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YR6 Rheumatology > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

What is RA?

A

Chronic systemic inflammatory AI disorder primarily affecting joints

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2
Q

Describe epidemiology of RA

A

Common, ~1% of UK
Peak onset 30-50y
F > M

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3
Q

List 3 risk factors for RA

A

Genetic disposition: HLA-DR4 + HLA-DR1
FH
Smoking

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4
Q

What are the typical presenting symptoms of RA?

A

Symmetrical pain + swelling of joints in hands + feet
Morning stiffness >30 mins

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5
Q

Which joints are most commonly affected in RA?

A

Metacarpophalangeal (MCP)
Proximal interphalangeal (PIP)
Metotarsophalangeal (MTP)

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6
Q

Describe the pain in RA

A

Worse at rest + or during periods of inactivity

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7
Q

Describe the swelling in RA

A

Around joint (not bone swelling) giving a ‘boggy’ feel on palpation

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8
Q

List 4 hand deformities that may be seen in advanced RA

A

Swan neck deformity: PIP hyperextension + DIP flexion
Boutonniere deformity: PIP flexion + DIP hyperextension
Z-deformity of the thumb: hyperextension of IPJ with fixed flexion of MCP
Ulnar deviation of fingers

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9
Q

What deformity of the cervical spine may occur in RA?

A

Atlantoaxial subluxation

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10
Q

What test can be performed on examination in RA?

A

Metacarpophalaneal squeeze test
Pain on squeezing metacarpophalangeal / metatarsophalangeal joints together

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11
Q

Describe onset of RA

A

Variable
Most: insidious onset
Some: rapid or relapsing-remitting course

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12
Q

List 3 ways RA may present in addition to joint synovitis

A

Rheumatoid nodules
Extra-articular features
Systemic features

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13
Q

What are rheumatoid nodules?

A

Hard, firm non-tender swellings over extensor surfaces

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14
Q

List 4 systemic symptoms of RA

A

Malaise + Fatigue
Fever
Night sweats
Weight loss

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15
Q

List 4 extra-articular systems of RA

A

Vasculitis
Lungs
Eyes
Heart

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16
Q

List 3 ocular manifestations of RA

A

Keratoconjunctivitis sicca (most common)
Scleritis (erythema + pain)
Episcleritis (erythema)

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17
Q

Name 3 lung manifestations of RA

A

Pulmonary nodules
Pleuritis
Interstitial lung disease

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18
Q

Name 2 vasculitic manifestations of RA

A

Raynauds
Peripheral vasculitis manifests as lived reticularis

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19
Q

Name 3 cardiac manifestations of RA

A

Pericarditis
Myocarditis
Increased risk MI, stroke, CHF

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20
Q

Describe diagnosis of RA

A

Clinical diagnosis supported by bloods + imaging

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21
Q

What investigations are performed for RA?

A

Bloods
X-rays of hands + feet

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22
Q

Which bloods are performed for RA?

A

FBC, U+Es, LFTs
Rheumatoid factor
Anti-CCP
Anti-nuclear antibodies
CRP + ESR: usually raised

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23
Q

What is the first line antibody test for RA?

A

Rheumatoid factor (RF)
Usually IgM that reacts with Fc portion of own IgG
+ve in 60-70% of RA

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24
Q

What are high titres of RF associated with in RA?

A

Severe progressive disease
(NOT a marker of disease activity)

25
Q

List 5 conditions with positive RF other than RA

A

Felty’s syndrome
Sjogren’s syndrome
Infective endocarditis
SLE
Systemic sclerosis

26
Q

Which antibody can be detected up to 10y before development of RA?

A

Anti-cyclic citrullinated peptide antibody

27
Q

Describe the sensitivity and specificity of anti-CCP

A

Sensitivity ~70%
Specificity 90-95%

28
Q

What are 2 early x-ray features seen in rheumatoid?

A

Juxta-articular osteoporosis/ osteopenia
Soft-tissue swelling

29
Q

List 3 late x-ray changes in RA

A

Loss of joint space
Periarticular erosions
Subluxation

30
Q

Which imaging modalities may be more informative in early RA?

