Rheumatoid Arthritis Flashcards
what genes are associated w. RA
HLA-DRB1
PTPNN22
RA involves more efficient __ cells
that produce __
T cells
autoantibodies
3 rf for RA
female
smoker
25-55 yo
RA pathophys involves the formation of a __
which invades and destroys __
panus
bone and cartilage
what happens in the preclinical stage of RA
breakdown of tolerance
3 possible triggers for RA
bacterial antigens
viral antigens
smoking
RA involves proliferation of
synovium
RA usually has __ onset
with morning stiffness lasting >__
especially after __
insidious (chronic)
30 minutes
prolonged activity
RA involves __ swelling of joints
symmetric
RA is __articular
poly
joints mc affected by RA
lots of little joints:
PIP
MCP
wrists
ankles
MTP
RA gets __ w. activity
and OA gets __ w. activity
worse
better
hand manifestations of RA (3)
ulnar deviation of MCP joints
swan neck deformity
boutonniere deformity
hyperextension of PIP
flexion of DIP
swan neck deformity
flexion of PIP
extension of DIP
boutonniere deformity
extraarticular sx of RA (5)
fatigue, wt loss, low grade fever
rheumatoid nodules
vasculitis
what is this showing
rheumatoid nodules
what do you think when you see rheumatoid nodules
pt is almost surely RF (+)
where are RA nodules commonly found (3)
forearm extensors
over joints
pressure points
+/- lungs, sclerae, other tissues
describe RA nodules (2)
firm
not tender
what is this showing
RA vasculitis
ocular manifestations of RA
keratoconjunctivitis sicca
scleritis/episcleritis
scleromalacia
what do you think when you see RA and keratoconjunctivitis sicca, +/- xerostomia
secondary Sjorgen’s
mc pulmonary manifestation of RA
pleuritis
besides pleuritis, 3 other pulmonary manifestations of RA
pleural effusions
rheumatoid nodules
interstitial lung dz
cardiac manifestations of RA (3)
chronic inflammation → increased risk for CV dz
pericardial effusions
pericarditis
what does SANTA make you think of
RA → Felty syndrome
what does SANTA stand for
splenomegaly
anemia
neutropenia
thrombocytopenia
arthritis (RA)
in FELTY syndrome, neutropenia could be __
or the pt could have __
asymptomatic
frequent bacterial infxns
RA in FELTY syndrome is typically (3)
seropositive
erosive
severe
what % of RA pt’s are seronegative
15%
most specific bloodwork for RA
anti-CCP abs
seronegative RA involves a __ dx
clinical
standard RF panel (5)
anti-CCP
RF
ESR/CRP
CCB
CMP
do you need anti-CCP or RF for RA dx
no!
15% of pt’s are seronegative
what might CBC show for RA (4)
mild anemia
thrombocytopenia
WBC normal
mild leukocytosis
what do you think when you see: inflammatory effusion, leukocytosis, PMNs predominate
synovial fluid for RA
in RA, leukocytes are typically between
15,00-25,000
early imaging for RA will likely be
normal
initial signs of radiographic damage w. RA
soft tissue swelling
osteopenia around joints
earliest imaging e.o RA is seen in (2)
wrists
feet
late imaging findings of RA (2)
joint space narrowing
erosions
what categories does the American College of Rheumatology 2010 criteria include (4)
joint involvement
serology
acute phase reactants
duration of symptoms
a score of __ in the American College of RA criteria is diagnostic for RA
6
diagnostic criteria for RA (5)
inflammatory arthritis involving at least 3 joints
RF (+) AND/OR anti-CCP (+)
elevated ESR AND/OR CRP
duration of at least 6 weeks
excluded other causes
3 tx goals for RA
control pain/inflammation
preserve fxn
prevent deformity
what are DMARDs
disease modifying anti-rheumatic drugs
mc combo pharm tx for RA
MTX (DMARD)
PLUS
TNF
any pt on combo therapy needs
rheumatologist involvement
screening considerations for RA
hep B & C
baseline labs
ophthalmic screening
latent TB
r.o pregnancy
baseline radiographs
baseline labs for RA (5)
CBC
Cr
LFTs
ESR
CRP
what pharm may be used for sx of RA, but should never be used as monotherapy
NSAIDs
corticosteroids
tx for RA flare ups
steroids
tx for recurrent RA flare ups
increase MTX
what drug alleviates sx of RA AND slows rate of joint damage
corticosteroids
how are corticosteroids used in RA
as a bridge to starting DMARDs
d.c as soon as possible
starting bridging steroid and dose for
prednisone 5-20mg/day
methotrexate
sulfasazaline
hydroxychloroquine
are all
DMARDs
etanercept (Enbrel)
infliximab (Remicade)
Adalimumab
are all
biologics (TNF)
suffix for most biologics
-mab
also cept
mc DMARD
methotrexate
starting dose for MTX
7.5 mg PO weekly
pt should see improvement w. DMARD w.in
2-6 weeks
contraindications for DMARDs (3)
pregnancy
liver dz
heavy etoh
severe renal impairment
s.e of MTX (2)
GI upset
stomatitis
monitoring labs for MTX
CBC → cytopenias
LFTs → hepatotoxicity
all pt’s on MTX need to take
folic acid
OR
leucovorin calcium)
folate prevents __
hematologic s.e
TNF (biologics) inhibitors can be administered (2)
SQ
IV
biggest barrier to TNF tx
expensive!
major concern w. TNF inhibitors
higher risk for serious bacterial infxn
ex ganulomatous infxn
mc granulomatous infxn associated w. TNF inhibitors
reactivation of TB
screening test for all pt’s starting TNF inhibitor
latent TB
t/f: TNF inhibitors have a lot of s.e
false!
few s.e, work very well, well tolerated
1st choice for TNF inibitor
etanercept
all pt on TNF inhibitor should be followed by
rheumatologist
how do you monitor functional status of RA pt
pick a scale and stay consistent
RA pt need f.u radiographs every
2 years
highest cause of mortality in RA pt
CV dz from chronic inflammation
poor prognostic factors for RA (4)
RF OR anti-CCP (+)
extraarticular dz
functional limitation
erosions on radiograph
