Rheumatoid Arthritis Flashcards
Rheumatoid arthritis: presentation
swollen, painful joints in hands and feet
stiffness worse in the morning
gradually gets worse with larger joints becoming involved
presentation usually insidiously develops over a few months
positive ‘squeeze test’ - discomfort on squeezing across the metacarpal or metatarsal joints
deformities in late features of rheumatoid arthritis
Swan neck and boutonnière deformities
unlikely to be present in a recently diagnosed patient.
Unusual presentation of RA?
acute onset with marked systemic disturbance
relapsing/remitting monoarthritis of different large joints (palindromic rheumatism)
NICE have stated that clinical diagnosis is more important than criteria such as those defined by the American College of Rheumatology.
true
2010 American College of Rheumatology criteria
Target population. Patients who
1) have at least 1 joint with definite clinical synovitis
2) with the synovitis not better explained by another disease
Classification criteria for rheumatoid arthritis (add score of categories A-D;
a score of 6/10 is needed definite rheumatoid arthritis)
2010 American College of Rheumatology criteria what factors does it look at?
Joint involvement: 1 large joint 0 2 - 10 large joints 1 1 - 3 small joints (with or without involvement of large joints) 2 4 - 10 small joints (with or without involvement of large joints) 3 10 joints (at least 1 small joint) 5
Serology:
Negative RF and negative ACPA 0
Low-positive RF or low-positive ACPA 2
High-positive RF or high-positive ACPA 3
Acute phase reactants:
Normal CRP and normal ESR 0
Abnormal CRP or abnormal ESR 1
Duration of symptoms:
< 6 weeks 0
> 6 weeks 1
What is RF?
Rheumatoid factor (RF) is a circulating antibody (usually IgM) which reacts with the Fc portion of the patients own IgG.
RF can be detected by either
Rose-Waaler test: sheep red cell agglutination
Latex agglutination test (less specific)
RF is positive in ?% of patients
RF is positive in 70-80% of patients
high titre levels of RF are associated with severe progressive disease
true
high titre levels of RF are a marker of disease activity
false
Other conditions associated with a positive RF include:
Felty's syndrome (around 100%) Sjogren's syndrome (around 50%) infective endocarditis (around 50%) SLE (= 20-30%) systemic sclerosis (= 30%)
What % of general population have +ve RF
general population (= 5%)
RF is commonly +ve in TB, HBV, EBV, leprosy
False
rarely +ve
Anti-cyclic citrullinated peptide antibody may be detectable up to 10 years before the development of rheumatoid arthritis
true
Anti-CCP is more specific for RA than RF
true
much higher specificity of 90-95%.
Anti-CCP is more sensitive for RA than RF
false
sensitivity similar to rheumatoid factor (around 70%)
NICE recommends that patients with suspected rheumatoid arthritis who are rheumatoid factor negative should be test for anti-CCP antibodies.
true
Rheumatoid arthritis: x-ray changes - early
loss of joint space
juxta-articular osteoporosis
soft-tissue swelling
Rheumatoid arthritis: x-ray changes - late
periarticular erosions
subluxation
A number of features have been shown to predict a poor prognosis in patients with rheumatoid arthritis:
rheumatoid factor positive anti-CCP antibodies poor functional status at presentation HLA DR4 extra articular features e.g. nodules insidious onset
What X ray features have poor prognosis?
X-ray: early erosions (e.g. after < 2 years)
female gender is associated with a poor prognosis.
true
extra-articular complications occur in patients with rheumatoid arthritis - respiratory
pulmonary fibrosis pleural effusion pulmonary nodules bronchiolitis obliterans methotrexate pneumonitis pleurisy
extra-articular complications occur in patients with rheumatoid arthritis - ocular
keratoconjunctivitis sicca (most common) episcleritis scleritis corneal ulceration keratitis steroid-induced cataracts chloroquine retinopathy
extra-articular complications occur in patients with rheumatoid arthritis - bony
osteoporosis
extra-articular complications occur in patients with rheumatoid arthritis - cardiovascular
ischaemic heart disease: RA carries a similar risk to type 2 diabetes mellitus
extra-articular complications occur in patients with rheumatoid arthritis - psych
depression
RA causes increased risk of infections
true
Uncommon complications of RA
Felty’s syndrome (RA + splenomegaly + low white cell count)
amyloidosis
Initial therapy
DMARD monotherapy +/- a short-course of bridging prednisolone
Monitoring response to treatment?
