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
