Rheumatoid Arthritis Flashcards
Which of the blood test is most specific for rheumatoid arthritis?
Anti-cyclic citrullinated peptide (Anti CCP) is the most specific blood test for rheumatoid arthritis (RA) with a specificity of ~96%
Define rheumatoid arthritis
Autoimmune condition that causes chronic, systemic inflammation affecting multiple joints leading to chronic joint pain, swelling and stiffness
What is the genetic risk factor for rheumatoid arthritis
HLA DR4/DR1
Name some of the risk factors for rheumatoid arthritis
Combination of environmental and genetic
Presence of HLA DR4/DR1 gene
Women gender
Smoking
Family history
Note it is more common in middle age but can develop at any age
Name the two antibodies associated with rheumatoid arthritis
Rheumatoid Factor (RF)
Cyclic citrullinated peptide antibodies (anti-CCP antibodies)
Rheumatoid Factor (RF) and Cyclic citrullinated peptide antibodies (anti-CCP antibodies) are the two autoantibodies associated with rheumatoid arthritis.
Which is more sensitive and specific for rheumatoid arthritis
Cyclic citrullinated peptide antibodies (anti-CCP antibodies)
Patients with rheumatoid arthritis usually present with a history of bilateral, symmetrical pain and swelling of the small joints of the hands and feet.
How long is this pain usually lasted for
> 6 weeks
What in the body is commonly affected in rheumatoid arthritis
Small joints of the hands and feet
The pain and swelling of the joints associated with rheumatoid arthritis is what:
a) worse in the morning
b) worse at night
a) worse in the morning
The pain and swelling of the joints associated with rheumatoid arthritis is what:
a) worse after rest and improves with activity
b) worse with activity and improves with rest
a) worse after rest and improves with activity
Rheumatoid arthritis is associated with extr-articular manifestations.
Name some of these clinical features
Myalgia (muscle aches and pain)
Fatigue
Low-grade fever
Weight loss
Depression
Name 3 signs associated with rheumatoid arthritis
Synovitis (swollen and tender joints)
Deformities e.g. Swan neck deformity
Rheumatoid nodules
What test can be used to determine the presence of synovitis (a sign of rheumatoid arthritis)
Positive ‘squeeze test’ - discomfort on squeezing across the metacarpal or metatarsal joints
Name the four types of deformities associated with rhuematoid arthritis
Swan-neck deformity
Boutonniere deformity
Ulnar deviation at MCPs
Z-deformity at wrist
Describe the pathogenesis of swan neck deformity (seen in rheumatoid arthirits)
Hyperextension at the PIP joint
Flexion of the DIP joint
Describe the pathogenesis of Boutonniere deformity (seen in rheumatoid arthirits)
Flexion at the PIP joint
Hyperextension DIP joint
Describe the pathogenesis of ulnar deviation (deformity seen in rheumatoid arthirits)
Subluxation of the MCP joints with deviation of the fingers towards the ulnar bone
Describe the pathogenesis of Z-deformity (deformity seen in rheumatoid arthirits)
Hyperextension of interphalangeal joint of thumb (IP)
Hyperextension of metacarpophalangeal joint (MP)
Flexion of CMC joint
What are Extra-articular manifestations
Systemic clinical manifestations involving other organ systems
Extra-articular manifestations occur in 40% of patients with rheumatoid arthritis.
Name an ocular manifestation
Episcleritis: inflammation of superficial layer of sclera
Extra-articular manifestations occur in 40% of patients with rheumatoid arthritis.
Name an mouth manifestation
Oral ulcers
Extra-articular manifestations occur in 40% of patients with rheumatoid arthritis.
Name an pulmonary manifestation
Interstitial lung disease
Serositis (inflammation of the serous membranes i.e. pleural, pericardium, peritoneum)
Extra-articular manifestations occur in 40% of patients with rheumatoid arthritis.
Name an cardiac manifestation
Pericarditis (inflammation of the pericardium)
Myocarditis (inflammation of the myocardium)
How is rheumatoid arthritis diagnosed
Clinical diagnosis
Once a clinical diagnosis of rheumatoid arthritis is made, several laboratory tests help to determine prognosis.
Name a laboratory test can help determine prognosis
Antibody tests e.g. RF, anti CCP
Inflammatory markers (CRP; ESR)
Name an imaging modality that can be useful in investigating rheumatoid arthritis
X-ray
Ultrasound scan of the joints (confirm synovitis)
What are the X-ray features of rheumatoid arthritis
“PJ Look Smart”
P – Periarticular erosions (red arrow)
J – Juxta-articular osteoporosis (green circle)
Look – Loss of joint space (yellow, blue arrows)
Smart – Subluxation
Juxta-articular meanings near a joint
What is the aim of rheumatoid arthritis management
To induce and then maintain remission
What two things are used to monitor the success of treatment for rheumatoid arthritis
CRP
AND
DAS28
What is DAS 28
Scoring measuring the disease activity in rheumatoid arthritis
DAS stands for ‘disease activity score’
28 refers to the 28 joints that are examined in this assessment (examined for tenderness and swollen)
What is the initial management/flare up management of rheumatoid arthritis
Short course of corticosteroids
NSAIDs/COX-2 inhibitors are often effective but risk GI bleeding so are often avoided or co-prescribed with PPI
What is the 1st line medication used to induce remission in rheumatoid arthritis
Disease Modifying Anti-Rheumatic Drugs (DMARDs) - typically methotrexate
What is the second line management for inducing remission in rheumatoid arthritis
Two DMARDs used in combination
What is the third line management for inducing remission in rheumatoid arthritis
Methotrexate plus a biological therapy
What is the fourth line management for inducing remission in rheumatoid arthritis
Methotrexate plus rituximab
Why are steroids given with Disease Modifying Anti-Rheumatic Drugs (DMARDs) for the first 2-3 months
Bridging to allow time for the DMARD to take effect
What must be given along with methotrexate
Folic acid
What drug class is methotrexate
Disease modifying anti-rheumatic drug (DMARD)
Why are FBC and LFTs monitored when given methotrexate
Risk of myelosuppression and liver cirrhosis
What is the most common biological therapy (used in the third line therapy for remission of rheumatoid arthritis)
TNF inhibitor e.g. infliximab
What drug class is rituximab (used as a fourth line therapy for remission of rheumatoid arthritis)
Biological therapy
Causes B cell depletion
