Rheumatoid Arthritis Flashcards
features of RA affecting eyes
sjogrens syndrome
scleromalacia
hypertrophic osteoarthropathy
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.
treatment for RA
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
MS
IL-12 is a potent pro inflammatory cytokines in high concentration in early MS
what is rheumatoid arthritis?
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)
what are the genetic associations with RA?
HLA DR4 (RF+) HLA DR1
antibodies in rheumatoid arthritis
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.
how does rheumatoid arthritis present?
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
what is Palindromic Rheumatism
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
which joints are commonly affected in RA?
proximal interphalangeal joints (PIP) metacarpopharyngeal joints (MCP
anatomy of the joints
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
what is atlantoaxial subluxation?
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
what are rheumatoid signs in hands?
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)
what are some extra-articular manifestations of RA?
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
how to investigate for RA?
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
expected Xray changes in RA
LESP
Loss of joint space / joint destruction deformity
Erosions (boney)
Soft tissue swelling
Periarticular osteopenia
referral for RA
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.
diagnosis of RA
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.
DAS28 score
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
prognosis of RF
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
how is RA managed?
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
pregnancy and RA meds
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)
examples of biological tehrapies
*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
surgery for RA
joint defomity
what is methotrexate and how does it work?
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
leflunoamide
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
sulfasalazine
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
hydroxychloroquine
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
anti-TNF drugs
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
rituximab
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
side effect in summary
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
biopsy of nodules (swan neck deformity)
swan neck deformity- hyperextension of PIP and flexion of DIP
subcuteanous nodules and enlarged knuckles. fibrinoid necrosis surrounded by palisading epithelioid cells.
what is Felty syndrome
triad of splenomegaly, neutropenia in patients with RA.
skin changes to lower limb
50-70 yo
treat underlying RA
