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Rheumatology > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

what is rheumatoid factor

A

circulating antibody, usually IgM
binds to Fc of host IgG

first-line ab test for pt with ?RA (anti-CCP if RF-)

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2
Q

how to detect RF?

A

Rose-Waaler test - sheep red agglutination
Latex agglutination test - less specific

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3
Q

what conditions are a/w + RF?

A

RA (70-80%) - high titre levels a/w severe progressive disease but NOT MARKER OF DISEASE ACTIVITY

felty syndrome - 100%
sjogren’s - 50%
infective endocarditis - 50%
sle - 20-30%
systemic sclerosis - 30%

general population - 5%
rare - tb, hbv, ebv, leprosy

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4
Q

what is the most specific antibody for RF?

A

anti-cyclic citrullinated peptide ab (90-95% specificity)
maybe detectable ~10y before dev of RA
correlate w disease progression

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5
Q

ix for ?RA?

A

x-rays of hands and feet
RF (and anti-CCP if RF -ve)

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6
Q

what conditions is raised ESR important in?

A

pmr
temporal arteritis
multiple myeloma

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7
Q

what antibodies are a/w ra?

A

anti-ccp
anti-phospholipid (also + in sle, anti-phospholipid syndrome)
rf

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8
Q

initial mx of RA?

A

DMARD monotherapy (usually methotrexate) ± short-course bridging prednisolone

monitoring tx response using CRP + disease activity (composite score like DAS28)

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9
Q

mx of RA flares?

A

corticosteroids - oral, intra-articular injection, or IM
e.g. methylprednisolone acetate, triamcinolone acetonide

can use NSAIDs but only short-course - not as effective compared to steroids but useful in reducing pain and inflammation (+ PPI cover)
paracetamol for pain

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10
Q

what DMARDs may be used in RA mx?

A

methotrexate most common

sulfasalazine
leflunomide
hydroxychloroquine

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11
Q

when should TNF-inhibitors be started in RA mx?

A

if inadequate response to at least 2 DMARDs (incl methotrexate)

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12
Q

which TNF inhibitors are used in RA mx?

A

etanercept
infliximab
adalimumab

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13
Q

what is etanercept?

A

recombinant human protein
acts as decoy receptor for TNFa
sc administration
can cause demyelination, reactivation of TB

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14
Q

what is infliximab?

A

mAb
binds to TNFa, preventing binding with TNF receptors
IV administration
can cause reactivation of TB

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15
Q

what is adalimumab?

A

mAb
sc administration

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16
Q

what is rituximab?

A

anti-CD20 mAb, causing B-cell depletion
2 1g IV infusions 2 weeks apart
infusion reactions are common

17
Q

what is abatacept?

A

fusion protein modulating key signal required for T cell activation
reduces T cell proliferation + cytokine production
given as infusion

not recommended for RA rn

18
Q

how long do DMARDs take to become effective?

A

~2-3 months

so changing dose not useful for acute flares despite being helpful in long-term management

19
Q

what should be prescribed with methotrexate?

A

folate to reduce risk of bone marrow suppression

methotrexate inhibits DHF which is an enzyme involved in folate metabolism; folic acid essential to DNA synthesis; so reduction can lead to myelosuppression where RBCs/WBCs/platelets are reduced in number -> can lead to severe infection/other comps

20
Q

poor prognostic features of RA?

A

RF +
anti-CCP ab
poor functional status at presentation
hla dr4
extra-articular features e.g. nodules
insiduous onset
x-ray: early erosions e.g. after <2y

female?

21
Q

joitn aspirate in RA?

A

high WBC (20-50k leucocytes), predominantly PMNs
appearance: yellow, cloudy, absent of crystals
variable neurophil count
negative gram stain
no crystals

22
Q

joint aspirate in septic arthritis?

A

cloudy/obqque
>50k leucocytes per microlitre
>90% neutrophils
usually + gram stain

23
Q

respiratory comps of rheumatoid arthritis?

A

pulmonary fibrosis
pleural effusion
pulmonary nodules
bronchiolitis obliterans
methotrexate pneumonitis

24
Q

ocular comps of rheumatoid arthritis?

A

keratoconjunctivitis sicca
episcleritis
scleritis
corneal ulceration
keratitis
steroid-induced cataracts
chloroquine retinopathy

25
Q

ortho comps of rheumatoid arthritis?

A

osteoporosis
atlantoaxial subluxation (can lead to cervical cord compression)

26
Q

cardiac comps of rheumatoid arthritis?

A

ischaemic heart disease (similar risk to T2DM)

27
Q

immuno comps of rheumatoid arthritis?

A

increased risk of infections

28
Q

psychiatric comps of rheumatoid arthritis?

A

depression

29
Q

what are less common comps of RA?

A

Felty’s syndrome
amyloidosis

30
Q

what is the core triad in felty’s syndrome?

A

ra
splenomegaly (resulting in anaemia secondary to hyposplenism)
low WCC (neutropenia)

31
Q

how do pt with felty’s syndrome present

A

recurrent, severe infections (which can lead to sepsis)

32
Q

why does felty’s syndrome present with anaemia?

A

secondary to hyposplenism

33
Q

why does felty’s syndrome present with neutropenia?

A

RA causes inflammatory splenomegaly
chronic activation of neutrophils leads to neutropenia

34
Q

what imaging needs to be done preop for pt with RA?

A

ap and lateral cervical spine radiographs
to screen for atlantoaxial subluxation

ensure pt has c-spine collar during surgery + neck is not hyperextended on intubation

35
Q

what score can be used to measure disease activity in rheumatoid arthritis?

A

disease activity score-28 (DAS-28)

includes tender joint count, swollen joint count, esr, global health

36
Q

what must absolutely be monitored with methotrexate?

A

FBC & LFTs due to the risk of myelosuppression and liver cirrhosis

37
Q

list some examples of dmards?

A

methotrexate
sulfasalazine
leflunomide
hydroxychloroquine

38
Q

what is a/w good prognosis in ra?

A

rf negative

39
Q

what results from bone subluxation in RA?

A

z-thumb appearance in hand
bone subluxation occurs due to erosion

Rheumatology (31 decks)

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