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Rheumatology > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

features of RA affecting eyes

A

sjogrens syndrome

scleromalacia

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2
Q

hypertrophic osteoarthropathy

A

clinical syndrome of finger clubbing, periostitis of long bones and arthritis

thigh pain (femur)
joint swelling 
finger clubbing

ALP and ESR are elevated

can be idiopathic/primary or secondary to an underlying malignancy.

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3
Q

treatment for RA

A

NSAID for symptomatic relief
DMART (methotrexate) to slow down progression

1st line- methotrexate
others- sulfasalazine, hydroxychloroquine, lefluonmide

biologic agents- TNF alpha (adalimumab, entanercept)
IL-1
CD20

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4
Q

MS

A

IL-12 is a potent pro inflammatory cytokines in high concentration in early MS

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5
Q

what is rheumatoid arthritis?

A

autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa. ( a type of inflammatory arthritis )

*symmetrical
*affects multiple joints
(symmetrical polyarthritis)

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6
Q

what are the genetic associations with RA?

A 
HLA DR4 (RF+)
HLA DR1
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7
Q

antibodies in rheumatoid arthritis

A

rheumatoid factor
an autoantibody present in 70% of RA patients. targets the Fc portion of the IgG antibody. this causes activation of the immune system against the patients own IgG which causes systemic inflammation

anti CCP
*cyclic citrullinated peptide antibodies
these are autoantibodiess which are more sensitive and specific to rheumatoid arthritis than rheumatoid factor is. anti CCP can pre-date the development of RA.

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8
Q

how does rheumatoid arthritis present?

A

symmetrical distal polyarthropathy

  • pain
  • swelling
  • stiffness
small joints (hands, feet, wrist, MCP and PIP joints)
larger (knees, shoulders, elbows). can be rapid or over months / years

systemic symptoms

  • fatigue
  • weight loss
  • flu like illness
  • muscle aches and weakness

worse after rest
improves with symptoms
>30 minute morning stiffness

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9
Q

what is Palindromic Rheumatism

A

inflammatory arthritis with joint pain, stiffness, swelling typically affects only a few joints. episodes last 1-2 days then completely resolve. RF and anti CCP +ve can suggest a progression to full rheumatoid arthritis

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10
Q

which joints are commonly affected in RA?

A 
proximal interphalangeal joints (PIP)
metacarpopharyngeal joints (MCP
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11
Q

anatomy of the joints

A 
DIP
PIP
MCP
wrist and ankle
metatarsophalangeal joints
cervical spine
large joints (knee, hip, shoulder)

DIP are usually never affected
large DIP is usually Herberden’s nodes in OA

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12
Q

what is atlantoaxial subluxation?

A

it occurs in the cerivcal spine- his (C2) and the odontoid peg shift within he atlas (C1) caused by local synovitis and damage to the ligaments and burs around the odontoid peg of the axis and atlas.

this can cause spinal cord compression which is an emergency

! relevance to GA and itubation
MRI can visualise changes pre-op

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13
Q

what are rheumatoid signs in hands?

A

palpation around the synovium will give a boggy feeling

Z shaped deformity of thumb

swan neck deformity (hyperextended PIP with flexed DIP) (swan down for a dip)

boutonniers deformity
(hyperextended DIP, flexed PIP) (bout out PIP) this is due to a tear in the central slip of the extensor components of the fingers so when a patient tries to straighten their finger, the lateral tendons around the PIP (Flexor digitorum superficial) puts on the distal pharynx which causes the DIP to extend and the PIP to flex

ulnar deviation for he fingers and the knuckle (MCP)

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14
Q

what are some extra-articular manifestations of RA?

A

Pulmonary fibrosis with pulmonary nodules (Caplan’s syndrome)
Bronchiolitis obliterans (inflammation causing small airway destruction)
Felty’s syndrome (RA, neutropenia and splenomegaly)
Secondary Sjogren’s Syndrome (AKA sicca syndrome)
Anaemia of chronic disease
Cardiovascular disease
Episcleritis and scleritis
Rheumatoid nodules
Lymphadenopathy
Carpel tunnel syndrome
Amyloidosis

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15
Q

how to investigate for RA?

A

bloods:

  • rheumatoid factor
  • if negative then check anti CCP
  • inflammatory markers CRP and ESR

imaging:

  • X-ray of hands and feet
  • ultrasound to confirm / evaluate synovitis
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16
Q

expected Xray changes in RA

A

LESP

Loss of joint space / joint destruction deformity
Erosions (boney)
Soft tissue swelling
Periarticular osteopenia

17
Q

referral for RA

A

refer any adult with persistent synovitis even with negative RF, anti CCP and inflammatory markers

urgent if small joint and hands/feet , multiple joints or symptoms have been present for 3 months.

18
Q

diagnosis of RA

A

Diagnostic criteria come from the American College of Rheumatology (ACR) / European League Against Rheumatism (ELAR) from 2010:

Patients are scored based on:

The joints that are involved (more and smaller joints score higher)
Serology (rheumatoid factor and anti-CCP)
Inflammatory markers (ESR and CRP)
Duration of symptoms (more or less than 6 weeks)
Scores are added up and a score greater than or equal to 6 indicates a diagnosis of rheumatoid arthritis.

