Rheumatoid arthritis 08/10/18 Flashcards
What is Rheumatoid Arthritis?
Symmetrical inflammatory arthritis affecting mainly the peripheral joints
What can RA lead to if left untreated?
Joint damage
Irreversible deformities
Loss of function
Increased morbidity and mortality
What surfaces does RA affect?
Both articular and extra-articular
Which gender are more affected by RA?
Women x3
What is the mediator for RA?
HLA-DR4
What are potential triggers for RA?
Infections
Stress
Cigarette smoking
What does the severity of Ra depend on?
Genetic factors
Presence of autoantibodies
What is the main structure involved in RA?
The synovium
Where does the synovium line?
The inside of a synovial joint capsule and tendon sheaths
What spinal joints are synovium lined?
C1/C2
What are some joints that are lined with synovium?
Hand joints wrists elbows shoulders TMJs Knees Hips Ankles Feet
What cells are present in a pannus?
Osteoclasts Fibroblasts Macrophage Dendritic cell T cell Plasma cell B cell Extensive angiogenesis Hyperplastic synovial lining
What is classified as early RA?
Less than 2 years since symptom onset
What is the 1987 criteria for RA?
Morning stiffness Arthritis of 3 or more joint areas Arthritis of hands Symmetric arthritis Rheumatoid nodules Serum RF Radiographic changes
How is RA diagnosed?
History and clinical examination Blood testing Inflammatory markers Autoantibodies Imaging
what are the clinical features of RA?
Prolonged morning stiffness
Involvement of small hand a feet joints
Symmetric distribution
Positive compression tests of MCP and MTP joints
What are the clinical features of RA?
PIP,MCP,wrist ,MTP synovitis. Monoarthritis. Tenosynovitis. Trigger finger. Carpal tunnel syndrome. Polymyalgia rheumatica. Palindromic rheumatism. Systemic symptoms. Poor grip strength.
What are the autoantibodies for RA?
Rheumatoid factor (IgM) Anti-CCP antibodies
What are the characteristics of Anti-CCP antibodies?
Can be present before articular symptoms
Associated with smoking
Remains positive despite treatment
Low sensitivity
What is the imaging for RA?
Plain hand an feet X-rays
Ultrasound
MRI
What can be seen on plain x-rays?
Soft tissue swelling
Periarticular osteopaenia
Erosions
Why is ultrasound good imaging for RA?
Increased sensitivity for early disease
SUperior to clinical examination
Detects 7x MCP erosiosn
What can MRI detect in RA?
Bone marrow oedema Integrety of tendons Synovitis Erosions Disease activity
What is the management for RA?
Early recognition Rheumatology care Anti-rheumatic drugs NSAIDs and steroids Education MDT
What is the treatment pyramid for RA?
NSAIDs \+steroids \+DMARD \+DMARD2 \+DMARD3 Gradually withdraw treatments
How are steroids used in RA?
Shown to improve symptoms
Combination with DMARDs
Orally IA or IM
Methylprednisolone
What is a DMARD?
DISEASE MODIFYING ANTI-RHEUMATIC DRUGS-DMARDS
Name three Dmards
Methotrexate
Sulfasalazine
Hydroxychloroquine
What is the initial drug of choice in RA?
Methotrxate
What is the dosage of methotrexate>
Start at 15 mg/week with rapid escalation
Maximum dose 25 mg/week
Folic acid 24 hours after MTX dose
Are DMARDS safe in pregnancy?
No - Teratogenic
What can go wrong with DMARDs?
Regular monitoring needed. Bone marrow suppression. Infection. Liver function derangement. Pneumonitis in case of methotrexate. Avoid Sulfasalzine in septrin allergy and G6PD deficiency
What are some biological treatments that are used for RA?
Anti TNF agents- Infliximab,Etanercept,Adalimumab, Certolizumab,Golimumab T cell receptor blocker-Abatacept. B cell depletor-Rituximab IL-6 blocker-Tocilizumab. JAK 2 inhibitors-Tofacitinib.
What are complications of untreated RA?
Boutonniere deformity of thumb
Ulnar deviation of MTP joints
Swan neck deformity of fingers
