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Week 11- Musculoskeletal > Rheumatoid arthritis > Flashcards

Rheumatoid arthritis Flashcards

1
Q

What is rheumatoid arthritis?

A

Autoimmune disease which results in chronic joint inflammation

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2
Q

What can untreated rheumatoid arthritis lead to?

A
  • Joint destruction
  • Deformity
  • Loss of function
  • Extra articular complications
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3
Q

What is the pathophysiology of rheumatoid arthritis?

A
  • Genetic predisposition (HLA DR4) plus an environmental precipitant
  • Immune system acting against own immune system and joints
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4
Q

What is the usual age of onset of rheumatoid arthritis?

A

between 30 and 60

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5
Q

In which populations is rheumatoid arthritis more aggressive?

A
  • African American

* Hispanic

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6
Q

What are the symptoms of rheumatoid arthritis?

A
  • Pain
  • Stiffness (early morning and joint gelling)
  • Swelling
  • Tends to be smaller joints over larger joints and also tends to be symmetrical
  • Persistent
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7
Q

What are the signs of rheumatoid arthritis?

A
  • Synovitis (joint swelling)
  • Deformity (not early stage)
  • Rheumatoid nodules
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8
Q

What are the deformities seen in rheumatoid arthritis?

A
  • Swan neck
  • Boutonniere
  • Z-thumb
  • Ulnar deviation
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9
Q

What should you consider as a differential diagnosis in rheumatoid arthritis?

A
  • Polyarticualr gout
  • Psoriatic arthritis
  • osteoarthritis
  • SLE
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10
Q

What investigations should be carried out in suspected rheumatoid arthritis?

A

Lab non specific:
•CRP/ESR
•FBC
•Bone/urate

Lab specific:
•Immunology

Imaging:
•Plain radiograph (X ray won’t show early stages)
•Ultrasound
•MRI

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11
Q

What antibodies can you test for in rheumatoid arthritis?

A
  • Rheumatoid factor

* CCP Ab

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12
Q

What is rheumatoid factor?

A
  • IgM antibody
  • Directed against the Fc portion of the IgG antibody
  • Found in a multitude of conditions
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13
Q

What is the specificity and sensitivity of testing for rheumatoid factor in rheumatoid arthritis?

A
  • Sensitivity = 70%

* specificity 80-85%

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14
Q

In what conditions is rheumatoid factor found?

A
  • Rheumatoid arthritis
  • SLE
  • bacterial endocarditis
  • Sjogren’s
  • Primary biliary cirrhosis
  • Hepatitis B and C
  • Increasing age
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15
Q

What is CCP Ab?

A
  • Inflammation leads to cellular damage
  • Enzymatic process leads to the conversion of arginine residues to citrulline
  • Alteration of shape creates a foreign antigen from self anti citrullinated cyclic peptide antibodies
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16
Q

What is the sensitivity and specificity of CCP Ab?

A
  • Sensitivity: 66%

* Specificity: 90%

17
Q

What is the name of the classification criteria for Rheumatoid Arthritis and what score fulfils the classification criteria for rheumatoid arthritis?

A

EULAR, a score of 6 or more

18
Q

What are the first changes seen on X ray in patients with rheumatoid arthritis?

A
  • Peri-articular osteopenia

* Soft tissue swelling

19
Q

What are the late changes seen on imaging in patients with rheumatoid arthritis?

A
  • Erosion
  • Joint destruction
  • Subluxation
20
Q

What are the aims of the treatment of rheumatoid arthritis?

A
  • Reduce inflammation
  • Maintain joint function
  • Prevent progression
21
Q

Explain initial therapy for patients with rheumatoid arthritis

A
  • Aims to reduce inflammation
  • NSAIDs - ibuprofen/naproxen/diclofenac
  • COX-2 inhibitors - Etoricoxib
  • Steroids - short term - oral prednisolone, intramuscular or intra-articular depomedrone
22
Q

What are the first line drugs in rheumatoid arthritis?

A
  • cDMARDs (conventional disease modifying anti rheumatic drugs) should be offered within 3 months of symptom onset
  • Methotrexate
  • Leflunomide
  • sulfasalazine
  • Hydroxychloroquine if mild or if palindromic disease
23
Q

What is methotrexate?

A

Folate antagonist

24
Q

How often is methotrexate taken in RA?

A

Once weekly

25
Q

What are the side effects of methotrexate?

A
  • Mucosal effects: mouth ulcers
  • GI effects: nausea
  • Rare: pneumonitis or hepatitis
26
Q

What needs to be monitored if a patient is on methotrexate?

A

FBC and LFTs

27
Q

When is methotrexate contra indicated?

A

In pregnancy as it is teratogenic

28
Q

What is sulfasalazine?

A

cDMARD that is immunomodulatory with several actions including against T and B cells and folate

29
Q

How often is sulfasalzine taken for RA?

A

Once daily

30
Q

What are the side effects of sulfasalazine?

A
  • GI
  • Headache
  • Rash
  • Normally avoided if you gradually increase the dose
31
Q

What do you need to monitor in patients on sulfasalazine?

A
  • FBC
  • U&Es
  • LFTs
32
Q

What is hydroxychloroquine?

A

blocks toll like receptors on plasmacytoid dendritic cells (that release IFN), thus reducing dendritic cell activation

33
Q

How often is hydroxychloroquine taken for RA?

A

Daily

34
Q

What are the side effects of hydroxychloroquine?

A
  • Headache
  • Nausea
  • Muscle pain
  • Rash
35
Q

What do you need to monitor in patient on hydroxychloroquine?

A

Ocular monitoring to look for retinopathy

36
Q

What is used for disease monitoring in RA?

A

DAWN

37
Q

What must you do before starting a patient on a bDMARD for RA?

A
  • Screen for viral hepatitis, HIV, varicella,
  • ensure vaccination against influenza and pneumococcal infection
  • Ensure no contraindications
  • Monitor for infection, malignancy, check bloods (FBC and LFT) throughout treatment
38
Q

What are the contraindications to bMARDs?

A
  • Active infection
  • Active or latent TB
  • Pregnancy

Week 11- Musculoskeletal (11 decks)

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