Rheumatoid and Osteoarthritis Flashcards
What joints are involved in Rheumatoid Arthritis?
HAND JOINTS
- MCP
- PIP (NO DIP)
WRIST
ELBOWS
FOOT
- MTP
- Mid-Tarsal
- Cricoarytenoid
CERVICAL SPINE (Vs Lumbosacral in Osteoarthritis)
What 2 deformities are seen in RA?
Swan-neck= Hyperextesion of PIP with Flexion of DIP
Boutonniere=Flexion of PIP and Extesion of DIP
What 2 lipid component is often low in RA?
Total cholesterol and HDL are low in RA because of inflammtion of the vessel walls
Low BMI in a patient with RA increase what type of risk?
Increase CVD risk
Which RA med have the lowest risk of hyperlipidemia?
Hydroxycholoroquine
What are some extra-articular manifestions of RA?
- Rheumatoid Nodules-can be seen in internal organs like the heart and lungs, MTX can increase them dramatically.
- Rheumatoid Vasculitis: seen in whites with severe longstanding RA and high titer of RF/anti-ccp
- Pleural effusion with very low glucose
- Caplan Syndrome= Pulm. fibrosis + pulm nodule+ RA
- Eye: Kerattoconjunctivitis sica, episcleritis, and scleritis
What are the manifestations of RA Vasculitis?
- Digital arteritis leading to splinter hemorrhages, mononeuritis multiplex (wrist drop/ foot drop)
- Visceral arteritis can present as MI, bowel ischemia
What other autoimmune disorder can present with RA?
Sjogren
What is Felty’s syndrome?
Seropositive RA+ Neutropenia (<500) + Splenomegaly
Renal involvement in RA is due to what?
AA amyloidosis presenting as nephrotic syndrome
What does the synovial fluid in RA show?
- TURBID fluid (low viscosity vs high viscosity in OA)
- Increase protein
- Low Glucoe
- WBC >2000
- Decrease complement
What are the non-biologics used in RA?
Methotrexate (1st line) Leflunomide Hydroxychloroquine Sulfasalazine Minocycline Azathioprine
Prior to starting Azathioprine what should be checked?
Thiopurine methyltransferase should be checked as deficiency can lead to toxicity
What are the Biological agents?
TNF inhibitors:
- Etanercept
- Infliximab
- Adalimumab
Non-TNF Biologics: Anakinra (anti-IL 1) Abatacept (T cell costimulation inhibitor) Rituximab Tocilizumab, Sarilumab (Anti-IL 6) Tofacitinib (JAK inhibitors)
If RA severity remains moderate to high despite MTX monotherapy how should we escalate therapy?
1. Combining DMARDS Or 2. TNF inhibitor +/- MTX Or 3.Non-biologics TNFi +/- MTX
If diseae activity remains high despite this then add Steroids
Anti TNF inhibitors and Abatacept are contraindicated in what scenarios?
- Acute bacterial infection, URI with fever >101
- Latent TB (treat at least 1 month prior to startingand continue while on therapy), If active TB stops TNF and treat the TB
- Active VZV
- Previously treated lymphoproliferative disease
- CHF
- Acute hep B/C
- Liver disease with Child Pugh B/C
- MS or demyelnating disease
- No live vaccines during therapy
- Flu shot, pneumonccocal, hep B vaccine should be given prior to therapy if needed
Methotrexate and Leflunomide are C/I in what?
- Acute bacterial infection, URI with fever >101
- Latent TB (treat at least 1 month prior to startingand continue while on therapy), If active TB stops TNF and treat the TB
- Active VZV
- Pulmonary Fibrosis (MTX)
- Creatine clearance <30 (MTX)
- Acute hep B/C
- Liver disease with Child Pugh B/C
- Myelodysplastic syndrome, Leukopenia, Thrombocytopenia
- Pregnant
Rituximab is associated with reactivation of what diseases?
Hep B (Prophylaxis with tenofovir or entecavir)
Progressive multifocal leucoencephalopthy
TNF inhibitors are associated with reactivation of what infections? and cancers?
TB
Disseminated histoplasmosis
Hep B
Cancer
- Lymphoma in children and adolescents)
- Non-Melanoma skin cancers in adults
TNF inhibitors are associated with what systemic side effects?
Cytopenia CHF Demyelinating disease Lupus like syndrome Hepatotoxicity Infusion reaction
Which vaccine should be given to RA patient older than 60
Zoster vaccine 2 weeks prior to therapy
A monoarticular flare in a patient with RA should be approached in what way?
as if it is a septic arthritis until proven ortherwise because patients on immunosupressive therapy may not mount a fever or leukocytosis
How is RA managed in pregnancy?
MTX and LEF are discontinued 90 days prior to conception
NSAID used only during second trimester
Steroid use only after first trimester
Sulfaslazine and Hydroxychloroquine are safe during pregnancy
What are the causes of Secondary OA?
- Trauma
- Metabolic (Hemochromatosis)
- Endocrine (acromegaly)
- Inflammatory (OA after RA or ankylosing spondylitis)
