Rheumatoid arthritis Flashcards
Rheumatoid arthritis
Symmetrical polyarthropathy
3x more common in women
Genetic associations
HLA DR4 (often RF positive patients)
HLA DR1 (occasionally RA positive)
Antibodies
Rheumatoid factor
Anti-cyclic citrullinated peptide antibodies
Rheumatoid factor
Present in 70% of RA patients
Targets Fc portion of the IgG antibody
Causes activation of the immune system against the patients own IgG causing systemic inflammation
Anti-CCP antibodies
More sensitive and specific to rheumatoid arthritis than RF
Often pre-date the development of RA and give indication that a patient will develop it at some point
Presentation
Symmetrical distal polyarthropathy
Pain, swelling, stiffness
Systemic symptoms: fatigue, weight loss, flu-like illness, muscle aches and weakness
Common joints affected
PIP
MCP
Wrist and ankle
MTP
Cervical spine
(DIP almost never affected by RA)
Hand signs
Z shaped deformity to the thumb
Swan neck deformity (hyperextended PIP with flexed DIP)
Boutonnieres deformity (hyperextended DIP with PIP)
Ulnar deviation
Extra-articular manifestations
Pulmonary fibrosis
Bronchiolitis obliterans
Felty’s syndrome
Secondary Sjogren’s syndrome
Anaemia of chronic disease
CVD
Episcleritis
Rheumatoid nodules
Lymphadenopathy
Carpal tunnel syndrome
Amyloidosis
Investigations
Clinical diagnosis
Check rheumatoid factor and anti-CCP
Inflammatory markers
Xray of hands and feet
Xray changes
Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions
DAS28
Disease activity score based on assessment for 28 joints and points given for:
- swollen joints
- tender joints
- ESR/ CRP result
HAQ
Measures functional ability
Worse prognosis
Younger onset
Male
More joints affected
Presence of RF and anti-CCP
Erosions seen on xray
Flare management
NSAIDs/ COX-2 inhibitors
Prescribe with PPI
DMARD guidelines
1st line: methotrexate, leflunomide or sulfasalazine
(hydroxychloroquine in mild disease)
2nd line: 2 in combination
3rd line: methotrexate + biological therapy
4th line: methotrexate + rituximab
DMARDs in pregnancy
Sulfasalazine and hydroxychloroquine safe
Biological therapy
TNF inhibitors: adalimumab, influximab and etanercept
Anti-CD-20: rituximab
All lead to immunosuppression
Methotrexate
Interferes with the metabolism of folate and suppresses certain components of the immune system
Also prescribe folic acid 5mg OW on a different day
Side effects:
- mouth ulcers and mucositis
- liver toxicity
- bone marrow suppression and leukopenia
- teratogenic
Leflunomide
Immunosuppressant medication that works by interfering with the production of pyrimidine
Side effects:
- mouth ulcers and mucositis
- increased BO
- rashed
- peripheral neuropathy
- liver toxicity
- bone marrow suppression and leukopenia
- teratogenic
Sulfasalzine
Immunosuppressive and anti-inflammatory medications
Safe in pregnancy
Side effects:
- temporary male infertility (reduced sperm count)
- bone marrow suppression
Hydroxychloroquine
Interferes with Toll-like receptors, disrupting antigen presentation and increasing the pH in the lysosomes of immune cells
Safe in pregnancy
Side effects:
- nightmares
- reduced visual acuity
- liver toxicity
- skin pigmentation
Anti-TNF drugs
Adalimumab, infliximab, golimumab, etanecept
Side effects:
- vulnerability to severe infections and sepsis
- reactivation of TB and hepatitis
Rituximab
Monoclonal antibody targets the CD20 protein on the surface of B cells causing destruction
Side effects:
- vulnerability to severe infections and sepsis
- night sweats
- thrombocytopenia
- peripheral neuropathy
- liver and lung toxicity
