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arthritis > RA > Flashcards

RA Flashcards

1
Q

Define RA

A

Systemic symmetrical inflammatory destructive polyarthropathy
most likely autoimmune but aetiology not well known

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2
Q

Epidemiology of RA

A

more common in women
a/ highly w/ disability, mortality, high socioeconomic burden
most common age - 30-50

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3
Q

Risk factors of RA

A

gender-female
genetics- a/w HLADR4 and DR a/ alleles
shared epitope
environment - smoking which can interact with genes to increase the susceptibility up to 20 to 40 fold. The most likely mechanism for the environmental component is repeated activation of innate immunity by factors such as smoking: poor dental hygene and air pollution may be other features.

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4
Q

Describe of pathology RA

A
  • destruction of cartilage ( joint space narrows)
  • bone erosion
  • pannus formation- abnormal layer of fibrovascular tissue / granulation tissue
  • synovitis- inflam of synovial membrane- plasma cells and lymphocytes present in surface of synovial villi - seen in nodular clusters

AUTOIMMUNE RX

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5
Q

Describe physiology of RA

A

cytokine signalling pathways involved in RA
TNF alpha is secreted by macrophages (insitu and recruited) and lymphocytes. Induces other cytokines, mettaloproteinases, adhesion molecules etc. This causes the destructive effects of RA - synovitis and ultimately bone erosion and cartilage destruction

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6
Q

Symptoms a/w RA

A

Pain and stiffness
-stiffness >30 mins after sitting and in the morning

Redness and warmth

Loss of function

Limited movement

Difficulty sleeping

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7
Q

Signs aw RA

A
  • symmetrical,deforming polyarthritis w typical pattern joint involvement (wrists, MCPs, PIPs, MTPs, then knees, ankles,shoulders, neck etc)
  • tender, warm soft tissue swelling at joints
  • typical deformities in established disease
  • volar sublaxation of hand , Boutonniere’s deformity , Swan neck deformity , Z deformity
  • extra-articular manifestations of RA- sicca syndrome, rheumatoid nodules
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8
Q

Define volar sublaxation of hand

A

metacarpophalangeal (MCP) joint involves partial dislocation of the joint in which the proximal phalanx slips away from the metacarpal head and moves in the palmar direction.

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9
Q

Define Boutonniere’s deformity

A

PIP flexion and DIP hyperextension

can occur in toes and fingers

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10
Q

Define Swan neck deformity

A

PIP hyperextension, DIP flexion

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11
Q

Z deformity?

A

occurs at thumb
Z shape of thumb
hyperextension of interphalangeal joints, flexion and sublaxation of MCP

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12
Q

How to distinguish Early RA from established RA

A

Early RA- Symmetrical soft tissue swelling at MCP and PIP joints. No damage
DIPs spared

Established RA-Ulnar deviation at MCPJs,
Z deformity of thumb
Atrophy of intrinsic muscles
radial deviation at wrist

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13
Q

How does RA present in the foot?

A
  • metatarsalgia- inflam of ball of foot
  • rheumatoid flat foot
  • valgus hallux- aka bunions ; medial deviation of first metatarsals and lateral deviation of big toe/hallux
  • collapsed metatarsal
  • bunions and forefoot pain
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14
Q

What are the extraarticular manifestations ?

A

eyes ( sicca syndrome- dry eyes and mouth, scleritis, sclermalacia perforans)
leg ulcers (vasculitis)
rheumatoid nodules
lung (pleural effusions and lung fibrosis, nodules)
compression neuropathies
GIT (gastritis and peptic ulcers)
osteoporosis
cardiac- (raised cholesterol or raised BP,accelerated atheroma; CVD , pericarditis)
renal- analgesic nephropathy,amyloid
haem- anaemia

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15
Q

What is a result of vasculitis ?

