Rheumatoid arthritis Flashcards
8 week pain and stiffness. What is your differential diagnosis?
RA, psoriasis arthritis, OA, reactive arthritis, AI connective tissue disease
Which genes are associated with RA?
HLA DR4 and HLA DR1
What are the side effects of steroids?
CUSHINGOID FAM cushing's ulcers HTN infectious necrosis growth restriction osteoporosis immunosuppression diabetes fluid retention acute pancreatitis myopathy
What is the management of RA?
pain relief
DMARD- steroids, methotrexatae + sulphasalazine, biologics
MDT_ physio, OT, podiatry
What are the side effects of methotrexate?
immunosuppression, bone marrow suppression, GI upset, hepatotoxicity
SE of sulphasalazine?
immunsuppression, bone marrow suppressiob, GI upset, hepatotoxicity, RASH
What is hydroxychloroquine used to treat?
RA
What are the SE of hydroxychloroquine?
generic: immunosuppression, bone marrow suppression, GI upset
Visual changes, skin
Which RA drugs are safe in pregnancy?
hydroxychloroquine and sulphasalazine
What are the components of a biologic screening?
CXR, TB test, HIV/hep B + C, VZV, FBC U+E LFT CRP
Which RA blood marker is highly specific?
Anti-CCP (RF is more sensitive but not as specific)
Explain a high CRP and low Hb in patient with RA
Anaemia of chronic disease- due to ongoing chronic inflammatory process= use up iron
CRP- transient protien that is realeased during active acute inflammation
Name two ocular complications associated with RA
scleritis and episcleritis
Name two blood tests to confirm RA
RF and anti-CCP
What is the treatment for RA?
NSAIDs, steroids, biological, DMARDs
Name four features of XR of RA
loss of joint space juxta articular osteopenia subchondral cysts periarticular erosion soft tissue swelling
Define RA
Chronic systemic inflammatory disease characterised by
a symmetrical, deforming, peripheral polyarthritis.
What is the genetic association of RA?
HLA-DR4/DR1
State three specific deformities seen in RA
- Swan neck
- Boutonniere
- Z-thumb
- Ulnar deviation of the fingers
- Dorsal subluxation of ulnar styloid
Three extraarticular features of RA?
Nodules Pericarditis Carpal tunnel syndorome Pleural effusion Episcleritis Sjorgen's syndrome Raynaud's Felty's syndrome Vasculitis Lymphadenopathy
Define felty’s syndrome
RA +splenomegaly + neutropenia
Two tests that are highly specific to RA?
RF and anti-CCP
Three investigations for RA?
- Bloods- FBC (anaemia, neutropenia), CRP
- RF +anti-CCP
- Radiography, US, MRI
Discuss three aspects of medical management in RA
- DMARDs/biologics
- Steroids
- NSAIDs
- CV prevention
- Osteoporosis prevention
- Gastric ulcers prevention
Prophylaxis for which condition must be managed in RA?
Cardiovascular events associated with athersclerosis
List two DMARDs and provide one SE of each
- Methotrexate- hepatotoxic
- Sulfasalzine- hepatotoxic
- Hydroxychloroquine- retinopathy
One side effect common in all DMARDs?
myelosuppression -> pancytopenia
Two examples of biologics?
Infliximab: chimeric anti-TNF Ab
Etanercept: TNF-receptor
Adalimumab: human anti-TNF Ab
Rituximab (anti-CD20 mAb)
Two side effects of biologics?
infection, autoimmune disease, cancer
MOA of infliximab?
anti-TNF
MOA of adalimumab?
anti-TNF
Which sex is a risk factor for RA?
females
What was the old classification for RA?
4/6 symptoms: morning stiffness, >2 joints, hand and wrist joints, rheumatoid nodules, RF positive (serology), and X-ray changes
What is the most recent classification of RA?
presence of bilateral MCP or PIP joint enhancement on MRI
How do sero-negative inflammatory arthropathies differ from RA?
normal bone density, periostitis, ankylosis (fusion), asymmetrical pattern
Describe the pathophysiology of RA
- Initiation in the periphery 2. Propagation in the synovium 3. Tissue damage- bone and cartilage. Involves dysregulated inflammation with antigen presentationm T cell activation, and autoantibody production. Fibroblasts are activated, forming inflammatory panus. Activation of osteoclasts, leading to erosion of bone.
In which other conditions is rheumatoid factor raised?
SLE, infection, increasing age
One example of early RA stage you can see on XR?
peri-articular osteopenia, soft tissue swelling
Two late stage examples of RA seen on XR?
erosion, joint destruction, subluxation/angulation
Name two NSAIDs used in the treatment of RA?
ibuprofen, naproxen, diclofenac
Which DMARD is teratogenic?
methotrexate
Pregnant lady with RA, which DMARD?
sulfasalasine, hydroxychloroquine
How can you monitor disease progession in RA?
DAS28= disease activity in 28 joints= scoring system.
Three components of DAS28?
CRP/ESR, XR changes, pain, swelling, subjective assessment/questionnaire
Which screening is conducted prior to biologic DMARD therapy
viral hep, HIV, varicella (chickenpox), CXR (TB), and vaccinations (influenza)