combination of CRP and disease activity (using a composite score such as DAS28) to assess response to treatment
mx flares
flares of RA are often managed with corticosteroids - oral or intramuscular
methotrexate is the most widely used DMARD.
true
monitoring for methotrexate
Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis.
Side effects methotrexate?
pneumonitis
myelosuppression and liver cirrhosis.
indication for a TNF-inhibitor
inadequate response to at least two DMARDs including methotrexate
What is etanercept?
Route?
Side effects?
recombinant human protein, acts as a decoy receptor for TNF-α
subcutaneous administration
can cause demyelination, risks include reactivation of tuberculosis
What is infliximab?
Route?
Side effects?
monoclonal antibody, binds to TNF-α and prevents it from binding with TNF receptors
intravenous administration
risks include reactivation of tuberculosis
What is adalimumab?
Route?
monoclonal antibody
subcutaneous administration
What is Rituximab?
Route?
Side effects?
anti-CD20 monoclonal antibody, results in B-cell depletion
two 1g intravenous infusions are given two weeks apart
infusion reactions are common
What is Abatacept?
Route?
Side effects?
fusion protein that modulates a key signal required for activation of T lymphocytes
leads to decreased T-cell proliferation and cytokine production
given as an infusion
not currently recommend by NICE
Side effects of Sulfasalazine?
Rashes
Oligospermia
Heinz body anaemia
Interstitial lung disease
Side effects of Leflunomide
Liver impairment
Interstitial lung disease
Hypertension
Side effects of Hydroxychloroquine
Retinopathy
Corneal deposits
Side effects of Prednisolone
Cushingoid features Osteoporosis Impaired glucose tolerance Hypertension Cataracts
Side effects of Gold
Proteinuria
Side effects of Penicillamine
Proteinuria
Exacerbation of myasthenia gravis
Side effects of NSAIDs (e.g. naproxen, ibuprofen)
Bronchospasm in asthmatics
Dyspepsia/peptic ulceration
Osteoarthritis aetiology
Mechanical - wear & tear*
localised loss of cartilage
remodelling of adjacent bone
associated inflammation
Osteoarthritis and rheumatoid arthritis: comparison - gender?
OA: Similar incidence in men and women
RA: More common in women
Osteoarthritis and rheumatoid arthritis: comparison - age?
OA: Seen most commonly in the elderly
RA: Seen in adults of all ages
Osteoarthritis and rheumatoid arthritis: comparison - Typical affected joints?
OA: Large weight-bearing joints (hip, knee)
Carpometacarpal joint
DIP, PIP joints
RA: MCP, PIP joints
Osteoarthritis and rheumatoid arthritis: comparison - Typical history?
OA: Pain following use, improves with rest
Unilateral symptoms
No systemic upset
RA: Morning stiffness, improves with use
Bilateral symptoms
Systemic upset
X-ray findings OA
Loss of joint space
Subchondral sclerosis
Subchondral cysts
Osteophytes forming at joint margins
NICE published guidelines on the management of osteoarthritis (OA) in 2014
all patients should be offered help with weight loss, given advice about local muscle strengthening exercises and general aerobic fitness
paracetamol and topical NSAIDs are first-line analgesics. Topical NSAIDs are indicated only for OA of the knee or hand
second-line treatment is oral NSAIDs/COX-2 inhibitors, opioids, capsaicin cream and intra-articular corticosteroids.
A proton pump inhibitor should be co-prescribed with NSAIDs and COX-2 inhibitors. These drugs should be avoided if the patient takes aspirin
if conservative methods fail then refer for consideration of joint replacement
OA non-pharmacological treatment options
non-pharmacological treatment options include supports and braces, TENS and shock-absorbing insoles or shoes
