Rheumatoid Arthritis Flashcards
what is it?
most common seropositive inflammatory arthropathy
auto-immune inflammatory systemic polyarthropathy
pathogenesis
immune response against synovium inflammatory pannus forms - attack and denudes articular cartilage joint destruction tendon ruptures soft tissue damage joint instability subluxation
who gets it?
more common in women
prevalence !% increasing with age
35-50yr
genetic factors 50% of the risk
1st degree relatives are 2-3x more likely
definite association between smoking and RA
how does it present?
symmetrical synovitis (doughy swelling) mainly small joints of the hands and feet MCP & PIP, wrists affected DIP spared morning stiffness extra-articular manifestations it may affect C1-C2 dangerous!
extra-articular manifestations of RA?
rheumatoid nodules - 25% extensor surfaces/ mechanical irritation sites lung - pleural effusion, interstitial fibrosis, pulmonary nodules CV: morbidity and mortality increased occular involvement - keratoconjunctivitis sicca - episcleritis - uveitis - nodular sceritis - scleromalacia
how is it investigated?
x -ray
ultrasound - detecting synovial inflammation
serology
how does it present on x-ray?
onset of disease
- often show no joint abnormality
- peri-articular osteopenia (bone thinning)
- soft tissue swelling
later in disease
- periarticular erosions
what is the serology presentation?
rheumatoid factor
Anti-CCP - more specific
15-20% of patients with RA are seronegative!!!
how is it diagnosed?
clinical presentation
radiographic findings
serological findings
ACR and EULAR RA criteria scoring system
how is it managed?
DMARD therapy within the 1st 3 months of symptom onset
if diseased doesn’t respond 2 DMARDs (methotraxate and sulfalazinre
if still not responsive - biologic therapy (if high DAS28)
symptom relief
other therapies
what is methotrexate?
first line (teratrogenic) pregnancy test before starting contraception taken! 1 a week – 15mg start regular blood tests Folic acid 1/week (3 days after drug) • If you’re low on folate: nausea, alopecia
if patient wants to be pregnant:
• stop methotrexate for 3 months before conception - still need to take contraceptive pill
• RA gets better during pregnancy
• after pregnancy it gets worse, so you give them sulphalazine (not methotrexate because of breastfeeding)
DMARDs
methotrexate sulphalazine hydroxychloroquine leflunomide side effects: immunosuppressive – need to monitor bloods
biologic therapy
anti-TNF
injection - toxlizumab, rituximab, abatacept
risks
- increased risk of infection
- latent TB reactivation – need to screen
• if positive: latent TB therapy
• and then start biologics
what is given for symptom relief?
simple analgesia
NSAIDs
intramuscular/ intra-articular and oral steroids
what are the other therapies which can be used?
physiotherapy, OT, podiatrist, orthotists
surgery for resistant disease - synovectomy, joint replacement, joint excision, tendon transfers, arthrodesis (fusion), cervical spine stabilization