A

splinter haemorrhage and necrotic areas at finger tips/around nails -> skin infarction
changes also seen in SLE, polyarteritis nodosa

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16
Q

Define Episcleritis

A

inflam of episclera ( located between conjunctiva and connective tissue layer which all forms the sclera/white of the eye) occurs in superficial layers of the nasal portion of the eye- causing tenderness and discomfort

17
Q

Define rheumatoid nodule/ olecranon

A

A large subcutaneous nodule is located on the extensor surface of the forearm near the elbow. Rheumatoid nodules may be fixed or movable and are usually nontender
a/w high titres of rheumatoid factor - occurs in 20% of pts

Also seen w/ SLE and mixed connective tissue disease

18
Q

What occurs in the spine in RA

A

cervical spine involved
altlantoaxial sublaxation with pannus formation

Example:
separation between the anterior arch of C1 and the odontoid process of greater than 2.5 mm indicating subluxation

disc narrowing from C3-C7 w osteophyte formation can occur

19
Q

Describe pulmonary nodules

A

seen bilaterally in pulmonary parenchyma
same histological appearance as rheumatoid nodules
DISCRETE and identical to opacities seen in mets disease.

20
Q

List the differential diagnoses for RA

A 
osteoarthritis (Diff hand involvement) 
fibromyalgia
post viral arthritis (rubella, hep B, erythrovirus) 
seronegative arthritis 
-ankylosing spondylitis
-reactive arthritis
-psoriatic arthritis
-enteropathic arthritis
21
Q

Difference between osteoarthritis and RA

A

OA is defined as joint stiffness caused by loss of cartilage between joints due to wear and tear, while RA stems from an autoimmune attack on joints
Bony enlargement can be seen in distal and proximal interphalangeal joints. The changes in proximal interphalangeal joints (Bouchard’s nodes) and distal interphalangeal joints (Heberden’s nodes) are common findings in degenerative joint disease of the hands. These changes are more frequently found in women after menopause and often show a genetic predisposition.

22
Q

Recall the diagnosis for diagnosis of Ra

A

2010 ACR/EULAR criteria
-definite diagnosis of RA is due to presence of synovitis in at least 1 joint and absence of alternative reason for synovitis occurring.

AND

-at least 6/10 in 4 domains
;number and site of joints involved (large joints, small joints)
;serological abnormality (ACP or RF)
;symptoms lasting more than 6 weeks
;acute phase response (CRP/ESR above ULN)

23
Q

List the radiological features of RA

A

pulmonary nodules
cervial spine- atlantoaxial sublaxation w pannus formation
erosive changes at joints

24
Q

Distinguish RA from psoriatic arthritis

A

both autoimmune and causes inflam arthritis(pain, swelling, stiffness) but psoriatic has diff joint distribution and involves skin- psoriatic skin lesions

Psoriatic affects only one side of body and can affect back and pelvis (as well as toes and fingers) unlike RA which more so impacts smaller joints and bigger joints like elbow, shoulder, knee, ankles and is bilateral

25
Q

Define enteropathic arthritis

A

Enteropathic arthritis, or EnA, is a form of chronic, inflammatory arthritis associated with the occurrence of an inflammatory bowel disease (IBD), ulcerative colitis and Crohn’s disease

26
Q

Define ankylosing spondylitis

A

a form of spinal arthritis, chiefly affecting young males, that eventually causes ankylosis(stiffening and immobility of joint due to fusion) of vertebral and sacroiliac joints

27
Q

Describe diagnostic investigations for RA

A

Clinical presentation is key to diagnosis

other ancillary tests:
RF- IgM autoantibody against FC fragment of IgG - low specificity
anti CCP- 98% specific – predicts more aggressive and erosive disease course

seronegative -antibodies negative
seropositive-antibodies +ve

28
Q

Describe investigations-screening for complications and aetiology

A 
-FBC, U&E, LFTs
May show normocytic normochromic anaemia
U&E and LFTs should be normal unless result of drug toxicity or complications
-ESR/CRP
Elevated
-Plain film radiographs
Diffuse joint space narrowing
Periarticular joint margin erosions may be present in carpal bones, ulnar styloid, MCPs, and MTPs
-Joint aspiration
Leukocyte count > 2000 WBC/mm3
-If trying to rule out other differential diagnoses
Uric Acid
ANA
SPEP
29
Q

Define principles of management of RA pt

A

Patient education
Symptomatic relief
Prevent joint destruction
Early use of DMARDs as soon as diagnosis made
Maintain and maximize function
Decrease morbidity and mortality
Minimise medication-related toxicity and complications

30
Q

What is the basis for giving pharmacological tx ?

