rheumatoid arthritis Flashcards
what
autoimune condition, chronic synovitis of joints, tendon sheaths and bursa
symmetrical polyarthriris
genetic associations
HLA DR4
HLA DR1
antibodies
rheumatoid factor
cyclic citrullinated peptide antibodies (anti-CCP antibodies)
RF
autoantibody that targets Fc portion of IgG –> activation of immune system against patients own IgG causing systemic inflammation
presentation
symmetrical distal polyarthropathy - joint pain, swelling + stiffnesss (worse after rest, improves w activity)
systemic symptoms - fatigue, weight loss, muscle aches
palindromic rheumatism
self-limiting short episodes of inflammatory arthritis
1-2 days then completely resolves
positive antibodies indicates it may progress to full RA
commonly affected joints
PIPJ MCPJ MTPJ wrist ankle cerival spine
which joints are almost never effected by RA
distal IP joints
enlarged, painful DIPJ most likely heberden’s nodes due to OA
atlantoaxial subluxation
axis (C2) and odontoid peg shift within atlas (c1)
can cause spinal cord compression
signs in hand
boggy feeling synovium Z shaped deformity thumb swan neck deformity boutonniers deformity ulnar deviation at MCP joints
extra-articular manifestations
rheumatic nodules pulmonary fibrosis bronchiolitis obliterans IHD pericarditis pericardial effusion carpal tunnel syndrome felty's syndrome episcleritis + scleritis amyloidosis anemia of chronic disease
felty’s synrdome
RA
neutropenia
splenomegaly
Ix
RF anti-CCP antibodies CRP, ESR X-Ray of hands, feet USS - synovitis
x-ray changes
joint destruction + deformity soft tissue swelling periarticular osteopenia boney erosions subluxation reduced joint space
when to suspect RA
those with swollen joint and a suggestive clinical history which is not better explained by another disease
diagnosing RA
diagnostic criteria
score of 6+ is diagnostic
diagnosis critera: pt scores based on
- joints involved (more and smaller joints score higher)
- serology (RF and anti-ccp)
- inflammatory markers - CRP, ESR
duration of symptoms (more or less than 6wks)
DAS28 score
disease activity score - useful in monitoring disease and response to Rx
assessment of 28 joints - points given for swollen joints, tender joints, ESR/CRP
worse prognosis with…
younger onset male more joints + organs effected RF and anti-CCP +ve erosions seen on xray
Mx optoins
referral
MDT - physio, OT, psychology, podiatry
steroids
aim of management
induce remission - use CRP and DAS28 to monitor
reduce dose to minimal effective dose
DMARD guidelines
- monotherapy with methotrexate, leflunomide or sulfasalazine. Hydroxychroloquine if mild
- use 2 of above drugs in combination
- methotrexate + a biologic (usually a TNF inhibitor)
- methotrexate + rituximab
managing RA in pregnant women
pregnant women tend to have symptoms improvement
sulfasalazine or hydroxychloroquine
anti-TNF examples
adalimumab
infliximab
etanercept
anti-CD20 exable
rituximab
methotrexate - how does it work
interferes with metabolism of folate and suppresses cetrian components of immune system
taken by injection o rtablet once a week
what needs to be prescribes alongside of methotrexate
folic acid 5mg , once a week taken on a different day to methotrexate
methotrexate side effects
mouth ulcers + mucosiitis
liver toxicity
pulmonary fibrosis
bone marrow suppression and leukopenia
teratogenic - needs to be avoided prior to conception in male and females
Leflunomide
immunosuppresant
Leflunomide side effect
peripheral neuropathy
teratogenic
Sulfasalzine
immunosupressive and anitinflammatory
Sulfasalzine side effects
reduced sperm count
bone marrow suppresoin
Hydroxychloroquine side effects
nightmares
macular toxicity
liver toxicity
skin pigmentation
rituximab
monoclonal antibody that targets CD20 protein on surface of B cells
