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MsK > Rheumatoid arthiritis > Flashcards

Rheumatoid arthiritis Flashcards

1
Q

What is RA

A

Rheumatoid arthritis is an autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa.

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2
Q

What type of arthritis is RA

A

Inflammatory

Synovial inflammation is called synovitis

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3
Q

Is RA symmetrical or unsymmetrical

A

SYMMETRICAL

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4
Q

RA epidemiology

A

1% population
2-3x more common in females
Main risks – family history and smoking
Middle age (but any age can be affected)

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5
Q

is RA more common in men or women

A

WOMEN

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6
Q

Genetic associations of RA

A

HLA DR4 (a gene often present in RF positive patients)
HLA DR1 (a gene occasionally present in RA patients)

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7
Q

Whats joints are involved in RA

A
  • Symmetrical small joints, hands, wrists, feet
  • Big joints involved later, bad prognostic sign if involved at presentation
  • No spinal involvement
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8
Q

Pathophysiology of RA

A

-Rheumatoid factor is an autoantibody
-Targets the fc portion of of the IgG antibody
-Causes activation of the immune system against the patients own Igg
-Causes systemic inflammation

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9
Q

What is the role of T cells once activated

A

-T cells secrete cytokines (e.g. Interferon-gamma and IL-17) to recruit macrophages.

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10
Q

What is the role of macrophages once activated

A

Macrophages also produce cytokines (TNF, IL-1 and IL-6) which causes synovial cells to proliferate.

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11
Q

After proliferation what occurs

A

-This creates a pannus (thick synovial membrane made of fibroblasts, myofibroblasts and inflammatory cells).
- This can damage the cartilage, soft tissue and bones.

Inflammatory cytokines also cause T-cells to express RANKL which can bind to osteoclasts, causing breakdown of bone

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12
Q

Role of ANTI- CCP

A

targets cirtrullinated proteins. This forms an immune complex which can accumulate and activate complement system, promoting joint inflammation and injury.

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13
Q

Signs of RA

A

-Symmetrical polyarthritis
- Pain
-Swelling
-Stiffness

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14
Q

Is pain from inflammatory arthritis better or worse after activity

A

Worse after rest but improves with activity

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15
Q

What hand deformities would be present with RA

A
  • Ulnar deviation
    -Swan Neck
    -Boutonniere deformity
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16
Q

Clinical presentation of RA

A
  • Pain and Swelling of joints
  • Typically small joints hands, wrists, forefeet
  • Early morning stiffness (often prolonged)
  • Sudden change in function
17
Q

Physical examination for RA

A

Decreased grip strength / fist formation
Often subtle synovitis – MCPs, PIPs, MTPs, ankles
DIPs are spared
Usually symmetrical

18
Q

Primary investigations of RA

A

ESR and CRP = raised markers of inflammation
RF- in 70% of patients
Anti- CCP- Present in 80% of patients

19
Q

X-ray of RA

A
  • Soft tissue swelling
  • Periarticular osteopenia
  • Joint space narrowing
20
Q

how would synovitis be found

A

US scan of the joints

21
Q

When would referral be useful

A

NICE recommend referral for any adult with persistent synovitis, even if they have negative rheumatoid factor, anti-CCP antibodies and inflammatory markers.

22
Q

Management of RA

A

Primary care:
- NSAID : low dose NSAID cover the period between symptom onset and rheumatology referral

23
Q

Secondary care management of RA

A

1st line - disease modifying anti- rheumatic drug DMARD
Methotrexate 10-25mg per week

24
Q

Monitoring methotrexate

A

Monthly:

  • Measure CRP
  • Disease activity - using a composite score such as DAS-28. DAS-28 takes into account the overall health of the patient, the number of swollen joints, and the ESR count.

Annually:

  • Assess disease activity e.g. DAS-28 score
  • Measure impact on life and functional ability e.g. health assessment questionnaire (HAQ)
  • Check for comorbidities and complications
  • Assess need for surgery
25
Q

5 cardinal signs of inflammation

A

Heat
Redness
Swelling
Pain
Loss of function

26
Q

Basic Summary of inflammatory arthritis

A

New onset joint SWELLING
- synovial
-often red
-warm to touch
Worst in morning / inactivity
Stiffness > 30 mins (usually longer)
Constant or intermittent
Patterns of joint +/- spine involvement vary by arthritis type

27
Q

Main risk factors for RA

A
  • Family History
  • Smoking
28
Q

Features of degenerative arthritis

A
  • usually later in life
  • slow- over years
  • initially asymmetrical monoarthritis
  • weight bearing joints
  • stiffness <1 hr and worse at the end of the day
29
Q

Mechanism of methotrexate

A

Inhibits dihydrofolate reductase preventing DNA synthesis

30
Q

Differential diagnosis of RA

A

Psoriatic arthritis
Infectious arthritis
Gout
SLE
Osteoarthritis

31
Q

How do you manage flareups of RA

A

NSAIDS
Glucocorticoids

32
Q

RA complications

A

Corneal ulceration
Pericarditis
Increased risk of Heart disease
Carpal tunnel

MsK (14 decks)

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