A

Goal is to suppress inflammation, treat pain and prevent or minimise disability
Aggressive early DMARD use prevents disability & improves prognosis
Bad prognosis RA should be treated early and aggressively

31
Q

Outline pharm and non pharm therapies , with examples

A

NSAIDS, corticosteroids
DMARDS (Conventional) - methotrexate, sulfasalazine,leflunomid, hydroxychloroquine

DMARDS(biological) - anti TNF agents, anti IL6 agents, anti B cell agents, T cell activation inhibitors

-med management and monitoring needed

Non pharm
-MDT management Rheumatologist, RA nurse, GP, physiotherapist, Occupational therapist, social worker, dietician, orthopaedics, orthoptist/chiropodist

Annual vaccinations

32
Q

Describe drugs that cause symptomatic relief for RA

use, any concomitant drugs,adverse rx?

A

NSAIDs - helps relieve night pain and morning stiffness;; consider concomitant PPI - aspirin, ibruprofen, celebrex
-Gi bleed

Corticosteroids- IM, intra-articular and oral (oral used to induce remission) consider concomitant vit D, calcium and bisphosphonates if on corticosteroids for more than THREE months
Adverse reaction- secondary osteoporosis, increased fracture risk
oral- prednisolone
high dose short term
low dose <10mg daily - long term
used for relieving symptoms w active RA

33
Q

Describe therapeutic management of pt w RA

A

DMARDs
Methotrexate- antimetabolite effects dihydrofolate reductase
onset of action - 2-3 months
concomitant use of folic acid if needed
side effects; mouth ulcers, hepatotoxicity, pulmonary fibrosis, GI- nausea, bone marrow suppression, B12/folate deficiency
-monitor every 3 months U&E, LFTs, FBC

BEWARE if pt has liver disease, alcohol use, renal impairment

sulfasalazine
combo of 5ASA and sulfapyridine 
safe for use during pregnancy 
use 3-6 months for 50% pts 
risk of leucopenia and thrombocytopenia thus blood monitoring necessary

hydroxychloroquine - can be used alone / with another DMARD
can cause retinopathy rare

leflunomide - prevents pyrimidine production in lymphocytes
given to pts if METHOTREXATE FAILED
can cause self limiting diahrrea

BIOLOGIC
TNF inhibitors - adalimumad, infliximab, etanercept (self administered SC injection)
These are more expensive thus used after at least 2 conventional DMARDS failed; can be given with methotrexate
Side effects– precipitate heart failure, reactivation of latent TB and Hep B , rare cause of demyelination

Tocilizumab - anti IL6 monoclonal antibody - given weekly injection subcutaneously/infusions

Abatacept- prevents T cell activation ; subcutaneous weekly injections

Rituximab-anti CD19 B-lymphocyte cytotoxic antibody- given as intermittent course of infusions every 6-12 months

34
Q

What important exercises are to be done by RA pts?

A

strengthening , aerobic and resistance exercises

35
Q

What are the complications of RA?

A

Septic arthritis - Staph aureus ; tx w antibiotics
amyloidosis- chronic inflam causes build up of Serum amyloid A protein
atherosclerosis- accelerated by chronic inflam

36
Q

What are some unmmentioned extraarticular manifestations a/w RA?

A

all manifestations stated above

bronchiolitis obliterans
mononeuritis multiplex
felty’s syndrome-splenomegaly, neutropenia

37
Q

What are some poor prognostic indicators/

A 
Older age &amp; lower educational level
Female sex
Symmetrical small joint involvement
Morning stiffness >30 mins
>4 swollen joints
Cigarette smoking
Co-morbidities
CRP >20 g/dL
Positive RF and anti-CCP antibodies
38
Q

If commencing a biologic agent, what investigations should be done?

A

CXR and mantoux test ; screen for TB/Hep B

39
Q

What are the causes of anemia in RA?

A

Anaemia of chronic disease
Macrocytic anaemia from folate/B12 deficiency
Felty’s syndrome
Drug induced / pancytopaenia ( Methotrexate, GOLD, Penicillamine)
Anaemia from GI bleed from NSAID use

arthritis (2 decks)

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