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Practice Topics Exam 8 > Rheum 1 - RA > Flashcards

Rheum 1 - RA Flashcards

1
Q

What is RA

A

Symmetric inflammatory polyarthritis with significant morning stiffness

Thought to be an immune mediated process leading to joint inflammation and destruction

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2
Q

RA vs. OA for the what is it

A

OA - more mechanical - more wear and tear - the morning stiffness is not as significant

RA - immune system is over active so a lot of meds are immunosuppressants

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3
Q

ACA criteria for diagnosis of RA - need how many for how long

A

Need at least 4 of the criteria and must be present for more than 6 weeks

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4
Q

ACA criteria diagnosis for RA

A

1 Morning stiffness typically lasting more than 1 hour
2 Swelling of more than 3 joints
3 Symmetric distribution
4 Involvement of hand joints - esp wrists, MCPs, and PIPs, sparing DIPs
5 Pos RF (80% of pts with RA)
6 Rheumatoid nodules on extensor surfaces, esp the olecranon

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5
Q

OA vs. RA for joints involved

A

OA - CMC, PIP, DIP

RA - MCP, PIP

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6
Q

What causes RA?

A

We really don’t know!

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7
Q

What has been studied as a cause for RA?

A

Infectious agents - mycoplasma, EBV, cytomegalovirus, parvovirus B19

Occupational and SES

Smoking - recent studies suggest strong association

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8
Q

Who does RA affect?

A

1% of the population
3:1 W to M
Incidence increases in adulthood and continues through 70s+
Genetics account for 15% of risk and other 85% is environmental factors

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9
Q

Lab studies for RA

A

RF
Anti CCP
Inflammation - CRP, ESR
CBC, ALT/AST, Albumin, Creatinine, Alk phos, UA

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10
Q

Lab studies - Rheumatoid factor

A

More than 13 ng/mL is considered seropositive
Just because someone has positive RF though does not mean that they have RA (other diseases can have + RF like Hep C, TB, Symphilis, SLE, myositis)
30% with RA will not develop a + RF

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11
Q

Lab studies - Anti CCP

A

Anti cycle citrullinaed peptide
More specific to RA - if this is positive, they definitely have RA
Levels of over 20 ng/mL are considered pos
Might be present months prior to onset of clinical symptoms

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12
Q

Lab studies - Seropositive vs. seronegative RA

A

Seropositive denotes RA patients with a positive RF

40% of seronegative RA patients are anti CCP positive

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13
Q

Lab studies - if in flare will see what

A

Increase in CRP (C reactive protein) and ESR (Erythrocyte sedimentation rate)

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14
Q

Joints commonly involved in RA

A 
MCPs
PIPs
Wrists
MTP joints
Cervical spine (NOT LUMBAR)
Hips
Knees
Ankles
TMJ
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15
Q

Course of RA

A

Some experience mild disease and have spontaneous remission

Most suffer a chronic course with intermittent disease flares and progressive joint deformities

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16
Q

Synovitis

A

When synovial fluid is produced in excess amount we get synovitis - excessive synovial fluid in joint capsule

Differentiate with OA - touch - OA will be hard because it is bony hypertrophy

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17
Q

Ulnar deviation

A

Because of joint erosions

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18
Q

Deformities that can be seen with RA

A 
Synovitis
Ulnar deviation
Telescoping
Swan neck and Boutonniere
Hallux valgus
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19
Q

Radiographic changes

A

Need to get a baseline and every 1 to 2 year of the hands and feet
Erosions can be seen - 70% develop them in the 1st 2 years
Osteopenia (Classic for RA)
Loss of articular cartilage (seen with OA too)

20
Q

RA vs. OA changes in the knee

A

RA will see medial and lateral are equally affected

OA will see more medial affected

21
Q

RA - affects other than the joints

A

Neuro - Nerve entrapment, cervical spine instbaility
Cardiac - pericardial effusions, pericarditis
Renal/GI - amyloidosis
Hematologic - microcytic anemia
Skin - nodules, vasculitic ulcerations
Ocular - sicca dry eye, scleritis
Pulmonary - fibrosis, nodules (multiple)

22
Q

Treatment of RA

A

Corticosteroids
NSAIDs
DMARDs
Biologic therapy

23
Q

Treatment of RA - corticosteroids

A

Rapidly acting but do NOT affect disease course
Used for flares or as chronic therapy
Bridge therapy - can help control symptos while waiting for action of second line agents
Burst and taper can be given (prednisone)
Oral dose pack tapering - Methylprednisolone
Intramuscular steroids
Intra articular joint injections

24
Q

Treatment of RA - corticosteroids - side effects

A

Short term = mood change, sleep is hard

Long term = bone loss, bruising, cataracts, inc appetite/weight gain, buffalo hump, moon face

