Rheumatoid arthritis Flashcards
Respiratory manifaestations of RA
pulmonary fibrosis
pleural effusion
pulmonary nodules
bronchiolitis obliterans methotrexate pneumonitis
pleurisy
Ocular manifestations of RA
keratoconjunctivitis sicca (most common)
episcleritis/ scleritis
corneal ulceration
keratitis
steroid-induced cataracts
chloroquine retinopathy
Complications associated with RA
osteoporosis
ischaemic heart disease
risk of infections
depression
Less common:
Felty’s syndrome (RA + splenomegaly + low white cell count)
amyloidosis
RA + splenomegaly + low white cell count
Felty’s syndrome
Criteria which increase likelihood of RA diagnosis
Multiple joints affected
positive anti-RF and anti-CCP
high inflammatory markers
Symptoms persisting >6 weeks
Which drug has the following side effects?
Myelosuppression
Liver cirrhosis
Pneumonitis
Methotrexate
Which drug has the following side effects?
Rashes
Oligospermia
Heinz body anaemia
Interstitial lung disease
Sulfasalazine
Which drug has the following side effects?
Liver impairment
Interstitial lung disease
Hypertension
Leflunomide
Which drug has the following side effects?
Retinopathy
Corneal deposits
Hydroxychloroquine
Which drug has the following side effects?
Cushingoid features
Osteoporosis
Impaired glucose tolerance
Hypertension
Cataracts
Steroids
Which drug has the following side effects?
Proteinuria
Gold
Which drug has the following side effects?
Proteinuria
Exacerbation of myasthenia gravis
Pencillamine
Which drug has the following side effects?
Demyelination
Reactivation of tuberculosis
Etanercept
Which drug has the following side effects?
Reactivation of tuberculosis
Infliximab/ Adalimumab
Which drug has the following side effects?
Infusion reactions are common
Rituximab
Which drug has the following side effects?
Bronchospasm in asthmatics
Dyspepsia/peptic ulceration
NSAIDs
Tests used to detect Rheumatoid factor (RF)
Rose-Waaler test: sheep red cell agglutination
Latex agglutination test
What percentage of patients with RA are positive for RF
70-80%
RF is considered a marker of RA disease activity. TRUE/FALSE?
FALSE
Other conditions in which RF is positive
Felty’s syndrome
Sjogren’s syndrome
infective endocarditis
SLE
systemic sclerosis
general population ~5%
rarely: TB, HBV, EBV, leprosy
Sensitivity and specificity of Anti-CCP
Sensitivity ~ 70%
Specificity ~ 90-95%.
initial treatment for RA
NICE recommend DMARD monotherapy +/- a short-course of bridging prednisolone
Options for DMARD therapy
Methotrexate
sulfasalazine
leflunomide
hydroxychloroquine
Why must patients have FBC and LFTs monitored on Methotrexate?
due to the risk of myelosuppression and liver cirrhosis.
How do we monitor response to DMARD treatment?
combination of CRP and disease activity score (DAS28 score)
management of RA flare
corticosteroids - oral or intramuscular
Indication for TNF inhibitor therapies
inadequate response to at least two DMARDs including methotrexate
options of TNF inhibitor therapies
etanercept
infliximab
adalimumab
Which anti-CD20 monoclonal antibody infusion can be used to treat RA?
Rituximab (B-cell depletion)
2x 1g intravenous infusions are given two weeks apart
What is Abatacept?
fusion protein that modulates a key signal required for activation of T lymphocytes
leads to decreased T-cell proliferation and cytokine production
(NOT YET APPROVED BY NICE)
RA symptoms tend to improve in pregnancy and flare following delivery. TRUE/FALSE?
TRUE
- patients with early or poorly controlled RA should be advised to defer conception until their disease is more stable
What DMARDs are safe in pregnancy?
SAFE: = sulfasalazine and hydroxychloroquine
UNSAFE = Methotrexate and leflunomide
low-dose corticosteroids may be used in pregnancy to control symptoms
Clinical features
swollen, painful joints in hands and feet
stiffness worse in the morning
gradually gets worse with larger joints becoming involved
insidiously onset
positive ‘squeeze test’
Describe the names given to RA bony deformities in the hands
Swan neck and boutonnière deformities
Poor prognostic features
rheumatoid factor positive
anti-CCP antibodies
poor functional status at presentation
X-ray: early erosions (< 2 years)
extra articular features
HLA DR4
insidious onset
Early XR findings in RA
loss of joint space
juxta-articular osteoporosis
soft-tissue swelling
periarticular erosions
subluxation
