RA Flashcards
what is RA?
- autoimmune, chronic, systemic
- infl dz, symmetrical
- targets synovial tissues, diarthrodial tissues
- polyarthritis
- extra-articular features
- idiopathic
RA- systemic features
- fatigue, fever, anemia
- elevated ESR, CRP
- constitutional sx’s- malaise, myalgia, depression
RA- immunopathogenesis
- RF produced by RA synovium
- RF’s fix complement- recruit PMN’s
- CCP ab’s
RA- pathophysiology
- genetic factors (1/3 of pts)- inc risk of severe RA
- infiltration of leukocytes, cytokines, macrophages- act T cells
- B cells prod autoab’s
- pannus formation
RA- imaging?
- Xrays- hands of feet
- CT- more sensitive detecting erosions
RA- tx
- NSAID- for pain control
- DMARD
- low dose steroid for a few wks
RA- epidemiology
- F 2-3X > M; 30-60 yo
- Native Ams- 5%
- improves during pregnancy
why is RA important?
- significant mortality- CAD, HF due to endo damage from chronic infl
- young adults- peak incidence
- disables pts
- no perfect tx
mortality assoc w RA
- infection (immunosuppressive drugs)
- renal dz
- GI dz
- HD
- malignancy
RA classification criteria
Aat least 1 joint w clinical synovitis
- joint involvement- mult, small joints
- serology- RF, ACCP
- CRP and ESR
- duration of sx’s (>6 wks)
Articular manifestations of RA
- diarthrodial synovial joint
- starts in hands and feet- MCP, PIP, MTP
- later larger joints
- C1-C2
- inc risk osteoporosis
Hands
- DIP almost never involved
- swan neck
- boutonniere
rheumatoid nodules
- elbow
- always RF +
RA- radiographic progression
- bony erosions
- feet- MTP
- wrist- radial deviation; carpal tunnel syndrome
- knee- Bakers cyst (popliteal)
- C1-2
PE
- tenderness, swelling, warmth, erythema fever
- wt loss, anorexia
- symmetrical joint involvement
- infl at least 6 wks
Extra-articular manifestations
- more common in RF or ACCP +
- subcutaneous nodules (elbow)
- Pyoderma gangrenosum
- rheumatoid vasculitis
- HF, pericarditis, CAD (chronic endo infl)
- lungs
- secondary sjogrens syndrome
Pyoderma gangrenosum
- tender reddish purple papule
- leads to necrotic, non-healing ulcer
Rheumatoid vasculitis
-purpura, petechial, splinter hemorrhages, digital infarct
RA- lungs
- pleuritis most common
- nodules, interstitial lung dz
- pulm fibrosis
Caplan syndrome
-nodular densities after exposure to coal or silica dust (pneumoconiosis) + RA
dry eyes/mouth- rule out what?
- SLE
- AIDS assoc keratoconjunctivitis
- vit A def
Sjogren’s syndrome- tests?
- Ro/SS-A; La/SS-B
- schirmer’s test (filter paper under eyelids- collects tears)
- slit-lamp exam
Sjogren’s syndrome- tx
- lubrication w artificial tears
- oral hygiene
Sjogren’s syndrome and RA
- SS seen in 35% of RA pts
- keratoconjunctivitis sicca (dry eyes)
Feltys syndrome
- RA
- splenomegaly
- neutropenia (<2000), anemia, thrombocytopenia
- fever
- RF and Anti-CCP +
RA- other joints
- atlantoaxial subluxation- erosion of odontoid process
- peripheral neuropathy
Dx of RA
-no SINGLE finding on PE or lab test is pathognomonic
RA- lab
- RF +; Anti-CPP ab (15-20% of RA pts are neg)
- ESR and CRP inc
- anemia, thrombocytosis, leukopenia
- ANA+ (30%)
- hyperglobulinemia
- low gluc in body fluids
- synovial fluid- 2/3 PMN’s; WBCs 5000-100,000
RA- tx
- articular rest
- goal is disease remission (50% of pts if tx’ed early)
- NSAIDs- for pain relief- GI toxicity
- corticosteroids- bridge tx!! (flare therapy)
- DMARDs- immunosuppressive- inc risk of infection- takes 2-6 months
RA tx- non-biologics
- Methotrexate (inhibits folic acid)- monitor labs; toxicity- hepatic, myelosupression, pulm; dont give during pregnancy
- Hydroxychloroquine (antimalarial)- safe in pregnant pts
- Leflunomide (pyrimidine antagonist)- dont use w pregnant!!!
- Sulfasalazine
RA tx- biologics- toxicity
- inc risk of infection
- react of latent TB!
- neoplasia
- MS
- autoimmune dz
RA tx- biologics
Anti- TNF alpha (pro-infl cytokine)
- Etanercept
- Infliximab
- Adalimumab
- Rituximab
Managing RA
- NSAID
- DMARD
- add biologic agent
- low dose steroids- flares/bridge
