RA, OA and others Flashcards
What is rheumatoid arthritis?
Autoimmune disease (chronic, systemic, inflammatory disorder affecting whole body and not just joints) Primarily synovial joints tho Has extraarticular manifestations More women (35-50 YO)
Etiology of rheumatoid arthritis
Interaction betwwen genes (HLA) and environment
Progression of RA
External trigger causing autoimmune rxn and inflammatory process
Synovial hypetrophy and chronic joint inflammation
Destruction of joints (bones and cartilage are eroded)
Joint deformity
Clinical features of RA
Symmetrical polyarthritis
Progresses from periphery to more proximal
Usually spare axial skeleton (except C1/2)
Gradual onset with difficulty performing ADLs
May have constitutional features
Predominant sxs of RA
Pain, stiffness and swelling of mostly small joints of hands, wrists and forefoot (can be elbows, shoulders, ankles and knees)
Morning stiffness OVER 1 HOUR (gets better with movement)
What is spared in RA?
DIP joints
Physical findings in RA
TTP or movement of joint
Squeeze tenderness of MCP and MTP joints
Palpable synovial thickening (boggy)
Effusion (fluctuance)
What do the hands look like in RA?
Symmetrical inflammation of MCP and PIP
Flexor tendon tenosynovitis (decreased ROM/grip strength, trigger finger)
Swan neck and boutonniere deformities
Ulnar deviation/drift
What do the wrists look like in RA?
Loss of extension
Carpal tunnel syndrome (entrapment of nerve due to inflammation)
What do the elbows look like in RA?
Loss of extension
Ulnar nerve compression
Rheumatoid nodules most common here
What do the shoulders look like in RA?
Seen late in disease (because disease moves distal to proximal)
Frozen shoulder
What do the LEs look like in RA?
Feet/ankles: callus formation, hallux valgus (bunion), hammer toes, compensated flexion
Knees: effusion, limited ROM (flexion), Baker’s cyst
Hips: in longstanding disease there is restriction of movement
When is the cervical spine affected in RA?
Atlantoaxial joint instability (C1/2) due to chronic inflammation
Cervical subluxation causes neck pain, stiffness and radicular pain (radiating numbness/tingling associated with spinal nerves) that can lead to cervical myelopathy (pinch spinal cord)
What is the significance of extraarticular manifestations in RA?
Marker of disease severity (associated with increased morbidity and premature mortality)
Pts more likely to see this: hx of smoking, early onset of physical disability, test + for serum RF
Where can you see extraarticular manifestations in RA?
Skin (subcutaneous nodules), eye, pulmonary, cardiovascular (CAD), MSK, hematologic (anemia), CNS (aseptic meningitis)
Felty syndrome
Triad of RA, splenomegaly and neutropenia
What is seen in radiography for RA?
Preferred INITIAL imaging study
Soft tissue swelling around joint, periarticular osteopenia, joint space narrowing, bony erosions, subluxation
What is the use of MRI and US in RA?
More sensitive at detecting changes resulting from synovitis
MRI is valuable for assessing cervical spine
What lab studies do you do for RA?
RF, anti-cyclic citrullinated peptide antibodies, ANA (30%), CBC, ESR/CRP, synovial fluid analysis
What is RF?
First autoantibody associated with RA
Seen in 75-80% of RA pts (some point in disease)
Moderate specificity
Prognostic value
What are anti-CCP antibodies?
Autoantibody most specific for RA
Present in 60-70% pts
Specificity for RA is high
Correlate strongly with erosive disease
CBC in RA
See anemia of any chronic disease, thrombocytosis or mild leukocytosis (indicative of an inflammatory process)
Why would ESR/CRP be elevated in RA?
Parallels the activity of the disease so it would be high in an active flare
Why is an arthrocentesis used in RA?
Diagnosis of exclusion of gout, psuedogout or infection
Synovial fluid analysis can reveal an inflammatory effusion
Who should be tested for RA?
People who have at least 1 joint with definite clinical synovitis and they have synovitis that is not better explained by another disease
What is seronegative RA?
When people lack both RF and anti-CCP antibodies
Can be diagnosed upon findings characteristic of RA if everything else is excluded
Refer to rheum
Main goals of RA tx
Early DMARDs, treat-to-target strategy to get remission of low disease activity, prevent joint injury, maintain muscle strength and joint mobility
Most important non-pharmacoloigc tx or RA
Smoking cessation
Pharmacologic tx of RA
Antiinflammatory agents to control pain and inflammation used in conjunction with DMARDs (disease modifying antirheumatic drugs)
What are DMARDs?
