Rheumatoid arthritis Flashcards
Define rheumatoid arthritis
A chronic auto immune systemic illness characterised by a polyarthritis and other systemic features
What is polyarthritis
When at least 5 joints are affected by arthritis
What joints are most affected by rheumatoid arthritis
Small joints of hands, feet and wrist are most affected - metacarpal-pharyngeal joint, proximal inter-pharyngeal joint
What joint in the hands doesn’t get affected by rheumatoid arthritis
Distal inter-pharyngeal
What is ACR criteria used for
Lupus and rheumatoid arthritis
What score in the ACR criteria is diagnostic of rheumatoid arthritis
6 or more
Which gender is rheumatoid arthritis most common in
Females 3 : 1 Males
What age does rheumatoid occur at
4th and 5th decade but can occur at any age after 16 years old
Which gene is associated with rheumatoid arthritis
HLA-DRbeta1
What environmental triggers can cause rheumatoid arthritis
Cigarette smoking
Chronic infection e.g epstein barr virus
What hormonal factors can cause rheumatoid arthritis
Early age menopause
Low testosterone in men
Describe how rheumatoid arthritis is caused
Arginine changes into citrulline - the body recognises the protein as a foreign pathogen and activated dendritic cells which produce B and T lymphocytes to defend - the protein is commonly found in the synovium which is the common site of infection of rheumatoid arthritis
Osteoclasts then become activated and start eroding bone
how does rheumatoid arthritis present
Pain
Morning stiffness which lasts longer than 30 minute - characteristic of inflammatory joint conditions
Poor function
Systemic symptoms
What is morning stiffness longer than 30 minutes characteristic of
Inflammatory joint conditions
What is expected to see on examination of a patient with rheumatoid arthritis
swelling
tenderness
the joints will feel warm and appear red
There will be restricted movement in the joints
What joints is rheumatoid arthritis normally not present in
the joints in the central line e.g spine
Distal inter-phalyngeal joint
What is ulnar deviation
All the fingers drift to the ulnar side - seen in hand deformity caused by untreated rheumatoid arthritis
What are the systemic symptoms of rheumatoid arthritis
Fatigue, weight loss, anaemia
What are the extra-articular manifestations of rheumatoid arthritis
Eyes, lungs, nerves, skin and kidneys
What is the long term complication which can occur due to rheumatoid arthritis
In any untreated inflammatory condition, there is increased cardiovascular risk
malignancy can occur as well
What are the haematological manifestations of rheumatoid arthritis
Anaemia
Thrombocytosis - high platelets
Fetty’s syndrome
What is Fetty’s syndrome
Triad of low neutrophils (neutropenia) , splenomegaly and rheumatoid arthritis
What bloods are checked in rheumatoid arthritis
FBC, kidney function, liver function, CRP and ESR
What investigations are done for rheumatoid arthritis
Baseline bloods
Immunology
X rays
Ultrasound
What is checked in the immunology for rheumatoid arthritis
Rheumatoid factor
Anti cyclic citrullinated antibodies (Anti-CCP)
What is used to assess rheumatoid arthritis
Disease activity score (DAS score)
What DAS numbers suggest remission
less than 2.6
What DAS numbers suggest need for biologic therapy
more than 5.1
What is the tactic for management of rheumatoid arthritis
early and aggressive intervention
What is the first line of management of rheumatoid arthritis
Methotrexate
What is used to treat symptoms when patient comes for the first time or during a flare up
NSAIDS - naproxen and ibuprofen
Glucocorticoids - prednisone, hydrocortisone, prednisolone
What kind of drug is methotrexate
conventional systemic DMARDs - disease modifying anti-rheumatic drugs
When is methotrexate not indicated as first line for rheumatic arthritis
Pregnant women - causes foetal abnormalities
Bad lung disease - can lower immune system and cause fibrosis
What are other examples of conventional synthetic DMARDs
Leflunomide
Hydroxychloroquine
sulfasalazine
What is the order of drugs given in treatment if no remission
Methotrexate (unless pregnancy or severe lung disease) - sulfasalazine - biologic DMARDs e.g infliximab, golimumab)
What is the function of conventional DMARDs
They are slow acting and have a slow onset effect
They don’t stop the process but they modulate the immune system to make the process slower
Has the risk of toxicity
What is the difference between biologic DMARDs therapy compared to non biologic
Biologic DMARDs are large complex proteins that work rapidly but can increase the risk of infection
What is TNFalpha inhibitor
Tumour necrosis factor alpha inhibitor - a biologic
What are the issues with biologics
Injection site reactions
Infection risk increase
Malignancy
Cost - they are very expensive