19
Q

DAS28 score

A

The DAS28 is the Disease Activity Score. It is based on the assessment for 28 joints and points are given for:

Swollen joints
Tender joints
ESR/CRP result
It is useful in monitoring disease activity and response to treatment.

HAQ- measure functional ability

20
Q

prognosis of RF

A

Prognosis varies between patients from mild and remitting to severe and progressive. There is a worse prognosis with:

Younger onset
Male
More joints and organs affected
Presence of RF and anti-CCP
Erosions seen on xray
21
Q

how is RA managed?

A

conservative:
MDT- nurses, physiotherapy, OT, psychology, podiatry

medical:
steroids (flare up)
NSAID / COX-2 inhibitors
\+ PPI
*induce remission
*monitor CRP and DAS28 for treatment

DMARDS

  • mono therapy with methotrexate, leflunomide, sulfasalazine, hydroxychlorquine
  • 2nd line is combo (2)
  • 3rd line is methotrexate plus a biological therapy (TNF inhibitor)
  • 4th line is methotrexate plus rituximab
22
Q

pregnancy and RA meds

A

pregnant women tend to experience an improvement in symptoms during their pregnancy probably due to higher natural production of steroids

  • sulfasalazine and hydroxychlorquine are SAFE
  • methotrexate is teratogenic in pregnancy (folate)
23
Q

examples of biological tehrapies

A

*third line with methotrexate

Anti-TNF (adalimumab, infliximab, etanercept, golimumab and certolizumab pegol)
Anti-CD20 (rituximab)
Anti-IL6 (sarilumab)
Anti-IL6 receptor (tocilizumab)
JAK inhibitors (tofacitinib and baricitinib)

all lead to immunosupressoin
can lead to re-activation of dormant infections like TB and hep B

24
Q

surgery for RA

A

joint defomity

25
Q

what is methotrexate and how does it work?

A

interfere with metabolism of folate and suppressing certain components of the immune system
injection / weekly tablet
folic acid 5mg is also prescribed (Taken a different day to methotrexate)

side effects:
Mouth ulcers and mucositis
Liver toxicity
Pulmonary fibrosis
Bone marrow suppression and leukopenia (low white blood cells)
It is teratogenic (harmful to pregnancy) and needs to be avoided prior to conception in mothers and fathers

26
Q

leflunoamide

A

Leflunomide is an immunosuppressant medication that works by interfering with the production of pyrimidine. Pyrimidine is an important component of RNA and DNA.

Notable Side Effects

Mouth ulcers and mucositis
Increased blood pressure
Rashes
Peripheral neuropathy
Liver toxicity
Bone marrow suppression and leukopenia (low white blood cells)
It is teratogenic (harmful to pregnancy) and needs to be avoided prior to conception in mothers and fathers

27
Q

sulfasalazine

A

Sulfasalazine works as an immunosuppressive and anti-inflammatory medications. The mechanism is not clear but may be related to folate metabolism. It appears to be safe in pregnancy however women need adequate folic acid supplementation.

Notable Side Effects

Temporary male infertility (reduced sperm count)
Bone marrow suppression

28
Q

hydroxychloroquine

A

Hydroxychloroquine is traditionally an anti-malarial medication. It acts as an immunosuppressive medication by interfering with Toll-like receptors, disrupting antigen presentation and increasing the pH in the lysosomes of immune cells. It is thought to be safe in pregnancy.

Notable Side Effects

Nightmares
Reduced visual acuity (macular toxicity)
Liver toxicity
Skin pigmentation

29
Q

anti-TNF drugs

A

Tumour necrosis factor is a cytokine involved in stimulating inflammation. Blocking TNF reduces inflammation. Some examples of anti-TNF drugs are:

Adalimumab
Infliximab
Golimumab
Certolizumab pegol
Etanercept
Adalimumab, infliximab, golimumab and certolizumab pegol are monoclonal antibodies to tumour necrosis factor. Etanercept is a protein that binds TNF to the Fc portion of IgG and thereby reduces its activity.

Notable Side Effects

Vulnerability to severe infections and sepsis
Reactivation of TB and hepatitis B

30
Q

rituximab

A

Rituximab is a monoclonal antibody that targets the CD20 protein on the surface of B cells. This causes destruction of B cells. It is used for immunosuppression for autoimmune conditions such as rheumatoid arthritis and cancers relating to B cells.

Notable Side Effects

Vulnerability to severe infections and sepsis
Night sweats
Thrombocytopenia (low platelets)
Peripheral neuropathy
Liver and lung toxicity
31
Q

side effect in summary

A

Methotrexate: pulmonary fibrosis
Leflunomide: Hypertension and peripheral neuropathy
Sulfasalazine: Male infertility (reduces sperm count)
Hydroxychloroquine: Nightmares and reduced visual acuity
Anti-TNF medications: Reactivation of TB or hepatitis B
Rituximab: Night sweats and thrombocytopenia

32
Q

biopsy of nodules (swan neck deformity)

A

swan neck deformity- hyperextension of PIP and flexion of DIP

subcuteanous nodules and enlarged knuckles. fibrinoid necrosis surrounded by palisading epithelioid cells.

33
Q

what is Felty syndrome

A

triad of splenomegaly, neutropenia in patients with RA.

skin changes to lower limb
50-70 yo

treat underlying RA

Rheumatology (20 decks)

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