Rheumatoid arthritis Flashcards
What is rheumatoid arthritis?
Autoimmune, chronic (>6 weeks) and progressive inflammation of synovial lining, tendon sheaths & bursa
What is the prevalence of RA?
0.24%-0.56%
What can cause RA?
- Infection can trigger
- Genetics
What are RF for RA?
- Genetics
- 2-4x increased risk if 1st degree relative
- Heritability RA appears to be approximately 40%, and is higher for seropositive RA than for seronegative RA
- Smoking
What is the normal epid for RA?
50-55 years
Female sex
What are key symptoms and signs for RA?
- Active symmetrical arthritis lasting >6 weeks
- Joint pain
- Joint swelling
- Morning stiffness
- Tenosyvitis and bursitis
- Fatigue
- Weight loss
- Recurrent soft tissue problems
What joints are usually affected in RA?
small joint of hands and feet, MCP, PIP, wrist
What are some DDx for RA?
- Psoriatic arthritis (PsA)
- Infectious arthritis
- Gout
- SLE
- Osteoarthritis
What test is used to diagnose RA?
- Clinical diagnosis
1. Rheumatoid factor (RF)
2. Anti-cyclic citrullinated peptide (anti-CCP) antibody
3. Radiographye
4. US
What would RF be in RA?
-positive 60-70%
What would Anti-cyclic citrullinated peptide (anti-CCP) antibody be in RA?
- positive 70%
- more sensitive and specific than
- can predate disease development
What would radiography in RA show?
- erosions
2. decreased joint space
What would US show in RA?
synovitis of wrist and fingers
What is 1st line acute treatment of RA?
1st line: Conventional synthetic disease-modifying anti-rheumatic drug (DMARD) e.g. hydroxychloroquine: 400-600mg/day
- Corticosteroid
- NSAID
What is 1st line ongoing treatment for RA?
1st line: methotrexate 7.5mg
- Biological agent
- corticosteroid
- NSAID
What is 2nd line ongoing treatment for RA?
2nd line: Triple DMARD therapy e.g. methotrexate plus hydroxychloroquine plus sulfasalazine
- corticosteroid
- NSAID
What other management is possible in RA?
- physio
- surgery
What are possible complications of RA?
- Work disability
- Increase joint replacement surgery
- Increased coronary artery disease
- Increased mortality
- Interstitial lung disease (ILD)
- TNF-alpha inhibitor-related infections
Etc.
What can RA cause?
Increased risk of cardiovascular and cerebrovascular disease as atherosclerosis is accelerated in RA
What sort of condition is RA?
autoimmune
What genes are associated with RA?
- HLA DR4 (often)
* HLA DR1 (occasional)
What joint is usually spared?
DIP
What are the chronic signs of RA?
- Z deformity (thumb)
- ulnar deviation at MCP
- Radial deviation at wrist
- Swan neck deformity
- Boutonniere’s deformity
What is Z deformity?
hyperextension of IP joint + fixed flexion and subluxation of MCP joint
What is swan neck deformity?
hyperextension of PIP joint and flexion of DIP joint
What is Boutonniere’s deformity?
permanent flexion of PIP joint and overextension of DIP joint
What are extrarticular manifestions of RA?
- Nodules (40%)
- Lung
- Cardiac: pericardial effusion, pericarditis
- Eye: episcleritis, scleritis
- Secondary Sjogren’s/sicca
- Carpel tunnel syndrome + rheumatoid nodules
- Tenosynovitis, bursitis
Where are nodules usally found?
elbows, lungs, cardiac, lymphadenopathy
What are lung manifestations for RA?
- plural disease
- interstitial fibrosis
- pulmonary fibrosis
- Bronchiolitis obliterans
What is needed for Clinical Diagnosis of RA?
- Characterised by symmetrical polyarthritis (>4joints)
- and extraarticular manifestations
- Of rapid or chronic onset (months -years)
+/- systemic upset – weight loss, fatigue, malaise
Whta is RF in RA?
1 No neccssary for Dx
- IgM antibody. Targets Fc portion of IgG antibody.
- Immune activation leads to systemic inflammation
What blood tests are done in RA?
- ESR: raised esp w active polyarthritis but can be normal
- Albumin low
- Anaemia
- Elevated CRP
What would Positive Antibodies & raised inflammatory markers suggest?
o aggressive disease
o worse prognosis
May prompt more aggressive Tx e.g., biologics
When do you refer for RA accoring to NICE?
Refer any adult with persistent synovitis
even if –ve RhF, anti CCP, inflammatory markers
When is there an urgent referral for RA?
- Small joints of hands, feet
- multiple joints
- Sx >3 months
What is the treatment prniciple in RA?
induce remission (or get as close as possible) & keep meds at “minimal effective dose” needed to control disease
What is Felty’s syndrome?
triad of RA, neutropenia and splenomegaly
When do you used short course of steroids?
to get flares undercontrol
What other medication can be used in RA?
NSAIDs / COX-2 inhibitors (remeber PPI)
What is the stepwise treatment for DMARDs?
Hydroxychloroquine if mild)
- Methotrexate, leflunomide, sulfasalazine
- 2 of these in combo
- Methotrexate + biologic (anti-TNF)
- Methotrexate + rituximab
Why is anti-TNF and rituximab dangerous?
Immunosuppression can cause serious infections and/or re-activation of TB, Hep B