25
Q

Treatment of RA - NSAIDs

A

Effective for swelling, pain, stiffness
NO disease modification
OTC - ibuprofen, naproxen Na (Aleve)
Rx - Sulindac, Meloxicam, Nabumetone

26
Q

Treatment of RA - NSAIDs - side effects

A

GI - ulceration, performation, dyspepsia
Renal - hypertension, decreased GFR
CV - CHF
Antiplatelet effect

27
Q

Pre medication screening - prior to starting meds need

A

Chest x ray - look for evidence of TB, infection, nodules
Heb B and C screen
TB test

28
Q

Immunizations

A

Vaccines recommended prior to therapy - Influenza, pneumonia

NOT live vaccines if they are on immunosuppressive drugs

29
Q

DMARDs

A

FIRST LINE - this is where they turn first - long term meds for these patients

Not all pts respond to therapy
Therapy may slow down but not always prevent joint damage
Frequently used in combo to improve efficacy
Have potential for significant untoward effects

30
Q

Gold standard DMARD

A

Methotrexate!
Gold standard for tx of RA
Dose in 2.5 mg tablets - once weekly or injection
NO ALCOHOL use while on it, also with preg is cat X

31
Q

Other common DMARD to know

A

Arava (Leflunomide)
Dosage 10-20 mg daily
Contraindicated in pregnancy

32
Q

Side effects of DMARDs - methotrexate and leflunomide

A

Neutropenia, liver damage, alopecia, oral ulcerations, dirrhea, nausea, infection, myelosuppression

33
Q

Other DMARDs used

A 
Sulfasalazine
Hydroxychloroquine
Azathioprine
Cyclosporine
Minocycline/Doxycycline
Gold salts
Cyclophosphamide
Penicillamine
34
Q

Biologic therapy for RA

A

TNF inhibitors

Injectable or IV

35
Q

Biologic therapy for RA - TNF inhibitors - Injectable

A

Enbrel (Etanercept)
Humira (adalimumab)
Cimzia (certolizumab pegol)
Simponi (golimumab)

36
Q

Biologic therapy for RA - TNF inhibitors -IV

A 
Remicade (Inliximab)
Simponi Aria (golimumab)
37
Q

Biologic therapy for RA - TNF inhibitors - Other

A

Rituxan (rituximab)
Orencia (abatacept) - T cell inhibitor
Actemra (Tocilizumab)
Xeljanx (Tofacitinib)

38
Q

Biologic therapy for RA - TNF inhibitors -Black box warnings

A

Opportunistic infections - Histoplasmosis, TB

Malignancies - Lymphoma, lung cancer

39
Q

Biologic therapy for RA - TNF inhibitors -Risks

A 
Inc risk of infections
Infusion rxns with IV Remicade
Avoid live vaccines 
Major elective surgeries should be avoided 2 wks before and after TNF therapy
Avoided in preg
Monitor for demyelinating disease
40
Q

Nonparmacologic therapy

A

PT
OT
Alt med - Chiropractic, acupuncutre, herbal remedies, vitamins

41
Q

ACA criteria for remission

A 
5 or more of the following must be met:
1 Morning stiffness less than 15 min
2 No fatigue
3 No joint pain (by hx)
4 No joint tenderness or pain in motion
5 No soft tissue swelling in joint or tendons
6 ESR F less than 30, males less than 20
42
Q

Pregnancy and RA

A

75% improve or go into remission during preg

Controversy over what RA meds can be used - Prednisone is probably the safest of them

43
Q

Prognosis for RA

A

Increase mortality rate - reduced survival by 10+ years

Most common causes of inc mortality = 2x inc rate of MI, Heart failure, and CV disease
Inc rate of certain CA including lymphoma
Serious infections

44
Q

Related conditions - Palindromic Rheumatism

A

Pts develop recurrent onsets of acute, self limited arthritis
Attacks usually last hours to a few days and may involve any set of joints - is usually a single joint stays there and then migrates to another single joint
Joint damage and systemic s/s are rare
Many later progress to RA
Tx similar to RA

45
Q

Related conditions - Felty’s syndrome

A

Triad of RA, splenomegaly, leukopenia
Occurs in pts with long standing seropositive RA
Manifestations = recurrent bacterial infections, LW ulcers, thrombocytopenia
Aggressive tx of underlying RA is the goal of tx

46
Q

Related conditions - Adult onset still’s disease

A

Adult version of JRA
Onset age between 16-35 with 10% after age 50
Daily spiking fevers that are high and occure at the same time each day
Chronic polyarthritis
Rash evident with febrile episodes (trunk, neck, extrem)
Tx = NSAIDs, Prednisone

47
Q

Drug tx

A

DMARDs = first line - methotrexate
?
Biologic agents are next step up (prevent disease from getting worse)

Practice Topics Exam 8 (12 decks)

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