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Z Year3 MSK Conditions > Rheumatoid arthritis > Flashcards

Rheumatoid arthritis Flashcards

1
Q

What is rheumatoid arthritis?

A

Autoimmune, chronic (>6 weeks) and progressive inflammation of synovial lining, tendon sheaths & bursa

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2
Q

What is the prevalence of RA?

A

0.24%-0.56%

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3
Q

What can cause RA?

A
  • Infection can trigger

- Genetics

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4
Q

What are RF for RA?

A
  1. Genetics
  2. 2-4x increased risk if 1st degree relative
  3. Heritability RA appears to be approximately 40%, and is higher for seropositive RA than for seronegative RA
  4. Smoking
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5
Q

What is the normal epid for RA?

A

50-55 years

Female sex

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6
Q

What are key symptoms and signs for RA?

A
  1. Active symmetrical arthritis lasting >6 weeks
  2. Joint pain
  3. Joint swelling
  4. Morning stiffness
  5. Tenosyvitis and bursitis
  6. Fatigue
  7. Weight loss
  8. Recurrent soft tissue problems
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7
Q

What joints are usually affected in RA?

A

small joint of hands and feet, MCP, PIP, wrist

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8
Q

What are some DDx for RA?

A
  1. Psoriatic arthritis (PsA)
  2. Infectious arthritis
  3. Gout
  4. SLE
  5. Osteoarthritis
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9
Q

What test is used to diagnose RA?

A
  • Clinical diagnosis
    1. Rheumatoid factor (RF)
    2. Anti-cyclic citrullinated peptide (anti-CCP) antibody
    3. Radiographye
    4. US
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10
Q

What would RF be in RA?

A

-positive 60-70%

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11
Q

What would Anti-cyclic citrullinated peptide (anti-CCP) antibody be in RA?

A
  • positive 70%
  • more sensitive and specific than
  • can predate disease development
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12
Q

What would radiography in RA show?

A
  1. erosions

2. decreased joint space

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13
Q

What would US show in RA?

A

synovitis of wrist and fingers

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14
Q

What is 1st line acute treatment of RA?

A

1st line: Conventional synthetic disease-modifying anti-rheumatic drug (DMARD) e.g. hydroxychloroquine: 400-600mg/day

  • Corticosteroid
  • NSAID
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15
Q

What is 1st line ongoing treatment for RA?

A

1st line: methotrexate 7.5mg

  • Biological agent
  • corticosteroid
  • NSAID
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16
Q

What is 2nd line ongoing treatment for RA?

A

2nd line: Triple DMARD therapy e.g. methotrexate plus hydroxychloroquine plus sulfasalazine

  • corticosteroid
  • NSAID
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17
Q

What other management is possible in RA?

A
  • physio

- surgery

18
Q

What are possible complications of RA?

A
  1. Work disability
  2. Increase joint replacement surgery
  3. Increased coronary artery disease
  4. Increased mortality
  5. Interstitial lung disease (ILD)
  6. TNF-alpha inhibitor-related infections
    Etc.
19
Q

What can RA cause?

A

Increased risk of cardiovascular and cerebrovascular disease as atherosclerosis is accelerated in RA

20
Q

What sort of condition is RA?

A

autoimmune

21
Q

What genes are associated with RA?

A
  • HLA DR4 (often)

* HLA DR1 (occasional)

22
Q

What joint is usually spared?

A

DIP

23
Q

What are the chronic signs of RA?

A
  1. Z deformity (thumb)
  2. ulnar deviation at MCP
  3. Radial deviation at wrist
  4. Swan neck deformity
  5. Boutonniere’s deformity
24
Q

What is Z deformity?

A

hyperextension of IP joint + fixed flexion and subluxation of MCP joint

25
Q

What is swan neck deformity?

A

hyperextension of PIP joint and flexion of DIP joint

26
Q

What is Boutonniere’s deformity?

A

permanent flexion of PIP joint and overextension of DIP joint

27
Q

What are extrarticular manifestions of RA?

A
  1. Nodules (40%)
  2. Lung
  3. Cardiac: pericardial effusion, pericarditis
  4. Eye: episcleritis, scleritis
  5. Secondary Sjogren’s/sicca
  6. Carpel tunnel syndrome + rheumatoid nodules
  7. Tenosynovitis, bursitis
28
Q

Where are nodules usally found?

A

elbows, lungs, cardiac, lymphadenopathy

29
Q

What are lung manifestations for RA?

A
  1. plural disease
  2. interstitial fibrosis
  3. pulmonary fibrosis
  4. Bronchiolitis obliterans
30
Q

What is needed for Clinical Diagnosis of RA?

A
  1. Characterised by symmetrical polyarthritis (>4joints)
  2. and extraarticular manifestations
  3. Of rapid or chronic onset (months -years)
    +/- systemic upset – weight loss, fatigue, malaise
31
Q

Whta is RF in RA?

A

1 No neccssary for Dx

  1. IgM antibody. Targets Fc portion of IgG antibody.
  2. Immune activation leads to systemic inflammation
32
Q

What blood tests are done in RA?

A
  1. ESR: raised esp w active polyarthritis but can be normal
  2. Albumin low
  3. Anaemia
  4. Elevated CRP
33
Q

What would Positive Antibodies & raised inflammatory markers suggest?

A

o aggressive disease
o worse prognosis
May prompt more aggressive Tx e.g., biologics

34
Q

When do you refer for RA accoring to NICE?

A

Refer any adult with persistent synovitis

even if –ve RhF, anti CCP, inflammatory markers

35
Q

When is there an urgent referral for RA?

A
  • Small joints of hands, feet
  • multiple joints
  • Sx >3 months
36
Q

What is the treatment prniciple in RA?

A

induce remission (or get as close as possible) & keep meds at “minimal effective dose” needed to control disease

37
Q

What is Felty’s syndrome?

A

triad of RA, neutropenia and splenomegaly

38
Q

When do you used short course of steroids?

A

to get flares undercontrol

39
Q

What other medication can be used in RA?

A

NSAIDs / COX-2 inhibitors (remeber PPI)

40
Q

What is the stepwise treatment for DMARDs?

A

Hydroxychloroquine if mild)

  1. Methotrexate, leflunomide, sulfasalazine
  2. 2 of these in combo
  3. Methotrexate + biologic (anti-TNF)
  4. Methotrexate + rituximab
41
Q

Why is anti-TNF and rituximab dangerous?

A

Immunosuppression can cause serious infections and/or re-activation of TB, Hep B

Z Year3 MSK Conditions (26 decks)

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