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Rheumatology (Long) > RA > Flashcards

RA Flashcards

1
Q

RA - PRICMCP?

A

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
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2
Q

Risk factor for RA? (2)

A

FH

Smoking

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3
Q

RA: PRICMCP?

A

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.

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4
Q

Side effects of MTX? (3) Patient should know what not to do?

A

Hepatotoxicity

Lung toxicity

BM suppression

Patient should know that they should not drink ETOH while on MTX!

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5
Q

Leflunomide side effects? (4)

A

LefluNomiDe

Liver: Hepatotoxicity

Lung: ILD

Neuropathy - peripheral/PN

Diarrhoa (30%)

Contraindicated in pregnancy.

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6
Q

Penicillamine side effects? (4)

A

Penicillamin is a dirty drug!

Nephrotic syndrome

Thrombocytopaenia

Autoimmune diseases: SLE, Polymyositis, Myasthemia, Good pastures

Pulmonary infiltrates

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7
Q

Hydroxychloroquine side effects? (3)

A

GI side effects

Retinotoxicity: Bull’s eye retinopathy, need regular ophthalmology review

Cardiotoxicity (conduction/cardiomyopathy) - remember hycroxyChloroquine

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8
Q

Sulfasalazine side effects? (4)

A

Rash, including SJS

Haematological (haemolysis, blood dyscrasias)

Hepatitis, Pancreatitis

Reversible oligospermia

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9
Q

Biologics - main side effects to ask?

A

Infections, including reactivatoin of TB

Lymphoma

Demyelination

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10
Q

RA - examination

A

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

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11
Q

What are DDx for symmetrical deforming polyarthropathies? (5)

A

RA

OA

Psoriatic + other sero-ve spondyloarthropathies

Gout (rarely symmetrical)

SLE

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12
Q

DDx for Arthritis + Nodules? (5)

A

RA

Tophaceous gout

Rheumatic fever (Jaccoud’s arthritis - v. rare)

SLE (rare)

Amyloid arthropathy

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13
Q

What are the diagnostic criteria for RA?

A

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)

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14
Q

What investigations would you ask for in the RA long case?

A

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).

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15
Q

What are the risk factors for destructive disease? (3)

A

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.

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16
Q

RA: Management?

A

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)
17
Q

What are the indications for starting DMARDs in newly diagnosed RA patients? (4)

A
  1. New presentation and active disease
  2. Seropositive disease
  3. Erosions on XR
  4. Clinical deformities
18
Q

How would you determine the severity of disease? (5)

A

No. of joints involved (less or more than 6)

Erosion

Active synovitis

RhF+ve

ESR/CRP high

If so, severe disease

19
Q

What would you ask patients on Hydroxychloroquine about the eye toxicity (3)?

A

Change in visual field

Colour blindness

Scotomas

20
Q

Treatment approach for severe disease (tx naive patients)?

A

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)

21
Q

Rules for use biologics in RA?

A

Failure of at least 6 months of DMARD - must include MTX and HCQ/Leflunomide or Sulfasalazine.

22
Q

Tx approach to mild disease? (<6 joints, Rf -ve, non-erosive)

A

NSAIDs + HCQ or Sulfasalazine. only if active disease.

23
Q

Work-up/precaution prior to starting Biologics?

A

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.

24
Q

What would you do if Mantoux/IGRA +ve?

A

Isoniazid for 2 months prior to starting therapy.

Continue for 9monthe following biologics.

25
Q

Tocilizimab: mode of action, efficacy, side effects (3)?

A

IL6 receptor Ab

Better efficacy than Adalimumab

SE = hepatitis, dyslipidaemia, bowel perforation - contraindicated in diverticulitis

26
Q

tofacitinib: MoA + side effects? (3)

A

Januse kinase inhibitor (small molecule)

Side effects similar to Tocilizumab (IL6): Hepatitis, Dyslipidaemia, Bowel perforation.

27
Q

Treatment options for those who failed on anti-TNFs? (3)

A

Consider:

Tocilizumab (IL6R mab)

Tofacitinib (JAKi)

Rituximab (only if sero-positive disease, or if patient developed infection/malignancy with anti-TNFs)

28
Q

Which drugs can you use in pregnancy?

A

HCQ

Sulfasalazine

Azathoprine

Contraindicated: MTX, Leflunomide, CsA, cyclophosphamide.

29
Q

What foods must you avoid if you are on biologics? (2)

A

Undercooked eggs (Listeria)

Undercooked meats (Salmonella)

30
Q

Adverse reactions of Rituximab? (2)

A

PML, infections

31
Q

What drugs should you stop before the pregnancy and how early?

MTX

Leflunomide

Aspirin/NSAIDs

Steroids

A

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.

32
Q

Notes on MTX?

A
  • 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
33
Q

Any idea if Leflunomide need to be ceased quickly?

A

Long time to get out of system with long t1/2 = 2 weeks

Can be washed out with Cholestyramine if SE develop.

Rheumatology (Long) (11 decks)

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