rheumatoid arthritis Flashcards
what type of arthritis is rheumatoid arthritis ?
inflammatory arthritis
which genes have been associated with an increased risk of rheumatoid arthritis?
HLA halotypes DR4 and DR1 , patients without the genes cannot get rheumatoid arthritis
what is pannus ?
synovial membrane infiltration
which cells produce the RF ?
b cells
what is the clinical picture of RA?
- mainly the affection of the small joints of the hand except the DIP
- symmetrical arthropathy
- effusion, pain and affection of the hand function
what is the arrangement of the cells in pannus formation ?
t-cells and b-cells are in the centre and plasma cells and macrophages in the periphery
what is the most common pattern of presentation in RA?
insidious onset affecting the small joints of the hand and feet progressing to the elbows, shoulders and knees
what is the presentation like in 20% of RA cases ?
abrupt acute polyarthritis
what is palindromic rheumatism ?
variable episodes of polyarthritis ( comes and goes continuously and reaches a point where it doesn’t go anymore)
what are the hand deformities that can be found ?
ulnar deviation of the MCP
radial deviation of wrists
boutonniere deformity of fingers
swan-neck deformity of fingers
z-deformity of thumb
what are the characteristics of swan-neck deformity ?
PIP joint: hyperextension
DIP joint: flexion
what are the characteristics of boutonniere deformity ?
PIP joint: flexion
DIP joint : hyperextension
what is specific about the morning stiffness associated with RA?
lasts for more than one hour and usually decreases with movement
what are the extra articular manifestations found in the skin ?
formation of nodules which develop at sites of pressure
what are the extra articular features found in the eye ?
keratoconjunctivitis sicca ( sjogren’s syndrome )
scleritis
scleromalacia perforans
what are the pulmonary affections associated with RA?
pulmonary nodules
pulmonary fibrosis
Caplan’s syndrome
what is the most common cardiac manifestation in RA?
pericarditis
what are the renal manifestations associated with RA?
renal amyloid
GN ( related to drugs)
what are the neurological complications associated with RA?
cervical cord compression (atlanto-axial)
entrapment neuropathies
peripheral neuropathy
mononeuritis multiplex
what is the presentation of mononeurtitis multiplex ?
nerve of the foot is affected causing a drop foot
what are the associated haematological manifestations ?
normochromic normocytic anemia
thrombocytosis
what is felty’s syndrome ?
it is an extra-articcular manifestation of serop-positive rheumatoid
SANTA
splenomegaly
anemia
neutropenia
thrombocytopenia
arthritis
what investigations would you order if you’re suspecting RA?
CBC ESR, CRP urea and creatininne, LFTs RF Anti-CCP
which Ab is more specific to look for in serology in RA?
Anti-CCP
what is rheumatoid factor ?
made by B-cells and are IgM against the Fcp portion of IgG
when is the titre of rheumatoid factor high ?
if the patient has :
extra-articular manifestation
nodules
in severe disease
can healthy people be positive for RF ?
yes
what difference inn prognosis is there inn seronegative and seropositive patients ?
seropositive patients have a worse prognosis
what non-lab investigations would be required ?
x-rays
joint aspiration
how is a diagnosis of RA made ?
presence of RF
CRP and ESR are usually raised
DAS28 is usually raised
what are the criteria in the ACR classification of RA ?
morning stiffness lasting at least 1 hour swelling in 3 or more joints swelling in hand joints symmetric joint swelling erosion or decalcification on X-ray rheumatoid nodules abnormal serum RF
what is the time period required to make a diagnosis of RA ?
at least 6 weeks
how many of the ACR criteria are required to make a diagnosis of RA ?
4 out of 7
with the updated classification of RA what is the number of criteria required to make a diagnosis ?
6/10 to overcome the problem of 6 weeks
what are the X-ray findings associated with rheumatoid arthritis ?
soft tissue swelling
periarticular osteopenia
narrowing of joint space
subluxations and deformities
what is the main line of treatment of RA ?
DMARDs along with NSAIDs
what are the important contraindications associated with NSAIDs ?
PUD
renal impairment
Asthma
what are the different DMARDs ?
methotrexate
hydroxychloroquine and chloroquine
salazopyrin
leflunomide
penicillamine
what are the side effects of methotrexate ?
hepatotoxic
bone marrow suppression
so monitor liver function and CBC carefully
what are the side effects of hydroxychloroquine ?
skin pigmentation
retinopathy
myopathy
what are the side effects of salazopyrine ?
rashes
liver abnormalities
what are the side effects of leflunomide ?
diarrhoea, alopecia, rash and abnormal liver function tests
what immunosuppressants can be used ?
azathioprine
cyclophosphamide
cyclosporine
what are the side effects of each type of immunosuppressant ?
AZA - BM suppression , malignancy
Cyclophosphamide - myelosuppression, gonadal toxicity, hemorrhagic cystitis
cyclosporine - hypertension and creatinine rise
what are the biologic drugs for RA ?
etanercept
infliximab
what must infliximab be given with ?
methotrexate
what is the first line treatment for adults newly diagnosed with RA ?
methotrexate
consider hydroxychloroquine for palindromic disease
what is the best treatment to control flaer ups of RA in pregnant women ?
hydroxychloroquine
sulfasalazine
along with folate supplementation
which DMARDs should be avoidd in pregnancy ?
leflunomide
methotrexate
before the initiation of biologic treatment what must be screened for first ?
mycobacterium TB
