessels
Felty’s - Splenomegaly, and neutropenia
Pulmonary - pleural effusions, pulmonary fibrosis, nodules
Ocular - keratoconjunctivitis sicca, inflammation, and nodules

Question 4

Lab indicators

Answer 4

anemia -
thrombocytosis,
ESR - Elevated in RA >20
CRP- >0.5mg/dL is positive
RF - most RA patients are RF+
ANA- reported as a titer
Anti-CCP/ACPA - marker of poor prognosis
joint aspiration - turbid, WBC: 5,000-50,000mm^3
radiographic finding - joint space narrowing and erosions of bone

Question 5

Treatment for DMARD-naive patients with moderate to high disease activity

Answer 5

Methotrexate

Question 6

Treatment in DMARD-naive patients with low disease activity

Answer 6

Hydroxychloroquine

Question 7

Rheumatoid arthritis VS osteoarthritis

Answer 7

RA : can happen at any age - systemic involvement, Inflammation, elevated ESR, bilateral joint involvement, >1 hour of morning stiffness, Pannus often present, RF positive, Subcutaneous nodules, typical presentation is malaise, fatigue, musculoskeletal pain, fever

Osteoarthritis: happens around 40 YO or older, unilateral or bilateral joint involvement with no inflammation and morning stiffness <30 minutes, and presentation is deep, aching pain

Question 8

bDMARDs

Answer 8

TNF inhibitors : Etanercept, Infliximab, Adalimumab, Golimumab, Certolizumab

Anakinra - IL-1 inhibitor

Abatacept - T-Cell co stimulation modulator

IL-6 inhibitors- Tocilizumab and Sarilumab

Rituximab - anti-CD20

Question 9

TNF inhibitors bDMARDs - ADRs

Answer 9

HA, rash, injection site reaction, risk of infection, exacerbation of CHF, risk of malignancy, risk of demyelinating disease

Question 10

tsDMARDs

Answer 10

JAK inhibitors - Tofacitinib, Baricitinib, Upadacitinib

Question 11

NSAIDs - Celecoxib

Answer 11

IF PATIENT HAS SULFA ALLERGY DO NOT USE CELECOXIB

Question 12

Corticosteroid Adverse effects Short term and long term

Answer 12

Short: Hyperglycemia, Gastritis, Mood changes, Elevated BP

Long: Aseptic Necrosis, Cataracts, obesity, growth failure, osteoporosis

Question 13

Methotrexate dosing regimen

Answer 13

2.5mg tablets
Dose: 7.5mg per week by mouth or intramuscularly
(up to 15-20mg - weekly dose can be taken in one day)
Onset: 1-2 months

Question 14

HCQ monitoring

Answer 14

Vision exams every 6-12 months and at baseline
HCQ can cause ocular effects and impact vision

Question 15

Treatment algorithm

Answer 15

Therapy with MTX should be first strategy and for patient with contraindications ot MTX start leflunomide or sulfasalazine

Can combine with short term glucocorticoids

If patient has inadequate response and poor prognostic factors add bDMARD or tsDMARD (JAK inhibitors)

If patient has inadequate response and no poor prognostic factors change to or add a second csDMARD

If patient has inadequate response to csDMARD + bDMARD or tsDMARD combo therapy change the bDMARD or JAK inhibitor

Question 16

Used for moderate to severe disease

Answer 16

Golimumab
Certolizumab
Anakinra - for pts who have failed one or more DMARDs
Abatacept - for pts who had inadequate response to one or more DMARDs
Tocilizumab - for pts who had inadequate response to one or more DMARDs
Sarilumab - for pts who had inadequate response to one or more DMARDs
Rituximab - for pts who had inadequate response to TNF inhibitors
JAK inhibitors - for pts who had inadequate response to TNF inhibitos

Question 17

If patient has sulfa allergy what meds are contraindicated

Answer 17

Sulfasalazine
Celecoxib