RA

Question 1

What are risk factors for RA? What gene is related?

Answer 1

Genetics- HLA-DRB1 genes - “shared epitope”

Female>>>male

Smoking

Incidence peaks between ages 25-55

Question 2

What is the main target for autoimmune process in RA?

Answer 2

Synovial tissues.

Question 3

Synovial proliferation results in what? What does this do?

Answer 3

Synovial proliferation forms a pannus. The pannus invades and destroys bone and cartilage.

Question 4

What are the clinical manifestations in the joints for RA?

Answer 4

Usually an insidious onset with morning stiffness lasting more than 30 minutes or after prolonged IN-activity.

Symmetric swelling of many joints that are tender/painful.

Question 5

What joints are most commonly affected in RA?

Answer 5

PIP, MCP, wrists, ankles, knees, MTP

Question 6

______ deviation of the MCP is classic in RA

Answer 6

Ulnar

Question 7

A swan neck deformity is?

Answer 7

Hyperextension of the PIP, and flexion of the DIP.

Question 8

A boutonniere deformity is?

Answer 8

Flexion of the PIP, extension of the DIP.

Question 9

What are some general symptoms that people with RA can present with?

Answer 9

Fatigue, weight loss, low-grade fever.

Question 10

What are rheumatoid nodules? Where are they located?

Answer 10

These are firm, non-tender nodules located on the extensor surfaces (esp forearms) that are only found in those that are RF positive.

They may also be in the lungs, sclerae, and other tissues.

Question 11

What vascular abnormality can people with RA have?

Answer 11

Vasculitis.

Question 12

What are the ocular manifestations in RA?

Answer 12

Keratoconjunctivitis sicca (secondary Sjogren syndrome, could also include xerostomia)

Also can see scleritis, and scleromalacia

Question 13

What kind of pulmonary manifestations arise in RA?

Answer 13

Plueritis

Pleural effusions

Rheumatoid nodules

Interstitial lung disease.

Question 14

People with RA also have cardiac comorbidities. What are they?

Answer 14

CV disease due to chronic inflammation

Pericardial effusions

Pericarditis.

Question 15

What is felty syndrome?

Answer 15

Splenomegaly

Neutropenia - asymptomatic or recurrent bacterial infections

RA - typically seropositive, erosive, and severe.

Question 16

What is the most specific test for RA?

Answer 16

Anti-ccp antibodies.

Question 17

What percentage of patients are seronegative in RA? What does this mean

Answer 17

15%

Means they don’t test positive for RF or CCP

Question 18

What inflammation marker is typically elevated in RA?

Answer 18

Elevated ESR/CRP

Question 19

TF - people with RA might have anemia, thrombocytosis, WBC on the normal end or more mild leukocytosis

Answer 19

True lol

Question 20

Synovial fluid analysis in RA shows? What cell predominates?

Answer 20

Inflammatory effusion, leukoctyes usually 1500-25,000, PMNs predominate

Question 21

What do initial radiographs show in RA? Where are the earliest changes?

Answer 21

Show soft tissue swelling, osteopenia around the joint

Earliest changes are in the wrists or feet.

Question 22

Later in the disease process of RA, radiographs show what?

Answer 22

Joint space narrowing and erosions.

Question 23

What do you need to make the diagnosis of RA?

Answer 23

Inflammatory arthritis in 3 or more joints

Positive RF and/or anti-CCP – if seronegative, can still diagnose RA if you excluded other causes and all other characteristics are met

Elevated ESR/CRP

Duration > 6 weeks

Excluded all others causes.

Question 24

Treatment goals of RA?

Answer 24

Control pain and inflammation

Preserve function

Prevent deformity

Early diagnosis and inititation of DMARDs ( disease-modifying- antirheumatic drugs)

Rheumatologist involvement

Patients often need combinations of DMARDS -MTX + TNF inhibitor most common.

Question 25

What pretreatment screening do you need for RA?

Answer 25

Hep B & C

Baseline CBC, Cr, LFTs, ESR, CRP

Ophthalmic screening

Check for latent TB

Rule out pregnancy

Baseline radiographs

Question 26

Are NSAIDS helpful in the treatment of RA?

Answer 26

They help with symptoms, but are not disease modifying.

Not for monotherapy and all are about equal.

Question 27

How should you use corticosteroids in the treatment of RA? What dose should you start with?

Answer 27

Use for symptom relief or slowing rate of joint damage, but not recommended for monotherapy or long term use

Good to use as a bridge when starting a DMARD

Start with prednisone 5-20mg/day - depending on how severe.

Question 28

What are 3 conventional DMARDS?

Answer 28

Methotrexate, sulfasalazine, Hydroxychloroquine

Question 29

What is the DMARD of choice for RA? Whats the starting dose and how long does it take to become effective?

Answer 29

Methotrexate is the DMARD of choice.

Start with 7.5mg PO weekly - notice improvements within 2-6 weeks.

Question 30

When is methotrexate contraindicated in RA?

Answer 30

Pregnancy, liver disease, heavy alcohol use, severe renal impairment

Question 31

What should you order for monitoring your patient when they are on methotrexate?

Answer 31

CBC to monitor for cytopenias, and LFTs for hepatotoxicity

Question 32

Everyone taking methotrexate should take this supplement

Answer 32

Folic acid 1mg PO daily or leucovorin calcium 2.5-5mg weekly to prevent hematologic and other side effects.

Question 33

TNF inhibitors have a much higher risk of what? What TNF is the drug of choice?

Answer 33

Much higher risk of serious bacterial infections, as well as granulomatous infections (esp reactivation of TB) - so must screen for latent TB

Etanercept - 1st choice

Question 34

Follow up radiographs for RA should be every?

Answer 34

2 years.

Question 35

Higher mortality with RA patients is contributed to what? What are poor prognostic factors?

Answer 35

Higher mortality is attributed to CV disease from chronic inflammation

Poor prognostic factors are RF or anti-CCP positive, extraarticular disease, functional limitation, and erosions on radiograph.