rheumatoid arthiritis Flashcards
define rheumatoid arthritis
Anautoimmune conditionthat causeschronic inflammationin thesynovial liningof thejoints,tendon sheathsandbursa.
risk factors for rheumatoid arthritis
- women 30-50
- smoking
- genetics
- other autoimmune diseases
what is the genetic link to rheumatoid arthritis?
HLADR4/HLADRB1 genes
where does rheumatoid arthritis affect
affects multiple joints symmetrically across the body
pathophysiology of rheumatoid arthritis
- arginine to citrulline mutation in T2 collagen
- results in formation of Anti-cyclic citrullinated peptide antibodies (anti-CCP antibodies)
- INF alpha causes further pro-inflammatory recruitment to synovium
- synovial lining expands and a tumour like mass (pannus) grows past joint margins
- pannus destroys subchondral bone and articular cartilage
what is rheumatoid factor (RF)
an autoantibody - is present in around 70% of RA patients.
It targets the Fc portion of IgG, and this causes immune system activation against the patient’s own IgG, which causes systemic inflammation.
which antibody is RF
RF is mostly IgM, but it can be other types of immunoglobulins.
difference between RF and anti CCP antibodies
- anti CCP antibodies are more specific and sensitive
- anti CCP antibodies pre-date the development of RA, meaning they can be used to indicate if a patient is likely to develop RA.
general symptoms of rheumatoid arthiritis
- painful, swollen, stiff joints for more than an hour in the morning, better with movement
- Pain and stiffness in small joints (hands, feet, wrist, MCP, PIP) and larger joints (knees, shoulders, elbows)
- Fatigue
- Weight loss
- Flu like illness
- muscle aches
- weakness
- Synovial thickening of the affected joints (they feel “boggy”)
what is Palindromic Rheumatism
periods of inflammatory arthritis that is likely to progress to RA.
4 advanced RA signs
- Z-shaped deformity of the thumb
- Swan neck deformity (DIP joint flexes and the PIP joint extends)
- Boutonniere deformity (DIP joint hyperextends and the PIP joint flexes)
- Ulnar deviation
extra-articular manifestations of RA
- RA with pulm nodules (Caplan’s syndrome)
- Felty’s Syndrome (RA, neutropenia, splenomegaly)
- Anaemia of chronic disease
- Lymphadenopathy
- Secondary Sjogren’s Syndrome
- Amyloidosis
cervical spine signs of RA
Atlantoaxial subluxation -
synovitis/damage to ligaments causes the C2 vertebrae to shift within the C1 vertebrae, leading to spinal cord compression.
describe how the joints are inflamed in RA
they are symmetrical, hot and inflamed
most common in wrist, hands and feet
which joint is often spared in RA
DIPJ
describe the speed of onset of RA
the speed of onset can vary from slowly over years, to rapidly overnight.
what does NICE recommend regarding RA
NICE recommends urgent rheumatology referral for patients with persistent synovitis
initial investigations for RA
- Rheumatoid factor (sensitive)
- Anti-CCP antibodies (specific)
- Inflammatory markers (CRP and ESR)
- X-rays of hands and feet
- Ultrasound/MRI (to detect synovitis
- gnetic testing
what X ray changes are seen with RA
LESS
- lost joint space
- bony erosion
- Soft tissue swelling
- soft bones - periarticular osteopenia.
give 3 scoring systems used to assess the severity of RA
- ACR/EULAR classification
- Health Assessment Questionnaire
- Disease Activity Score 28 Joints
what is the ACR/EULAR classification used for
the criteria can be used to make the diagnosis
what is the Health Assessment Questionnaire used for
it measures functional ability.
what is the Disease Activity Score 28 Joints
used to monitor disease activity and response to treatment.
what is the aim of RA treatment
induce remission or get as close to remission as possible.
whats used to monitor RA treatment
CRP and DAS28 are used to monitor the success of treatment.
when are short term steroids used for RA
- at initial presentation
- when initiating new treatments
- or during flare-ups
what do short term steroids do for RA
reduce inflammation and control symptoms.
main treatment for RA
DMARDs:
- Monotherapy with methotrexate, leflunomide, or sulfasazine.
- Combination treatment with multiple DMARDs
- Biologic therapies, alongside methotrexate
- (Hydroxychloroquine –mildest DMARD- may be used in mild-disease and palindromic rheumatism)
can NSAIDS be used for RA
NSAIDS are helpful for pain but have risks and side-effects.
impact of pregnancy on RA
Pregnancy can either worsen or improve symptoms.
Methotrexate and Leflunomide are TERATOGENIC.
most common anaemia present in RA
normocytic normochromic anaemia
what is the 1st line biologics treatment
infliximab
given with methotrexate
what is the 2nd line biologics treatment
rituximab
- is a B cell inhibitor
