RA Flashcards
RA - PRICMCP?
MSK, constitutional and extra-articular.
- MSK: Dx date (dx >60 - worse prognosis), Morning stiffness (>60min), Which joints are involved?, tenosynovitis, tendon rupture, Atlanto-axial involvement (recurrent headache at the base of the skull/arm tingling)
- Constitutional: fatigue, weight loss
- Extra-articular
- Eyes: Sicca, scleritis, corneal ulcers
- Skin: Raynaud’s, ischaemic ulcers, gangrene, rheumatoid nodules (RF+ve)
- Heart: pericarditis, valve disease, artherosclerosis
- Lungs: ILD, pleural effusions, nodules
- Abdomen: Felty’s
- Neuro: compressive neuropathy (Carpal tunnel), Mononeuritis
- Haem: incresaed risk of B-cell lymphoma
Risk factor for RA? (2)
FH
Smoking
RA: PRICMCP?
P: onset, progression, symptoms (constitutional, MSK, extra-articular)
R: FH and Smoking
I: any recent IVx and why: CRP, ESR, RF CCP, XR or CT.
C: drug side effects
M: non-pharm: PT/OT, smoking cessation, pharm: NSAIDs, DMARDs, Biologics
C: major current problem (?decreasing hand function, severe pain, parasthesiae), current activity of disease (duration of early-morning stiffness**, joint swelling, pain, number of joint involved, weight loss and fatigue).
P: How is the patient coping wth disease at home, can walk up stairs, can perform fine-motor task, affecting work? Insight into disease & side effects of medications***, steroid action plan.
Side effects of MTX? (3) Patient should know what not to do?
Hepatotoxicity
Lung toxicity
BM suppression
Patient should know that they should not drink ETOH while on MTX!
Leflunomide side effects? (4)
LefluNomiDe
Liver: Hepatotoxicity
Lung: ILD
Neuropathy - peripheral/PN
Diarrhoa (30%)
Contraindicated in pregnancy.
Penicillamine side effects? (4)
Penicillamin is a dirty drug!
Nephrotic syndrome
Thrombocytopaenia
Autoimmune diseases: SLE, Polymyositis, Myasthemia, Good pastures
Pulmonary infiltrates
Hydroxychloroquine side effects? (3)
GI side effects
Retinotoxicity: Bull’s eye retinopathy, need regular ophthalmology review
Cardiotoxicity (conduction/cardiomyopathy) - remember hycroxyChloroquine
Sulfasalazine side effects? (4)
Rash, including SJS
Haematological (haemolysis, blood dyscrasias)
Hepatitis, Pancreatitis
Reversible oligospermia
Biologics - main side effects to ask?
Infections, including reactivatoin of TB
Lymphoma
Demyelination
RA - examination
App: Cushinggoid, echymoses, weight
Hands: symmetrical deforming polyarthropathy involving small+/- large joints of the hand, with/without active synovitis. Limited/intact fine motor function
Arms: Carpal tunnel, nodules, elbow/shoulder involvement
Face: dry eyes (Sjogren’s), scleritis/epi, cataract (steroids/HCQ), parotids (Sjogren’s), mouth - dry/ulcers, TMJ - crepitus?
Neck: cervical spine tenderness, LN
CVS: pericaridits (no-muffled, no friction rub)
Lung: pleural effusion, ILD
Abdomen: Splenomegaly for Felty’s
Hip/knee/feet tenderness/synovitis
LL neuro: mononeuritis, PN
What are DDx for symmetrical deforming polyarthropathies? (5)
RA
OA
Psoriatic + other sero-ve spondyloarthropathies
Gout (rarely symmetrical)
SLE
DDx for Arthritis + Nodules? (5)
RA
Tophaceous gout
Rheumatic fever (Jaccoud’s arthritis - v. rare)
SLE (rare)
Amyloid arthropathy
What are the diagnostic criteria for RA?
Americal College of Rheumatology (ACR) criteria
Score of 6 or more required
Clinical: based on number of joints involved (0-5), more small joints involved, higher the score.
Duration of symptoms (0-1): at least 6 weeks
Serology: RhF, Anti-CCP (0-3), higher score if strongly positive
Inflammatory markers: CRP, ESR (0-1)
What investigations would you ask for in the RA long case?
T: Confirm the Dx: RhF, Anti-CCP, CRP/ESR + ACR clinical criteria. XR hands to look for typical changes (LESS - loss of joint space, erosions, soft tissue swelling, soft bone (osteopaenia/OP).
Exclude other dx: dsDNA, anti-smith, ANA (SLE), if hx consistent, work up for septic arthritis (joint aspirate - suspect if WCC >50,000)
Assess Severity & activity of disease: +ve RhF/Anti-CCP associated with more severe and erosive disease. ESR/CRP/Normocytic anaemia/Albumin to check activity. Serial XR fims to asess progressive disease.
Consider MRI ; looking for synovitis, marroe oedema in bones surrounding inflamed joints
T: treatment baseline bloods including FBC, EUC, LFT, Coags.
Screen for complications: guided by symptoms - AAJ XR, ECG - IHD, CXR (pleural effusion), TTE to rule out pericardial effusion, valve disease. Spirometry. Urine looking for protein and blood (vasculitis, amyloid).
