Rheumatoid Arthritis Flashcards
Rheumatoid arthritis is the chronic inflammation of which part of the joint?
Synovial lining
Is rheumatoid arthritis usually symmetrical or asymmetrical?
Symmetrical (systemic)
Which sex is more commonly affected by RA?
3x more common in women
What are the genetic associations with RA?
HLA-DR4 (often present in RF+ patients)
HLA-DR1 (occasionally in RF+ patients)
What proportion of RA patients are positive for rheumatoid factor?
70%
What are the two most important antibodies associated with rheumatoid arthritis?
Rheumatoid factor (RF) Cyclic Citrillunated Peptide Antibodies (anti-CCP antibodies)
How does rheumatoid arthritis present?
Symmetrical distal arthropathy Pain Swelling Stiffness Pain is worse after rest but improves with activity
Which systemic symptoms may be present?
Fatigue
Weight loss
Flu-like illness
Muscle aches and weakness
What is palindromic rheumatism?
Self-limiting short episodes of inflammatory arthritis
Last 1-2 days then resolve
Which joints are commonly affected in rheumatoid arthritis?
PIP MCP wrist and ankle Metatarsophalangeal joints Cervical spine
Which joints are almost never affected by rheumatoid arthritis and what is it most likely to be instead?
Distal interphalangeal joints
Enlarged and painful DIP joints are most likely to be Heberden’s nodes due to osteoarthritis
What is atlantoaxial subluxation?
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.
Why is it important to check for atlantoaxial subluxation and when?
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
What are the key changes to look for in the hands?
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)
What causes Boutonnieres deformity?
Tear in the central slip of the extensor components of the fingers
What are the extra-articular manifestations of rheumatoid arthritis?
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
What is bronchiolitis obliterans?
Inflammation causing small airway destruction
What is Felty’s syndrome?
RA, neutropenia and splenomegaly
Which investigations should be done if RA is suspected?
Check RF
If RF negative, check anti-CCP
Inflammatory markers - CRP & ESR
X-ray of hands and feet
What are the x-ray changes present in RA?
Joint destruction and deformity
Soft tissue swelling on x-ray
Periarticular osteopenia
Bony erosions
Which scoring system is used to monitor disease activity and response to treatment?
DAS28
Which features would indicate a worse prognosis in RA?
Younger onset Male More joints/organs affected Presence of RF, anti-CCP Erosions seen on x-ray
What is first-line treatment according to NICE guidelines?
Monotherapy with methotrexate, leflunomide or sulfasalazine
Hydroxychloroquine for mild disease
What is second-line treatment according to NICE guidelines?
Two of methotrexate, leflunomide or sulfasalazine
What is third-line treatment according to NICE guidelines?
Methotrexate plus a biologic, usually a TNF inhibitor
What is fourth-line treatment according to NICE guidelines?
Methotrexate plus rituximab
What happens to RA symptoms when patients get pregnant?
They reduce
How does methotrexate work?
Interferes with metabolism of folate and suppresses the immune system
How is methotrexate given? (Route and frequency)
By injection or tablet once a week
What is always co-prescribed with methotrexate?
Folic acid 5mg, once a week on a different day to the methotrexate
What are some notable side effects of methotrexate?
Mouth ulcers and mucositis
Liver toxicity
Pulmonary fibrosis
Bone marrow suppression and leukopenia
Who must avoid methotrexate prior to conception - mother or father?
Both
How does leflunomide work?
Interferes with the production of pyrimidine (important component of RNA and DNA)
What are some notable side effects of leflunomide?
Same as methotrexate (minus pulmonary fibrosis), plus
Hypertension
Rashes
Peripheral neuropathy
What should you do if a patient on sulfasalazine falls pregnant?
Sulfasalazine appears to be safe in pregnancy however requires adequate folic acid supplementation
What are some notable side effects of sulfasalazine?
Temporary male infertility (reduced sperm count)
Bone marrow suppression
How does hydroxychloroquine work?
Interferes with Toll-like receptors, disrupting antigen presentation and increasing the pH in the lysosomes of immune cells
What are some notable side effects of hydroxychloroquine?
Nightmares
Reduced visual acuity (macular toxicity)
Liver toxicity
Skin pigmentation
What are some notable side effects of anti-TNF drugs?
Vulnerability to severe infections and sepsis
Reactivation of hep B and TB
Which protein does rituximab target?
CD20 on the surface of B cells
What are some notable side effects of rituximab?
Vulnerability to severe infections and sepsis Night sweats Thrombocytopenia Peripheral neuropathy Liver and lung toxicity
