Rheumatoid arthritis Flashcards
OVERVIEW
i) what is it? is it usually uni or bilat? is it more common in women or men?
ii) which two genes are usually associated? which one is often present in RF positive patients?
iii) which autoantibody is found in around 70% of RA patients? which antibody does it target? which other autoantibody is found that is more sensitive/specific to RA?
iv) what are the three key symptoms? does it worsen or improve with activity?
i) autoimmune chronic inflam of synovial lining of joints, tendon sheaths and bursa
symmetric polyarthritis
3:1 F:M
ii) HLADR4 - usually in RF positive patients
HLADR1 - ocassionally present
iii) 70% are rheumatoid factor positive > circ IgM that targets IgG
anti CCP is more specific - often pre dates disease and most patients will go on to develop RA
iv) pain, swelling and stiffness that improves with activity
CLINICAL MANIFESTATION OF RA
i) name five joints that are usually affected? which joints are almost never affected?
ii) what can occur in the cervical spine and what can this cause?
iii) name three deformities that may be seen in the hands
iv) name four extra articular manifestations
i) PIPs, MCPs, wrist, ankle, MTPs, cervical spine and large joints such as knee, hip, shoulder
DIPs are almost never affected - more likely to be heberdens nodes in OA
ii) atlantoaxial subluxation > spinal cord compression
iii) Z shaped thumb deformity, swan neck (hyper extended PIP with flexed DIP), boutonniers (hyperextended DIP with flexed PIP) and ulnar deviation of fingers at knuckles
iv) pulmonary fibrosis, bronchiolitis obliterans (inflam > small airway obstruction), secondary sjogrens, anaemia of chronic disease, lymphadenopathy, carpal tunnel
RA INVESTIGATIONS
i) how are most diagnoses made?
ii) name three markers that may be checked?
iii) what imaging may be done of hands and feet? name three things that may be seen
iv) what scan can be used to evaluate and confirm synovitis?
i) clinically - symmetrical polyarthropathy affecting small joints
ii) check RF, anti CCP, inflam markers eg ESR and CRP
iii) x ray - see joint destruction and deformity, soft tissue swelling, perarticular osteopenia and bony erosions
iv) US - useful if clinical exam is unclear
RA DIAGNOSIS
i) which two diagnostic criteria are used for diagnosis?
ii) what four things is the patient score based on? over what score indicates an RA diagnosis?
iii) what is the DAS28 score? how may joints are assessed? what three things are points given for? what is this useful for?
iv) name four things that confer a worse prognosis
i) american college of rheumatology (ACR) and eurp league against rheumatism (ELAR)
ii) joints involved, serology (RF and anti CCP), inflam markers (ESR and CRP) and duration of symptoms (more or less than 6 weeks)
score more than or =6 means RA
iii) DAS28 is disease activity score = assessment of 28 joints
points for swollen joints, tender joints, ESR/CRP result
good for monitoring response to treatment
iv) younger onset, male, more joints/organs affected, presence of RF/anti CCP, erosions on xray
RA MANAGEMENT
i) what can be prescribed at first presentation/during flare ups to quickly settle disease? name two other drug classes that are also useful but risk GI bleed? how can this risk be mitigated?
ii) name two things that can be sed to monitor success of treatment? what is the aim of treatment?
iii) what is the ‘mildest’ anti rheumatic drug?
iv) name three drugs that may be given in first line monotherapy? (DMARDs) what is done second line?
v) what type of drug is given third line? give an example? what is given fourth line?
i) short course of steroids
can also given NSAIDs/ cox2 inhibitors but risk GI bleed so also give a PPI
ii) monitor CRP and DAS28 - aim to reduce treatment dose to minimum effective dose
iii) hydroxychloroquine
iv) methotrexate, leflunomide or sulfasalazine - give these with an initial short course of bridging prednisolone
second line - use the drugs in combination
v) third line give a biologic eg TNF inhibitor = adalim, inflix, etanercept
fourth line - rituximab
RA TREATMENT
i) do pregnant women usually have improve or worsening of symptoms? name two DMARDs that can be used in pregnancy?
ii) name three TNF inhibitors that may be used? what can they all lead to?
iii) how does methotrexate work? how often is it given? what must be co prescribed and on which day? name three side effects of MTX?
iv) how does leflunomide work? name four side effects
v) when may sulfasalazine be given? name two side effects
i) usually improve in pregnancy but can be given sulfasalazine or hydroxycholoroquine
ii) adalimumab, inflixmab, etancerpt, certolizumab > can all lead to immunosupp and pts need screening before starting
iii) MTX interferes with folate metabolism - taken by injection or orally once a week and must also have folate taken on a different day of the week
SE - mouth ulcers, mucocitis, liver tox. BM supress, leucopenia, teratogenic
iv) leflu interferes with pyrimidine production
SE - mouth ulcers/mucocitis, increased BP, rashes, periph neuropathy, liver tox, BM sipp, teratogenic
v) sulfasal can be given in pregnancy
SE = temporary male infertility and BM supression
RA TREATMENT CONTINUED
i) how does hydroxychloroquine work? is it safe in pregnancy?
ii) name three SE of HCQ
iii) which drug can be used fourth line after anti TNF agents? what is it a MAB to? name three side effects
i) interferes with TLRs and safe in pregancy
ii) nightmares, reduced visual acuity, liver tox, skin pigmentation
iii) rituximab > MAB to CD20 on B cells
SEs = severe infections, sepsis, night sweats, thrombocytopenia, periph neuropathy, liver and lung toxicity
RA TREATMENT SIDE EFFECTS
i) which drug causes BM supression, leucopenia and is highly teratogenic?
ii) which causes high BP and periph neuropathy?
iii) which causes male infertility by reducing sperm count?
iv) which causes nightmares and reduced visual acuity?
v) which causes night sweats and thrombocytopenia?
i) MTX
ii) leflunomide
iii) sulfasalazine
iv) HCQ
v) rituximab
