Rheumatoid arthritis Flashcards
What investigations should be done for rheumatoid arthritis?
Bloods:
- FBC - low Hb and high plt
- CRP/ESR - raised
- Rheumatoid factor (RF) - +ve in 60-70%, but also seen in Hep C, chronic infection and rheumatological conditions.
- Anti-cyclic citrullinated peptide (anti-CCP) antibody - +ve in 80%
Imaging:
- X ray of hands and feet - erosions affecting subchondral bone first then causing joint space narrowing then.
- US/MRI - synovitis of the wrist and fingers
Other:
- Disease activity score - ARC score which includes tender joint count, swollen joint count, functional sttays , pain, global assessment and CRP/ESR
What is the management of a patient with suspected RhA?
NSAID at lowest effective dose for shortest possible time with PPI until a rheumatology appointment is available
Which biological treatments are used for RhA?
Inhibitors of:
- TNFalpha - Adalimumab, Etanercept
- IL-6 - Tocilizumab
- CD20 - Rituximab
- JAK-stat - Upadacitinib
NB: IL-17 (Secukinumab) is NOT effective.
Summarise the specialist medical management of RhA, including what can be offered when stepping up therapy.
Conventional DMARDs e.g. methotrexate, lenoflumide, sulfasalazine
Step up therapies:
- Dose escalation
- Switching therapies*
- If despite dose escalation targets not achieved then cDMARDs may be used in combination as step-up therapy
*When switching DMARDs glycocorticoids may be used to treat interim symptoms
Biological DMARDs
- Used in severe disease, non-responsive to combination of cDMARDs.
- May be useed alone or in combination with methotrexate
What instances would you refer RhA to surgeons?
- Pain due to joint damage or other soft tissue cause
- Worsening function of the joint
- Deformity
- Localised synovitis which persists
- Complications
- Nerve compression
- Fractures from stress
- Imminent or actual tendon rupture
What is rheumatoid arthritis? How common is it?
Chronic systemic inflammatory disease which typically presents as arthritis of the small joints of hands and feet (equally and symetrically) and progresses to affect any body system.
1% of UK population affected with peak onset at 30-50yrs. 2-4:1 F>M
What are the 3 main clinical features of RhA?
Pain — usually this is worse at rest or during periods of inactivity.
Swelling — around the joint (not bone swelling) giving a ‘boggy’ feel on palpation.
Stiffness — early morning stiffness usually last over 1 hour (a history of prolonged morning stiffness is more helpful when forming a diagnosis than currently having morning stiffness for early RA).
What is the onset of RhA?
Most people have an insidious onset, but others can have a rapid, or relapsing and remitting course (such as a palindromic presentation).
What are some differentials for RhA?
- Connective tissue disorders e.g. SLE
- Fibromyalgia
- Infectious arthritis e.g. viral/bacterial
- OA
- PMR
- Polyarticular gout
- PsA
- ReA
- Sarcoidosis
- Septic arthriti s
- Seronegative spondyloarthritis
Give examples of NSAIDs used in RhA.
- ibuprofen
- naproxen
- diclofenac
- -coxib e.g. celecoxib or etoricoxib
Should glucocorticoids be prescribed in primary care in suspected RhA?
“Do not prescribe a glucocorticoid in primary care before a specialist assessment is carried out — glucocorticoids may mask key clinical features of rheumatoid arthritis and delay diagnosis”
- NICE
What do patients with RhA use their GPs for ?
- Manegement of flares
- Drug monitoring e.g. methotrexate
- Check for comorbidities/complications e.g. HTN, IHD, osteoporosis and depression
- Vaccination - pneumococcal and influenza
Which glucocorticoids are used to manage flares of RhA?
IM glucocorticoids into gluteal muscle:
- Methylprednisolone acetate 40mg in 1ml
- Triamcinolone acetonide 40 mg in 1 ml
Oral prednisolone may also be offered usually 2-4 week course with 5mg descalations each week.
NSAID
What are the complications of drug treatment in RhA?
- GI problems - NSAIDs
- Infection - steroids
- Liver toxicity - methotrexate
- Malignancy - esp skin with TNF-a inhibitors
- Osteoporosis - steroids, although RhA alone increases risk of this too
What eye syndrome is seen in RhA?
keratoconjunctivitis sicca
peripheral ulcerative keratitis
What is Felty’s syndrome?
Triad of RhA, enlarged spleen and low WCC - affects <1% with RhA
What is the leading cause of death in people with RhA?
Cardiovascular disease especially accelerated atherosclerosis
How is methotrexate prescribed? What is the frequency of monitoring bloods?
Once weekly regimen with folic acid on the days when not taking methotrexate (or one 5mg folic acid dose the day after)
FBC, U&Es and LFTs
- every 2 weeks initially for 6 weeks
- then montly for 3 months
- then 3 monthly
What bloods should be done to monitor biologic DMARD?
- FBC, U&E, LFTs - at 3-4 months, then every 6 months
- Lipid profile - 4 to 8 weeks after beginning treatment
- Infections - Hep B, C and HIV, tuberculosis
- Urinalysis
- Skin examination
Which cytokines are most targetted by DMARDs in RhA?
- IL17/23
- TNF-alpha
- JAK pathway
Which cDMARDs may be used in pregnancy?
Safe:
- Low dose prednisolone
- Hydroxychloroquine
- Azathioprine
- Tacrolimus
- Ciclosporin
Teratogenic:
- Methotrexate
- MMF
Which calculator is used in RhA to monitor disease activity?
DAS28
How many cDMARDS must be used before biological treatment?
NICE: methotrexate and at least one other cDMARD must be used long enough to have activity before moving onto adalimumab/rituximab.
Which steroid injection is used in active RhA?
IM depomedrone
