RA Flashcards
What is RA?
Systemic inflammatory disease
What is RA characterised by?
symmetrical, deforming peripheral polyarthritis
What system can RA cause increased risk to?
CV
In which pt group is RA increased in?
Smokers
What is the gender ratio of RA pts?
2:1 F:M
When is the peak onset for RA?
5th and 6th decade
What markers are associated with increased severity of RA?
HLA DR4/DR1
What is the typical presentation of RA?
Symmetrical swollen, painful and stiff small joints of hands and feet
Worse in morning
Can fluctuate
Larger joints can become involved
When are RA symptoms worse?
Morning
Describe some less common presentations of RA?
Sudden onset widespread arthritis
Recurrent arthritis of various joints = palindromic arthritis
Persistent monoarthritis
Systemic illness with extra acicular symptoms
Recurrent soft tissue problems
What happens in early RA?
Inflammation but no joint damage
What are the signs of early RA?
Swollen MCP, PIP, wrist or MTP joint - often symmetrical
What may you see in late RA?
Joint damage and deformity
What are the signs of late RA?
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
What % of RA patients have extra articular features?
40%
Describe some of the extra articular features of RA?
Nodules: elbows, lungs, cardiac, vasculitis
Lungs: interstitial fibrosis, organising pneumonia, pleural disease
CVS: IHD, pericarditis, pericardial effusion, CTS,
Eye: scleritis
Osteoporosis
Amyloidosis
Investigations for RA?
Rheumatoid factor Anti-CCP Anaemia of chronic disease: Increased platelets, ESR and CRP Xray USS/MRI
What are high titres of rheumatoid factor associated with?
Severe disease, erosion and extra articular disease
What can anti-CCP be used to predict?
Disease progression in RA
What can be seen on a RA X-ray?
Soft tissue swelling
Juxta articular osteopenia
Decreased joint space
Bony erosions, subluxations, carpal destruction
In which patients should you suspect RA?
Pts with one more more swollen joint, and a suggestive clinical history which is not better explained by another disease
What is the diagnostic criteria for RA?
Joint involvement Serology Acute phase reactants (CRP and ESR) Duration of symptoms Score of 6 or above is diagnostic
What is important if you suspect RA?
Refer to rheumatologist early before irreversible damage
How is disease activity measured in RA?
DAS28
What is the treatment for RA?
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
What could you use in an exacerbation of RA?
Methylprednisolone IM 80-120mg
Pro/Con of intra articular steroids?
Rapid but short term effects
What may oral steroids be used for? at what dose?
Used to control difficult symptoms
oral prednisolone 7.5mg/day
What is the chief biological event in RA?
Inflammation
What leads to the systemic side effects seen in RA?
Over produced cytokines and cellular processes erode cartilage and bone
What are DMARDs?
Disease modifying anti rheumatic drugs
First line of treatment in RA
When should DMARDs be started?
After 3 months of persistent symptoms
How long do DMARDs take to start working?
6-12 weeks
What combination of DMARDs produces the best results in RA?
Methotrexate, sulfasalazine and hydroxychoroquine
What SE can you get with use of methotrexate?
Pancytopenia, increased susceptibility to infection and neutropenic sepsis
What tests should you do on people treated with methotrexate?
Regular FBC and LFT monitoring
Pre treatment Xray (pneumonitis)
Side effects of methotrexate
Pneumonitis, oral ulcer, hepatotoxicity, teratogenic
Side effects of sulfasalazine
Rash, decreased sperm count, oral ulcers, GI upset,
SE of leflunomide
Teratogenic, oral, ulcer, increased BP, hepatotoxicity,
SE of hydroxychloroquine
Retinopathy - do pretreatment and annual eye screen
When could biological agents be considered in the treatment of RA?
Pts with active disease despite adequate trial of 2 DMARDs
What tests should you do on a patient before starting biological therapy for RA?
Screen for TB, HIV, hepatitis b and c
What are the 4 actions of biologicals in treating RA?
TNFa inhibitors
B cell depletion
IL1 and IL6 inhibitio
Inhibition of T cell co stimulation
Give an example of an TNFa inhibitor
Infliximab
Response is really good initially but may be unsustained
Give an example of a biological agent that causes B cell depletion
Rituximab
Give an example of an IL6 inhibitor- what should you monitor?
Tocilizumab
Monitor for hypercholesterolaemia
What are the side effects of biological agents?
Serious infection, reactivation of TB and hep B, Worsening HF, hypersensitivity, injection site reaction, blood disorders, skin cancer
