Reu 4 - Osteoarthritis And Rheumatoid Arthritis

Question 1

What are Bouchard nodes?

Answer 1

Ostephytes in the proximal phalangeals of the hands.

Question 2

What are Heberden nodes?

Answer 2

Osteophytes in the Distal phalangeals of the hand.

Question 3

What are predisposing factors of osteoarthritis?

Answer 3

Age, obesity, Joint deformity.

Question 4

What are the treatments of osteoarthritis?

Answer 4

Acetaminophen (4 grams a day max), NSAIDs and COX-2 inhibitors, Steroids (intraarticular), Hyaluronic acid (intraarticular), Opioids. Definitive treatment is joint replacement.

Question 5

What is the mechanism of action of acetaminophen?

Answer 5

Reversibly inhibits cyclooxygenase, works mostly in the CNS and inactivated peripherally. It has antipyretic and analgesic effects and no anti-inflammatory effects. Fewer side effects than NSAIDs, maximum recommended dose is 4 grams/day (adults).

Question 6

What are the side effects the acetaminophen?

Answer 6

Causes liver problems and hepatic necrosis. The metabolite of acetaminophen is NAPQI, which binds to glutathione. When taking too much acetaminophen, glutathione is depleted and NAPQI goes around damaging liver cells.

Question 7

What is the antidote of acetaminophen?

Answer 7

N-acetylcysteine. It regenerated glutathione.

Question 8

What are the uses of N-acetylcysteine?

Answer 8

Acetaminophen overdose and Mucolytic (inhaled for cystic fibrosis). Can be used as well for contrast nephropathy prevention (for someone with renal failure).

Question 9

What is the mechanism of action NSAIDs?

Answer 9

Inhibiting cyclooxygenase (COX-1, COX-2). It inhibits synthesis of prostaglandins and reduces fever and pain. They are anti-inflammatory.

Question 10

What are the side effects of NSAIDs?

Answer 10

Acute renal failure (because they inhibit prostaglandin production, and they are vasodilators, which reduces renal blood flow). Acute interstitial nephritis. Fluid retention. Aplastic anemia, GI upset (gastritis, peptic ulcers; get a COX-2 inhibitor).

Question 11

What are two COX-2 inhibitors?

Answer 11

Celecoxib, Meloxicam.

Question 12

What are the uses of Aspirin?

Answer 12

It inhibits platelets (low-dose), analgesic effects (high-dose), Anti-inflammatory effects (high-dose). It irreversibly inhibits COX-1.

Question 13

What are the side effects of Aspirin?

Answer 13

Gastric Ulcers and GI bleeding. Tinnitus, Hyperventilation, and Acute renal failure.

Question 14

What is Rheumatoid arthritis?

Answer 14

A systemic autoimmune disease, affects synovial joints and Pannus formation in the metacarpal-phalangial and proximal (but not distal phalangial) joints. Causes ulnar deviation and subluxation and rheumatoid nodules and Baker cysts (big synovial cysts behind the knees). Swan neck deformity (fingers) and Boutonniere deformity.

Question 15

What is the difference between Swan neck deformity and Boutonniere deformity?

Answer 15

Boutonniere deformity: French for button hole, when the extensor tendon on the back of the fingers splits, and the PIP joint pokes thru, like a button going thru a button. So there is flexion in the PIP and extension on the at the DIP. Swan neck has Extension on the PIP and Flexion on the DIP. Both are common in advanced RA.

Question 16

What type of hypersensitivity is RA (rheumatoid arthritis)?

Answer 16

Type III hypersensitivity. Auto antibodies that bind to soluble antigen in the blood, forming immune complexes. These immune complexes get deposited in the tissue, causing trouble.

Question 17

What is a positive rheumatoid factor?

Answer 17

It is when IgM antibody against IgG. Around 80% of patients with RA have positive rheumatoid factor, but specificity is low (lots of patients positive with rheumatoid factor do not have RA).

Question 18

What is anti-citrullinated protein antibody (ACPA)?

Answer 18

A more specific test for rheumatoid arthritis. If you are positive for rheumatoid factor, do a ACPA test.

Question 19

What are the clinical presentations of rheumatoid arthritis?

Answer 19

Morning stiffness, pain is worse first thing in the morning but improves with use. They tend to have symmetric joint involvement and systemic symptoms: fever, fatigue, pleural effusion, pericarditis.

Question 20

What can we use for acute flares of rheumatoid arthritis?

Answer 20

NSAIDs, COX-2 inhibitors, Steroids (short period).

Question 21

What are DMARDs and in what disease are they used for?

Answer 21

DMARDs: disease modifying anti-rheumatic drugs. They are Methotrexate, Hydroxychloroquine, Sulfasalazine, TNF-alpha inhibitors.

Question 22

What is the classic presentation of osteoarthritis?

Answer 22

Joint pain that gets worse with use.

Question 23

What two antibodies are most useful in diagnosing rheumatoid arthritis?

Answer 23

Rheumatoid factor and Anti0citrullinated protein antibody (ACPA).

Question 24

By what two mechanisms do NSAIDs cause renal disease?

Answer 24

1. NSAIDs block prostaglandin synthesis, constricting renal vessels and reducing RBF. 2. NSAIDs can cause acute interstitial nephritis.

Question 25

RFF: Swollen, hard, painful finger joints.

Answer 25

Osteoarthritis.

Question 26

RFF: Swollen, boggy, painful finger joints.

Answer 26

Rheumatoid arthritis.

Question 27

RFF: Cartilage erosion with polished bone beneath.

Answer 27

Ebernation of the bone; Osteoarthritis.

Question 28

What are the three main therapeutic actions of NSAIDs?

Answer 28

Reduction of pain, inflammation and fever.

Question 29

What is Osteoarthritis?

Answer 29

It is a wear-and-tear disease, when the articular is spent and might even be totally gone, leaving bone to bone contact (eburnation of the bone). There is formation of osteophytes (bone spurs).