What are the risk factors for destructive disease? (3)
Clinical: constitutional sypmtoms, insidious onset, early rheumatoid nodule
Biochemical: RhF - high titre or +ve anti-CCP
Radiological: erosions early on XR.
So based on history, the key is constitutional symptoms + early nodules.
RA: Management?
Confirm Dx (ACR criteria, RhF/CCP/ESR/CRP)
Screen & treat for associated depression
Investigate for complications: fasting glucose, OGTT, HBA1C, lipids, DEXA, ECG, Spirometry.
Goals
- Optmise symptoms, maximise function
- Slow disease progression/induce complete remission
- Frequent monitoring to determine ?progressive disease
Non-pharm
- Educate: nature of progressive/incurable disease, complications, steroid plan, infection prevention
- Vaccination (not live!), hygiene, avoiding contact
- Life-style: healthy/mediterranean diet, exercise, weight loss, cessation of smoking***, cut ETOH (especially MTX)
- Aggressive CV risk factor modification: statin, anti-hypertensives.
- PT/OT, home modificaiton, falls prevention - rails/night lights/vital calls
Pharm
- Symptoms control: NSAIDs, panadol, steroid injections
- Disease progression: depends on situation. If new Dx start NSAID + Prednisolone + MTX (or Leflunomide if MTX contraindicated) - for 6m. If no response then switch or biological (dep on prognostic markers/activity).
- Consider surgery. e.g. joint replacement
Follow-up
- Review symptoms (constitutional, morning stiffness, functional), examination, bloods/serology, serial XR
- Continue monitoring for complications including metabolic syndrome, infection, opthalmic toxicity (HCQ), cardiac/pulmonary/neurological complications.
- Monitor for side effects: FBC (aplastic anaemia), LFT (hepatitis), opthalmology review (HCQ), urine (proteinuria)
What are the indications for starting DMARDs in newly diagnosed RA patients? (4)
- New presentation and active disease
- Seropositive disease
- Erosions on XR
- Clinical deformities
How would you determine the severity of disease? (5)
No. of joints involved (less or more than 6)
Erosion
Active synovitis
RhF+ve
ESR/CRP high
If so, severe disease
What would you ask patients on Hydroxychloroquine about the eye toxicity (3)?
Change in visual field
Colour blindness
Scotomas
Treatment approach for severe disease (tx naive patients)?
NSAID + Prednisolone (to bridge until DMARDs take effect) + MTX
DMARDs in general has slow onset of action.
If no response - increase the MTX dose or add 1 of (HCQ, Sulfasalazine or Leflunomide)
Rules for use biologics in RA?
Failure of at least 6 months of DMARD - must include MTX and HCQ/Leflunomide or Sulfasalazine.
Tx approach to mild disease? (<6 joints, Rf -ve, non-erosive)
NSAIDs + HCQ or Sulfasalazine. only if active disease.
Work-up/precaution prior to starting Biologics?
HBV/HCV/HIV/TB. Vaccinate for pneumococcus + flu.
No live vaccines for 3 weeks before + 3 months after.
Consider giving MTX together to reduce risk of auto-abs.
What would you do if Mantoux/IGRA +ve?
Isoniazid for 2 months prior to starting therapy.
Continue for 9monthe following biologics.
Tocilizimab: mode of action, efficacy, side effects (3)?
IL6 receptor Ab
Better efficacy than Adalimumab
SE = hepatitis, dyslipidaemia, bowel perforation - contraindicated in diverticulitis
tofacitinib: MoA + side effects? (3)
Januse kinase inhibitor (small molecule)
Side effects similar to Tocilizumab (IL6): Hepatitis, Dyslipidaemia, Bowel perforation.
Treatment options for those who failed on anti-TNFs? (3)
Consider:
Tocilizumab (IL6R mab)
Tofacitinib (JAKi)
Rituximab (only if sero-positive disease, or if patient developed infection/malignancy with anti-TNFs)
Which drugs can you use in pregnancy?
HCQ
Sulfasalazine
Azathoprine
Contraindicated: MTX, Leflunomide, CsA, cyclophosphamide.
What foods must you avoid if you are on biologics? (2)
Undercooked eggs (Listeria)
Undercooked meats (Salmonella)
Adverse reactions of Rituximab? (2)
PML, infections
What drugs should you stop before the pregnancy and how early?
MTX
Leflunomide
Aspirin/NSAIDs
Steroids
MTX: 3 months before conception. Not safe for breast feeding
Leflunomide: cease until undetectable in serum
Aspirin/NSAIDs - cease in 2nd trimester (risk of premature closure of ductus arteriosus), safe for breast feeding.
Steroids: cleft palate - warn.
Notes on MTX?
- Used in combination with most DMARD regimens (including biologicals)
- Side effects: oral ulcers, hepatotoxicity, pneumonitis, cytopenias
- Give with folic acid to reduce ulcers and nausea
- Check FBC and LFTs 2 weeks after starting then monthly for 6 months
Any idea if Leflunomide need to be ceased quickly?
Long time to get out of system with long t1/2 = 2 weeks
Can be washed out with Cholestyramine if SE develop.
