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Yr 3 Medicine Rheumatology > RA > Flashcards

RA Flashcards

1
Q

What is RA?

A

Systemic inflammatory disease

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2
Q

What is RA characterised by?

A

symmetrical, deforming peripheral polyarthritis

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3
Q

What system can RA cause increased risk to?

A

CV

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4
Q

In which pt group is RA increased in?

A

Smokers

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5
Q

What is the gender ratio of RA pts?

A

2:1 F:M

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6
Q

When is the peak onset for RA?

A

5th and 6th decade

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7
Q

What markers are associated with increased severity of RA?

A

HLA DR4/DR1

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8
Q

What is the typical presentation of RA?

A

Symmetrical swollen, painful and stiff small joints of hands and feet
Worse in morning
Can fluctuate
Larger joints can become involved

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9
Q

When are RA symptoms worse?

A

Morning

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10
Q

Describe some less common presentations of RA?

A

Sudden onset widespread arthritis
Recurrent arthritis of various joints = palindromic arthritis
Persistent monoarthritis
Systemic illness with extra acicular symptoms
Recurrent soft tissue problems

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11
Q

What happens in early RA?

A

Inflammation but no joint damage

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12
Q

What are the signs of early RA?

A

Swollen MCP, PIP, wrist or MTP joint - often symmetrical

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13
Q

What may you see in late RA?

A

Joint damage and deformity

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14
Q

What are the signs of late RA?

A

Ulnar deviation
Subluxation of wristband fingers
Boutonniere and swan neck deformity of fingers
Z deformity of thumb
Hand extensor tendons may rupture
Rarely atlanto axial subluxation may threaten spinal cord

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15
Q

What % of RA patients have extra articular features?

A

40%

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16
Q

Describe some of the extra articular features of RA?

A

Nodules: elbows, lungs, cardiac, vasculitis
Lungs: interstitial fibrosis, organising pneumonia, pleural disease
CVS: IHD, pericarditis, pericardial effusion, CTS,
Eye: scleritis
Osteoporosis
Amyloidosis

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17
Q

Investigations for RA?

A 
Rheumatoid factor 
Anti-CCP
Anaemia of chronic disease: Increased platelets, ESR and CRP
Xray
USS/MRI
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18
Q

What are high titres of rheumatoid factor associated with?

A

Severe disease, erosion and extra articular disease

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19
Q

What can anti-CCP be used to predict?

A

Disease progression in RA

20
Q

What can be seen on a RA X-ray?

A

Soft tissue swelling
Juxta articular osteopenia
Decreased joint space
Bony erosions, subluxations, carpal destruction

21
Q

In which patients should you suspect RA?

A

Pts with one more more swollen joint, and a suggestive clinical history which is not better explained by another disease

22
Q

What is the diagnostic criteria for RA?

A 
Joint involvement 
Serology 
Acute phase reactants (CRP and ESR)
Duration of symptoms 
Score of 6 or above is diagnostic
23
Q

What is important if you suspect RA?

A

Refer to rheumatologist early before irreversible damage

24
Q

How is disease activity measured in RA?

A

DAS28

25
Q

What is the treatment for RA?

A

DMARDs
Biological agents
Steroids
NSAIDs - for symptom relief but no effect on disease progression
PT/OT
Surgery
Accelerated risk of CV disease so treat risk factors

26
Q

What could you use in an exacerbation of RA?

A

Methylprednisolone IM 80-120mg

27
Q

Pro/Con of intra articular steroids?

A

Rapid but short term effects

28
Q

What may oral steroids be used for? at what dose?

A

Used to control difficult symptoms

oral prednisolone 7.5mg/day

29
Q

What is the chief biological event in RA?

A

Inflammation

30
Q

What leads to the systemic side effects seen in RA?

A

Over produced cytokines and cellular processes erode cartilage and bone

31
Q

What are DMARDs?

A

Disease modifying anti rheumatic drugs

First line of treatment in RA

32
Q

When should DMARDs be started?

A

After 3 months of persistent symptoms

33
Q

How long do DMARDs take to start working?

A

6-12 weeks

34
Q

What combination of DMARDs produces the best results in RA?

A

Methotrexate, sulfasalazine and hydroxychoroquine

35
Q

What SE can you get with use of methotrexate?

A

Pancytopenia, increased susceptibility to infection and neutropenic sepsis

36
Q

What tests should you do on people treated with methotrexate?

A

Regular FBC and LFT monitoring

Pre treatment Xray (pneumonitis)

37
Q

Side effects of methotrexate

A

Pneumonitis, oral ulcer, hepatotoxicity, teratogenic

38
Q

Side effects of sulfasalazine

A

Rash, decreased sperm count, oral ulcers, GI upset,

39
Q

SE of leflunomide

A

Teratogenic, oral, ulcer, increased BP, hepatotoxicity,

40
Q

SE of hydroxychloroquine

A

Retinopathy - do pretreatment and annual eye screen

41
Q

When could biological agents be considered in the treatment of RA?

A

Pts with active disease despite adequate trial of 2 DMARDs

42
Q

What tests should you do on a patient before starting biological therapy for RA?

A

Screen for TB, HIV, hepatitis b and c

43
Q

What are the 4 actions of biologicals in treating RA?

A

TNFa inhibitors
B cell depletion
IL1 and IL6 inhibitio
Inhibition of T cell co stimulation

44
Q

Give an example of an TNFa inhibitor

A

Infliximab

Response is really good initially but may be unsustained

45
Q

Give an example of a biological agent that causes B cell depletion

A

Rituximab

46
Q

Give an example of an IL6 inhibitor- what should you monitor?

A

Tocilizumab

Monitor for hypercholesterolaemia

47
Q

What are the side effects of biological agents?

A

Serious infection, reactivation of TB and hep B, Worsening HF, hypersensitivity, injection site reaction, blood disorders, skin cancer

Yr 3 Medicine Rheumatology (9 decks)

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