Slow/halt disease progression to preserve joint function
Start early
What is the pretreatment evaluation for before you can use DMARDs?
Baseline serology (CBC, creatinine, ESR/CRP, hep b or c)
Ophthalmologic screening for hydroxychloroquine use
TB test
Vaccines
Types of DMARDs
Nonbiologic (methotrexate)
Biologic (TNF inhibitors etc)
Prevalence of osteoarthritis
Increases over 50
More women over 55
Primary sx of OA
Joint pain and functional impairment
Most common joints involved in OA
Knees, hips, DIP/PIP/1st CMC joint, spine (cervical/lumbar), 1st MTP joints
Pathogenesis of OA
Involves all the joint tissues (cartilage, bone, ligaments, synovium) due to many factors
What happens to the joint in OA?
Progressive loss and destruction of cartilage (joint space narrows)
Bony changes to joint: thinking of subchondral bone (bone sclerosis), subchondral cysts, osteophytes (bone spurs)
Synovial inflammation
May see soft tissue components affected
What is pathognomonic of OA?
Osteophytes (bone spurs)
Factors thought to lead to OA
Aging, joint injury, obesity, genetics, anatomic factors, females
Clinical presentation of OA
Joint pain worse with use and relieved by rest
Stiffness is worse after effort (so seen in evening)
If there is morning stiffness, it is less than 30 min
Physical findings of OA
TTP, reduced ROM, bony enlargement/swelling, joint deformity, joint instability
What do the hands look like in OA?
Bilateral
Heberdens and Bouchards nodes (classic)
First carpometacarpal joint is squared off
What do the knees and hips look like in OA?
Knees: bilateral, swelling, joint line tenderness, crepitus, limited ROM
Hips: unilateral, restricted internal ROM, pain around hip/groin, may refer to knee (if you see hip problems on an xray that is advanced disease)
What is seen on an Xray in OA?
Joint space narrowing, osteophyte fomration, subchondral sclerosis, subchondral cysts
Pharmacologic tx of OA
Oral and topical NSAIDs used most
Topical capsaicin
Cymbalta (Duloxetine)- SSRI and NE inhibitors
And others
When do you do surgery for OA?
When they have failed the less invasive modes of therapy
Main presentation of polymyalgia rheumatica
Proximal aching and stiffness (pelvic girdle, shoulder and neck)
Worse in the morning over an hour because inflammatory
Prevalence of PMR
Mostly over 50
Peak between 70 and 80
Females
Northern European descent
What is PMR associated with?
Giant cell (temporal) arteritis
What causes the sxs of PMR?
Nonerosive synovitis and tenosynovitis
Clinical presentation of PMR
Recent, discrete change in sx
Bilateral
Shoulder and pelvic girdle pain
Morning stiffness and gel phenomenon (stiffness with inactivity)
What is seen on the physical exam with PMR?
Limited ROM (common to see limitation of active abduction)
Normal strength but subjective weakness
Synovitis
Diagnositc studies in PMR
Elevated ESR and/or CRP (ESR often over 50 mm/hr)
May see normocytic anemia
Normal and negative for other tests/antibodies
When is there the most rapid resolution of PMR?
With low dose glucocorticoids (10-20 mg/day)
What is fibromyalgia?
Chronic widespread musculoskeletal pain and tenderness often with fatigue, cognitive disturbances etc
More in women (20-50)
Often occurs with RA and SLE
Pathophysiology of fibromyalgis
Central pain processing (heightened/altered sensation of pain)
Strong genetic predisposition
Clinical presentation of fibromyalgia
Widespread MSK pain
Fatigue and poor sleep
Cognitive disturbances (fibro fog)
Psychiatric disturbances
Other sxs/disorders seen in fibromyalgis
Headache, pelvic pain, IBS, interstitial cystitis/painful bladder syndrome, obstructive sleep apnea, restless legs syndrome
History seen with fibromyalgia
Widespread MSK pain and tenderness (muscles and joints) for over 3 months
Achiness
What abnormalities are seen in labs with fibromyalgia?
None
Pharmacologic tx of fibromyalgia
Tricyclic antidepressants (amitriptyline)
Serotonin and NE reuptake inhibitors (SNRIs) like Cymbalta or Savella
Anticonvulsants (Lyrics or Neurontin)
NO OPIOID NARCOTICS
