Rheuma: Rheumatoid Arthritis Flashcards
definition of RA
chronic, systemic, inflammatory disorder of unknown cause which mainly involves the synovial joints
pattern which is affected
symmetrical which leads to destruction of joints due to erosion of cartilage and bone, causing joint deformities
features of RA
- insidious onset
- commoner in women
- commoner in younger people than in OA
- main symptoms are pain, stiffness and joint swelling
mention a few extra-articular features
- anaemia
- fatigue
- subcutaneous nodules
- pulmonary problems
- vasculitis
- pleuropericarditis
- episcleritis, scleritis
- splenomegaly
- sicca symptoms
diagnostic investigations
- Rheumatoid Factor
- Anti-citrullinated peptide antibodies
- inflammatory markers
- renal and liver profile
- xrays
- ultrasound
which is the classification criteria and what do they consider?
- ACR/EULAR RA Classification Criteria Criteria - no of swollen joints - symptom duration - acute-phase reactants - serology
- you need a score of 6 or above to diagnose RA
treatment of RA
- DMARD
- monitoring of the disease (so you can adjust the medication, as needed)
- methotrexate (antifolate which inhibits DNA synthesis)
- glucocorticoids
poor prognostic factors
- moderate to high disease activity
- high acute phase reactant levels
- high swollen joint counts
- presence of RF and/or ACPA, especially at high levels
- combinations of the above
- presence of early erosions
- failure of 2 or more csDMARDs
medication progression
- start with csDMARD
- if that fails, add a bDMARD or tsDMARD
- all 3 can also be combined in severe cases
- if either a bDMARD or tsDMARD fails, you should prescribe another drug from the same family or another drug with another mode of action
- if the patient is in remission, consider tapering the bDMARD regiment (and if on glucocorticoids, consider tapering that as well)
is there EMS?
yes, longer than 30 minutes
are there signs of inflammation
yes
- swollen and hot joints
what makes the pain worse
rest makes it worse, alleviated by exercise/activity
is there systemic involvement?
yes
- weight loss
- fever, chills, rigors
- night sweats
- fatigue
- myalgias
- lymphadenopathy
is there fatigue
yes
how are inflammatory arthritis classified?
- infectious
- crystal induced
- seronegative
- rheumatoid arthritis and its variants
- connective tissue diseases
examples of crystal-induced arthritis
gout, pseudogout, CPPD
examples of seronegative arthritis
reactive arthritis, ankylosing spondylitis, IBD-related, psoriatic arthritis
variants of RA
Sjogren’s and palindromic rheumatism
examples of connective tissue diseases
SLE, Sjogren’s, scleroderma, dermatomyositis, polymyositis
risk factors
- female
- family history
- smoking
- nulliparity
pathophysiology of RA
- T-cell immune response leads to cytokine release
- reduction in cartilage formation and activation of osteoclasts
- the complement response once RhF binds to antigen on the synovium causing degradation of hyaline cartilage and subchondral bone, hyperplasia of synovium, pannus formation (granulation tissue for fibrovascular tissue)
- angiogenesis increases vascular supply but these are very leaky, causing joint swelling
- vessel damage with joint movement leads to fibrous ankylosis, later on becoming bony ankylosis
features of RA found on inspection
- symmetrical pattern
- boggy enlargement of PIP and MCP joints
- redness
- Raynaud phenomenon
- muscle wasting
- deformities
features of RA found on palpation
- warm, swollen affected joints
- positive squeeze test
testing movement in RA
- prayer’s sign, reverse prayer sign
- thumb adduction, abduction, opposition
- finger abduction, adduction
- power grip
how to test functionality in RA
- pick a coin
- unfasten a button
- writing
deformities of RA
- ulnar deviation of fingers at MCPs
- radial deviation of hand at the wrist
- Z-deformity of the thumb
- swan neck deformity (extension of PIP; flexion of the DIP)
- splayed toes (synovitis and swelling of MTPs)
- claw toes
- hammer toes
- bunion deformity
features found on plain xray
- soft tissue swelling and osteoporosis in early RA
- late changes
- subchondral cyst formation
- subluxation
- ankylosis
- osteoporosis
- joint space narrowing
- marginal erosions
features found on ultrasound
- can assess multiple joints in a sitting
- assess the morphology of the joint and joint spaces
- synovial vascularity
features found on MRI
- bone erosions
- extensive bone oedema
- active synovitis and effusion
what is used to monitor the disease activity
- DAS28 score
- health assessment questionnaire score
- inflammatory markers
- VAS score for pain
non-pharmacological options for RA
- consume a lot of fruits, veggies and fibre
- reduce sugar, fats and red meat
- reduce processed foods
- med diet, veg diet, gluten-free vegan diet
- probiotic supplements
- ice and heat packs
- strengthening exercises
- splints
- appropriate footwear
why are hot packs used?
relax tense, tired muscles
why are cold packs used?
soothe hot, swollen joints
why are corticosteroids used?
- to bridge to better treatment for RA
- induce remission along with DMARDs
- maintain remission along with DMARDs
why are DMARDs used?
- control the signs and symptoms of joint involvement
- improve of functional status and quality of life
- retard radiological evidence of erosions
what do you do before starting DMARDs?
- educate patient about treatment
- check for HIV, HBV HCV
- exclude TB, infections, pregnancy, malignancy and CHF
- check for compliance with vaccination plan
which vaccines are contraindicated in patients using DMARDs?
live vaccines such as MMR, poliomyelitis oral vaccine, typhoid fever, yellow fever
which are vaccines that the doctor should recommend?
- yearly influenza shot
- pneumococcal
- herpes zoster
what are the goals for treatment?
- complete remission i.e. no inflammation, no radiographic progression and no functional disability
- low disease activity (minimal progression of joint damage and physical function)
- hopefully, this is done in the window of opportunity period which is when it is early on in the disease period which allows for halting the disease progression and maybe reversal of the disease progression with a complete return to normality
surgical options
- carpal tunnel release
- reconstructive arthroplasty
- correction arthrotomies of metatarsals
- arthroscopic synovectomy
- tendon release when contractures happen
- arthrodesis
complications of RA treatment
- recurrent infections
- NSAID-induced gastric ulcers
- osteoporosis (steroid use, inactivity and nutritional deficiencies)
- increased risk of CV disease and early artherosclerosis
- cataracts
- significant changes in weight
