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Adele Rheumatology > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

Rheumatoid arthritis is the chronic inflammation of which part of the joint?

A

Synovial lining

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2
Q

Is rheumatoid arthritis usually symmetrical or asymmetrical?

A

Symmetrical (systemic)

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3
Q

Which sex is more commonly affected by RA?

A

3x more common in women

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4
Q

What are the genetic associations with RA?

A

HLA-DR4 (often present in RF+ patients)

HLA-DR1 (occasionally in RF+ patients)

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5
Q

What proportion of RA patients are positive for rheumatoid factor?

A

70%

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6
Q

What are the two most important antibodies associated with rheumatoid arthritis?

A 
Rheumatoid factor (RF)
Cyclic Citrillunated Peptide Antibodies (anti-CCP antibodies)
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7
Q

How does rheumatoid arthritis present?

A 
Symmetrical distal arthropathy
Pain
Swelling
Stiffness
Pain is worse after rest but improves with activity
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8
Q

Which systemic symptoms may be present?

A

Fatigue
Weight loss
Flu-like illness
Muscle aches and weakness

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9
Q

What is palindromic rheumatism?

A

Self-limiting short episodes of inflammatory arthritis

Last 1-2 days then resolve

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10
Q

Which joints are commonly affected in rheumatoid arthritis?

A 
PIP
MCP
wrist and ankle
Metatarsophalangeal joints
Cervical spine
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11
Q

Which joints are almost never affected by rheumatoid arthritis and what is it most likely to be instead?

A

Distal interphalangeal joints

Enlarged and painful DIP joints are most likely to be Heberden’s nodes due to osteoarthritis

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12
Q

What is atlantoaxial subluxation?

A

The axis (C2) and the odontoid peg shift within the atlas (C1), caused by local synovitis and damage to the ligaments and bursa around the odontoid peg.

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13
Q

Why is it important to check for atlantoaxial subluxation and when?

A

Subluxation can cause spinal cord compression and is an emergency, this is particularly important if the patient is having a general anaesthetic and requires intubation

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14
Q

What are the key changes to look for in the hands?

A 
Z-shaped deformity
Swan necked deformity (hyperextended PIP with flexed DIP)
Boutonnieres deformity (hyperextended DIP with flexed PIP)
Ulnar deviation of the fingers at the knuckles (MCP joints)
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15
Q

What causes Boutonnieres deformity?

A

Tear in the central slip of the extensor components of the fingers

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16
Q

What are the extra-articular manifestations of rheumatoid arthritis?

A 
Pulmonary fibrosis with pulmonary nodules (Caplan's syndrome)
Bronchiolitis obliterans
Felty's syndrome 
Secondary Sjogren's syndrome (sicca syndrome)
Anaemia of chronic disease 
Cardiovascular disease 
Episcleritis and scleritis 
Rheumatoid nodules 
Lymphadenopathy
Carpal tunnel syndrome 
Amyloidosis
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17
Q

What is bronchiolitis obliterans?

A

Inflammation causing small airway destruction

18
Q

What is Felty’s syndrome?

A

RA, neutropenia and splenomegaly

19
Q

Which investigations should be done if RA is suspected?

A

Check RF
If RF negative, check anti-CCP
Inflammatory markers - CRP & ESR
X-ray of hands and feet

20
Q

What are the x-ray changes present in RA?

A

Joint destruction and deformity
Soft tissue swelling on x-ray
Periarticular osteopenia
Bony erosions

21
Q

Which scoring system is used to monitor disease activity and response to treatment?

A

DAS28

22
Q

Which features would indicate a worse prognosis in RA?

A 
Younger onset
Male
More joints/organs affected
Presence of RF, anti-CCP
Erosions seen on x-ray
23
Q

What is first-line treatment according to NICE guidelines?

A

Monotherapy with methotrexate, leflunomide or sulfasalazine

Hydroxychloroquine for mild disease

24
Q

What is second-line treatment according to NICE guidelines?

A

Two of methotrexate, leflunomide or sulfasalazine

25
Q

What is third-line treatment according to NICE guidelines?

A

Methotrexate plus a biologic, usually a TNF inhibitor

26
Q

What is fourth-line treatment according to NICE guidelines?

A

Methotrexate plus rituximab

27
Q

What happens to RA symptoms when patients get pregnant?

A

They reduce

28
Q

How does methotrexate work?

A

Interferes with metabolism of folate and suppresses the immune system

29
Q

How is methotrexate given? (Route and frequency)

A

By injection or tablet once a week

30
Q

What is always co-prescribed with methotrexate?

A

Folic acid 5mg, once a week on a different day to the methotrexate

31
Q

What are some notable side effects of methotrexate?

A

Mouth ulcers and mucositis
Liver toxicity
Pulmonary fibrosis
Bone marrow suppression and leukopenia

32
Q

Who must avoid methotrexate prior to conception - mother or father?

A

Both

33
Q

How does leflunomide work?

A

Interferes with the production of pyrimidine (important component of RNA and DNA)

34
Q

What are some notable side effects of leflunomide?

A

Same as methotrexate (minus pulmonary fibrosis), plus
Hypertension
Rashes
Peripheral neuropathy

35
Q

What should you do if a patient on sulfasalazine falls pregnant?

A

Sulfasalazine appears to be safe in pregnancy however requires adequate folic acid supplementation

36
Q

What are some notable side effects of sulfasalazine?

A

Temporary male infertility (reduced sperm count)

Bone marrow suppression

37
Q

How does hydroxychloroquine work?

A

Interferes with Toll-like receptors, disrupting antigen presentation and increasing the pH in the lysosomes of immune cells

38
Q

What are some notable side effects of hydroxychloroquine?

A

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

39
Q

What are some notable side effects of anti-TNF drugs?

A

Vulnerability to severe infections and sepsis

Reactivation of hep B and TB

40
Q

Which protein does rituximab target?

A

CD20 on the surface of B cells

41
Q

What are some notable side effects of rituximab?

A 
Vulnerability to severe infections and sepsis
Night sweats
Thrombocytopenia
Peripheral neuropathy
Liver and lung toxicity

Adele Rheumatology (2 decks)

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