Rheumatoid Arthritis Flashcards
What conditions come under inflammatory arthritis?
Rheumatoid Reactive Psoriatic SLE Gout Ankylosing spondylitis
What parts of the joints does RA target and which joints are generally effected?
Synovial lining
Tendon sheaths
Bursa
Affected multiple joints, tends to be small joints i.e. MCP and PIP
= SYMMETRICAL POLYARTHRITIS
NOTE: DIP never effected (differentiated from osteo)
Which antibodies are associated with RA? Which are more specific?
Rheumatoid factor (RF)
- autoantibody which targets Fc portion of IgG to activate immune system
- NOT specific
Anti-CCP antibodies
- more specific for RA
- can pre-date presentation of RA so be used to indicate that patient likely to develop RA in future
How might a patient with RA typically present?
Symptoms associated with SYNOVITIS
Pain stiffness and swelling in small joints of hands and feet
=symmetrical distal polyarthropathy
I.e. wrist, ankle, MCP, PIP
Boggy joints due to thickend synovium (due to dense immunological infiltrates in to the synovium)
Morning stiffness (>1 hr mins)
Pain and stiffness relieved with activity and worsens with rest
Which joints are commonly affected in RA?
PIP MCP Wrist and ankle MTP (metatarsophalangeal joints) Cervical spine Some large joints i.e. knee/hip/shoulders
What medical emergency can occur in RA involving the spine?
Atlantoaxial subluxation
- shift of odontoid peg within atlas due to synovitis and ligament damage
- can lead to spinal cord compression
What damage can synovial inflammation cause?
What signs in the hands is this associated with?
Damage:
- erosion of bones
- erosion of articular cartilage= loss of joint space
Boggy synovium
Z-shaped deformity of thumb
Swan-neck deformity (hyperextended PIP with flexed DIP)
Boutonnières deformity (hyperextended DIP with flexed PIP)
Ulnar deviation at MCP joints i.e. hand towards little finger side
What other conditions might be found in association with RA?
Pulmonary fibrosis
Bronchiolitis obliterans (inflammation causes destruction of small airway)
Anaemia of chronic disease
Sicca syndrome= dry eyes/mouth etc
How can RA be diagnosed?
NOTE: mainly a clincial diagnosis so can still make diagnosis even if all blood tests and plain radiographs are normal
+ve RF
+ve anti-CCP
CRP and ESR markers
Plain radiograph of hands + feet
-erosions and joint-space narrowing not usually present in early disease
-useful to establish a baseline
USS
-can be used to identify synovitis when clinical examinations not clear
I.e. Doppler signal can be used to show increased blood flow to joint due to increased vascularity
What are the classical X-ray changes seen in RA?
Sparing of DIP Peri-articular erosions/osteopenia Boney erosions Sublaxation -ligament damage leads to being unable to hold joint inplace Deformities -Swans neck and Boutonniere Ulnar deviation Narrowing of joint space Soft tissue swelling
How is RA managed conservatively?
Manage pain= analgesics/NSAIDs with PPI cover
(NOTE: best management of synovitis-associated pain is to treat the synovitis)
Education about disease + lifestyle advice i.e. smoking
Manage co-morbidities + CVS risk
Vaccinations i.e. pneumococcus
-to manage increased risk of infections when on immunosuppressive medication
What are the key principles of pharmacological treatment?
How is RA managed pharmacologically?
Treat early i.e. w/i 3-4 months of symptoms to decrease long term joint damage
Treat-to-target
-improve function + reduce long term joint damage to prolong life expectancy
1st line DMARD monotherapy
-Methotrexate
Or leflunomide/sulfasalazine if px trying to conceive
-glucocorticoids up to 3 months
What biological therapies can be used to treat RA?
DMD= disease modifiying drugs
Anti-TNF MAb
- Adalimumab
- Certolizumab
- golimumab
- infliximab
Anti-TNFR
-etanercept i.e. soluble TNF-R
Anti-IL6
- Tocilizumab
- Sarilumab
Anti-CD20
-Rituximab targets abundance of BC in synovium
Anti-CD80/86
-Abatacept blocks co-stimulatory molecules to prevent activation of TC
JAK inhibitors
- Tofacitinib
- Baricitinib
- block downstream signalling molecules of cytokines associated signalling pathways
How would you summarise RA?
Inflammatory symmetrical polyarthritis affecting small joints (MCP and PIP)
Associated with swan-neck and boutonnière deformities
What disease-related extra-articular features are associated with RA?
Fatigue Anaemia of chronic disease Skin nodules Interstitial lung disease Accelerated artherosclerosis Osteoporosis= due to systemic inflammation presentin RA
What treatment-related extra-articular features of RA can occur?
Infection
Osteoporosis= steroid-induced
Anaemia= NSAIDs induced peptic ulcer leading to chronic GI bleed
What are the 4 domains used as part of RA classification criteria?
What score would indicate RA was likely with this scoring system?
Joints (0-5)
- based on number and size of joints affected
- increased score for the number of joints and if they are small joints
Serology (0-3)
-higher the RF and CCF the higher the score
Symptom duration (0-1)
- <6 weeks
- > 6weeks
Acute phase response (0-1)
-whether CRP/ESR are normal or not
At least 6 points required for RA
What is the purpose of DAS28 in RA treatment?
What are the 4 main elements?
Score used to measure the disease activity of RA to see whether treatment regime needs changing or whether disease has entered remission
- Tender swollen joint
- Swollen joint count
- ESR/CRP
- Global patient assessment
High DAS28 when on methotrexate is indication to add DMD (disease modifiying drug)
What are the benefits of using biologic/targeted sythnetic DMARDs?
Improve efficacy of synthetic DMARD (methotrexate)
Reduce immunogeneicity
What is the order of stepping down treatment in RA and why?
Glucocorticoids
Biological/targeted synthetic DMARDs
Conventional synthetic DMARD
Removal of drugs can lead risk of disease flare
