rheumatoid arthritis Flashcards
what is rheumatoid arthritis
Initially a disease of the synovium with gradual inflammatory joint destruction
Different patterns of joint involvement
Sero-positive RA = rheumatoid factor present
Sero-negative RA = rheumatoid factor NOT present
most common serious joint disease
1% prevalence
6:1 female pre-menopause
3:1 female post-menopause
peaks in 3rd-5th decades (20-50yrs)
symptoms of RA
slow onset
morning stiffness
initally hands and feet
proximal spread
potentially ALL synovial structures
SYMMETRICAL polyarthritis
Occ. onset with SYSTEMIC symptoms
fever, weight loss, anaemia
early signs of RA
symmetrical synovitis of MCP joints
symmetrical synovitis of PIP joints
symmetrical synovitis of wrist joints
late signs of RA
ulnar deviation of fingers at MCP joints
hyperextension of PIP joints
“swan-neck” deformity
“Z” deformity of thumb
hyperflexion of MCP
hyperextension of IP joint
subluxation of the wrist
loss of abduction and external rotation of shoulders
flexion of elbows and knees
deformity of the feet & ankles
extra-articular features of RA
Due to systemic vasculitis
Inflammation of Blood Vessels
present in 75% of patients
Psoriasis in some patients
Give much more aggressive form of RA and in younger patients
- ‘psoriatic arthritis’
Eye involvement
scleritis & episcleritis,
dry eyes, Sjögrens syndrome
Subcutaneous nodules
pressure points
Amyloidosis
Pulmonary inflammation
Neurological
investigations of RA
Radiographs
erosions, loss of joint space, deformity
joint destruction & secondary osteoarthritis
Blood
normochomic, normocytic anaemia = failure of red blood cell stimulation
treatment of RA
“holistic management”
aim to improve quality of life
combinations of
physiotherapy
occupational therapy
drug therapy
surgery
physiotherapy for RA
Aim to keep the patient active for as long as possible!
active and passive exercises
to maintain muscle activity
to improve joint stability
to maintain joint position
occupational therapy during RA
maximising the residual function
providing aids to independent living
assessment & alteration of home
drug therapy most RA cases
analgesics
paracetamol, cocodamol
NSAIDs
Often combined with anti-PUD agents
Disease Modifying Drugs
hydroxychloroquine, methotrexate,
Less commonly now: sulphasalzine, penacillamine, gold,
Steroids - intra-articular
drug therapy – moderate and severe RA cases
immune modulators
Azathioprine
Mycophenolate
Biologics
TNF inhibitors - infliximab, adalimumab, entanercept
Rituximab (CD20) & tocilizumab (IL6r)
Steroids – oral prednisolone
surgery during RA
excision of inflamed tissue
joint replacement
joint fusion
osteotomy
Remember - patients often have a poor medical condition for surgery
joint replacements prognosis =
10% spontaneously remit
remainder have fluctuating course
RF and late onset have worse prognosis
10% severely disabled
remainder have mild/moderate disability
REMEMBER complications
infection, PUD, extra-articular, DRUGS
dental aspects of RA
disability from the disease
reduced dexterity
access to care
Sjögren’s syndrome
association of CT disease the dry eyes/mouth
Joint replacements
multiple - large & small joints
Drug effects
bleeding - NSAIDs & sulphasalazine
infection risk - steroids, azathioprine
oral lichenoid reactions
gold, sulphasalazine, hydroxychloroquine
oral ulceration - methotrexate
oral pigmentation – hydroxychloroquine
Chronic anaemia - GA problems
what is seronegative spondyloarthritides
FOCUS IS ON ARTHRITIS IN THE SPINE
ankylosing spondylitis
spinal joint arthritis
reiter’s disease
arthritis of IBD
association with HLA-B27
infection likely as a precipitant
genetic basis !!
often symmetrical peripheral arthritis
ocular & mucocutaneous manifestations
ankylosing spondylitis effects
Disabling progressive lack of axial movement
can’t move head side to side = need to move a whole body
symmetrical other joint involvement – e.g.hips
Results in:
low back pain
limited back and neck movement – turning spine restricted
limited chest expansion – breathing compromised
cervical spine tipped forward (Kyphosis)
movements restricted
respiratory diseases are hard to beat