A

US or MRI
Higher sensitivity for detecting early signs of inflammation
Typical RA findings on XR may be subtle/ absent

31
Q

Describe management of acute flares of RA

A

Intra-articular methylprednisolone acetate
or
IM methylprednisolone
or
PO Prednisolone

32
Q

Describe initial long term management of RA

A

DMARD mono therapy +/- short term bridging Prednisolone

33
Q

What is the most common first line DMARD used in RA? What monitoring is required?

A

Methotrexate once weekly

Monitoring FBC + LFTs essential due to risk of myelosuppression + liver cirrhosis

+ Folic acid supplementation to minimise adverse effects

34
Q

What monitoring is required when using methotrexate?

A
  1. 2 weekly
  2. Once on stable dose for 6w: once monthly for 3/12
    3 monthly

+ Baseline CXR + Lung function tests

35
Q

Name an important side effect of methotrexate

A

Pneumonitis

36
Q

What is the treatment for Methotrexate toxicity?

A

Folinic acid

37
Q

Which drugs should be avoided concurrently whilst taking methotrexate? Why?

A

Trimethoprim + co-trimoxazole (anti-folate abx)
Risk of bone marrow aplasia due to additive folate depletion
-> Fatal pancytopenia + megaloblastic anaemia

38
Q

Name 3 alternative DMARDs to methotrexate for RA

A

Sulfasalazine
Leflunomide
Hydroxychloroquine (mild or palindromic disease)

39
Q

How is response to treatment monitored?

A

CRP + disease activity score (DAS28)

40
Q

When is TNF-inhibitor therapy indicated for RA?

A

Inadequate response to at least 3 DMARDs inc. methotrexate

41
Q

List 3 TNF inhibitors used in RA

A

Etanercept (SC)
Infliximab (IV)
Adalimumab (SC)

42
Q

Other than TNF inhibitors, which biological DMARDs can be used in RA

A

Rituximab

(Abatacept; not currently recommended by NICE)

43
Q

What is Felty’s syndrome?

A

RA
Splenomegaly
Low WCC

44
Q

List 3 side effects of methotrexate

A

Myelosuppression
Liver cirrhosis
Pneumonitis

45
Q

List 4 side effects of sulfasalazine

A

Rashes
Oligospermia
Heinz body anaemia
Interstitial lung disease

46
Q

List 3 side effects of Leflunomide

A

Liver impairment
Interstitial lung disease
HTN

47
Q

List 2 side effects of hydroxychloroquine

A

Retinopathy
Corneal deposits

48
Q

List 5 side effects of Prednisolone

A

Cushingoid features
Osteoporosis
Impaired glucose tolerance
HTN
Cataracts

49
Q

Give 1 side effect of Gold

A

Proteinuria

50
Q

Name 2 side effects of Penicillamine

A

Proteinuria
Exacerbation of myasthenia gravis

51
Q

Name 2 side effects of Etanercept

A

Demyelination
Reactivation of TB

52
Q

Name a side effect of Infliximab

A

Reactivation of TB

53
Q

Name a side effect of Adalimumab

A

Reactivation of TB

54
Q

Name a side effect of Rituximab

A

Infusion reactions are common

55
Q

Name 2 side effects of NSAIDs

A

Bronchospasm in asthmatics
Dyspepsia/ peptic ulceration

56
Q

Which drugs for RA are safe during pregnancy?

A

Prednisolone
Hydroxychloroquine
Sulfasalazine

57
Q

List 8 poor prognostic factors in RA

A

RF +ve
Anti-CCP antibodies
Poor functional status at presentation
X-ray: early erosions (e.g. after < 2y)
Extra articular features e.g. nodules
HLA DR4
Insidious onset
Female

58
Q

What classification is used for research purposes (not diagnostically) in RA?

A

ACR/ EULAR classification criteria
High specificity but low sensitivity
Does not account for early disease/ predominant extra-articular manifestations
Can diagnose RA w/o fulfilling

YR6 Rheumatology (18 decks)

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