RA2 Flashcards
Classically in RA, the initial radiographic finding is
periarticular osteopenia.
Other findings on plain radiographs include:
- soft tissue swelling
- symmetric joint space loss
- subchondral erosions, most frequently in the wrists and hands (MCPs and PIPs) and the feet (MTP)
- offers the gene sensitivity for detecting synovitis and joint effusions, as well as early bone and bone marrow changes.
- These soft tissue abnormalities often occur before osseous changes are noted on x-ray.
MRI
Presence of ___ has been recognized to be an early sign of inflammatory joint disease and can predict the subsequent development of erosions on plain radiographs as well as MRI scans.
bone marrow edema
- has the ability to detect more erosions than plain radiography, especially in easily accessible joints.
- It can also reliably detect synovitis, including increased joint vascularity indicative of inflammation.
Ultrasound, including power color Doppler
as many as 10% of patients with inflammatory a fulfilling ACR classification criteria for RA will undergo a spontaneous remission within __ (particularly
seronegative patients)
6 months
As measured by the Health Assessment Questionnaire (HAQ), shows gradual worsening of disability over time in the face of poorly controlled disease activity and disease progression.
Disability
overall mortality rate in RA is two times greater than the general population, with ___being the most common cause of death followed by infection
ischemic heart disease
is the main driver of joint damage and is the most important cause of functional disability in the early stages of disease.
Joint inflammation
Several developments during the past two decades have changed the therapeutic landscape in RA. They include :
(1) the emergence of methotrexate as the disease-modifying antirheumatic drug (DMARD) of first choice for the treatment of early RA;
(2) the development of novel highly efficacious biologicals that can be used alone or in combination with methotrexate; and
(3) the proven superiority of combination DMARD regimens over methotrexate alone. The medications used for the treatment of RA may be divided into broad categories: nonsteroidal anti-inflammatory drugs (NSAIDs); glucocorticoids, such as prednisone and methylprednisolone; conventional DMARDs
- adjunctive agents for management of symptoms uncontrolled by other measures
- exhibit both analgesic and anti-inflammatory properties
- exhibit both analgesic and anti-inflammatory properties
- chronic use should be minimized due to the possibility of side effects, including gastritis and PUD disease as well as impairment of renal function
NSAIDs
- may be administered in low to moderate doses to achieve rapid disease control before the onset of fully effective DMARD therapy
- a 1- to 2-week burst may be prescribed for the management of acute disease flares, with dose and duration guided by the severity of the exacerbation
GLUCOCORTICOIDS
Chronic administration of low doses of ___ may be also warranted to control disease activity in px w/ an inadequate response to DMARD therapy
prednisone
may be necessary for treatment of severe extraarticular manifestations of RA, such as ILD
High-dose glucocorticoids
intraarticular injection of an intermediate-acting glucocorticoid
triamcinolone acetonide
treatment may be appropriate for
primary prevention of glucocorticoid-induced osteoporosis
bisphosphonate
- DMARD of choice for the treatment of RA and is the anchor drug for most combination therapies
- stimulate adenosine release from cells, producing an anti-inflam effect
METHOTREXATE
- inhibitor of pyrimidine synthesis
- appears similar to that of methotrexate
- shown in well-designed trials to be effective for the treatment of RA as monotherapy or in combination with methotrexate and other DMARDs
LEFLUNOMIDE
- similar to the other DMARDs in Its slow onset of action
- has not been shown to delay radiographic progression of disease and thus Is not considered to be a true DMARD
- In clinical practice, generally used for treatment of early, mild disease or as adjunctive therapy in combination with other
Hydroxychloroquine
particularly challenging to treat because some of the DMARDs used for the treatment of RA are associated with pulmonary toxicity, such as methotrexate and leflunomide.
RA-ILD
High doses of corticosteroids and adjunctive immunosuppressive agents, such as azathioprine, mycophenolate mofetil, and rituximab have been used for treatment of
RA-ILD
Oral Triple therapy for RA
- Methotrexate
- sulfasalazine
- hydroxychloroquine
A clinical state defined as low disease activity is the optimal goal of therapy, although most patients never achieve complete of it despite every effort to achieve it.
REMISSION
as the total absence of all articular and extraarticular inflammation and immunologic activity related to RA.
Complete remission
A patient may be considered in remission if he or she
(1) meets all of the clinical and laboratory criteria
or
(2) has a composite SDAI score of <3.3 The SDAI is calculated by taking the sum of a tender joint and swollen joint count (using 28 joints), px global assessment (0-10 scale), physician global assessment (0-10), and CRP (in mg/dL).
Provisional Definition of Remission in Rheumatoid Arthritis
At any time point, patient must satisfy all of the following:
- Tender joint count <1
- Swollen joint count <1
- Patient global assessment <1(on a 0-10 stale)
OR
At any time point, px must have a simplified disease activity index score of <_ 3.3
all patients with RA should receive a prescription for
exercise and physical activity
Dynamic strength training, community-based comprehensive physical therapy, and physical-activity coaching (emphasizing ____ of moderately intensive activity most days a week) have all been to improve muscle strength and perceived health status.
30 min
SURGERY for RA
- total joint arthroplasty
- Silicone implants
¢ Arthrodesis and total wrist arthroplasty
- Up to 75% of female RA patients will note overall improvement in symptoms during pregnancy, but often will flare after
delivery
Flares during pregnancy are generally treated with low doses of
prednisone
Are probably the safest DMARDs to use during pregnancy
- hydroxychloroquine
- sulfasalazine
- Aging leads to a gradual decline in renal function that may raise the risk for side effects from NSAIDs and some DMARDS
- is usually not prescribed for patients with a serum creatinine >2 mg/dL.
Methotrexate
