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PR - MUSCULOSKELETAL > RHEUMATOID ARTHRITIS > Flashcards

RHEUMATOID ARTHRITIS Flashcards

1
Q

What is rheumatoid arthritis?

A
  • Chronic inflammatory disease affecting joint synovial membrane
  • Degeneration of cartilage and joints due to lymphocytes
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2
Q

RF

A
  • FMHx
  • Female
  • Smoking
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3
Q

Factors which aggravate RA?

A

Pain and stiffness worsens with rest, inactivity and heat in the joints

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4
Q

Symptoms of RA

A
  • pain and stiffness of joints
  • swelling of joints
  • deformity of the fingers and thumbs
  • malaise, fatigue, fever, and weight loss
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5
Q

What are the extra-articular symptoms of RA?

A
  • Sjogren’s syndrome (dry mouth or dry eyes)
  • Vasculitis (inflammation of blood vessels
  • Neuropathy (damage to nerves)
  • Subcutaneous nodules
  • Lymphadenopathy
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6
Q

Diagnosis

A
  1. American Rheumatism Association criteria
    - List of criteria e.g. morning stiffness, number of joints affected etc.
  2. Biochemical investigations for markers that confirm an inflammatory condition:
    - ESR
    - CRP
    - Rheumatoid factor (RF)
  3. Imaging
    - X-ray
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7
Q

Non-drug treatment

A
  1. physiotherapy
    - strengthens joints and helps reduce pain
  2. Occupational therapy
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8
Q

Drug treatment

A
  1. NSAIDs and analgesia
  2. Disease-modifying anti-rheumatic drugs (DMARDs)
  3. Corticosteroids
  4. Biologics (Cytokine inhibitors
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9
Q

NSAIDs for RA

A

NSAIDs can be used in pain relief - withdrawn when response to DMARDs is enough

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10
Q

OTC NSAIDs

A

Can’t give NSAID OTC to pt with RA
However, if prescribed by Dr is ok

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11
Q

What are the two
types of corticosteroid treatment for RA?

A
  1. Systemic
    Or
  2. Local
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12
Q

What is involved in systemic corticosteroid
treatment and in what situation would you give it to them?

A
  • Given as either, IM, IV or Oral
  • usually used during acute flare-ups or when bridging treatment between DMARDS
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13
Q

Why is systemic treatment not given for the long term in RA?

A
  • Because of the risks of osteoporosis
  • Also, when patients stop, relapse occurs
  • Systemic CS are only better for short-term use during initiation of DMARDS (which are used as long-term treatment)
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14
Q

What is involved in local corticosteroid treatment?

A
  1. Intra-articular injection
    - Used to reduce inflammation and pain
    - Injected directly into the joint e.g. Knee
    - Examples of corticosteroids used are: Dexamethasone, Hydrocortisone, Methhylprednisolone, Prednisolone, triamcinolone
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15
Q

How do DMARDs work and how many types are there?

A
  • They alter the underlying disease rather than treat symptoms
  • There are two types:
    1. Conventional DMARDs
    And
    2. Biologic DMARDs (Cytokine inhibitors)
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16
Q

How long does it take for DMARDs to work?

A
  • 2 - 6 months
17
Q

List the conventional DMARDs used in RA

A
  1. Methotrexate
  2. Ciclosporin
  3. Sulfasalazine
  4. Hydroxychloroquine
  5. Azathioprine
  6. Cyclophosphamide
  7. Leflunomide
  8. Penicillamine
18
Q

First line treatment

A

(DMARDs):
First Line → Methotrexate, leflunomide, or sulfasalazine (hydroxychloroquine in mild)

Second Line → MoAbs: TNF alpha inhibitor adalimumab, etanercept, infliximab, tocilizumab, baricitinib
Bridge with corticosteroids when rapid suppression is needed

19
Q

Which DMARD is usually given in RA?

A
  • Methotrexate, Sulfasalazine or Hydroxychloroquine
  • A combination of TWO DMARDs (e.g. methotrexate with another DMARD) and short-term corticosteroid is usually given in newly diagnosed (ideally within 3 months)
  • If contraindicated to the two combination drugs, then give a single drug only
20
Q

General SE of DMARDs

A

Bone marrow suppression, Increased risk of infection
Methotrexate: hepatotoxicity and renal impairment
Ciclosporin: HT

21
Q

hydroxychloroquine SE

A
  • Retinal toxicity: report any changes in vision
  • SE: abdominal pain, DNV
  • MHRA warning: Increased risk of CV events when hydroxychloroquine given with Macrolide Abx
22
Q

DMARD monitoring

A
  1. FBC
  2. Renal
  3. Hepatic
  4. ESR, CRP and Rheumatoid factor
    - Tto see how the patient is responding
23
Q

What are the two types of Biologic
DMARDS (cytokine inhibitors)?

A
  1. Anti-TNF therapies
    And
  2. Non- Anti-TNF therapies
24
Q

Which Biologic is an Anti-TNF?

A
  1. Adalimumab
  2. Certolizumab
  3. Etanercept
  4. Golimumab
  5. Infliximab
    All are administered parentally
25
Q

How often are anti-TNF’s administered?

A

All Except for Etanercept, are given every 2 weeks
Etanercept is given weekly

26
Q

How are anti-TNFs administered?

A

Infliximab is Intravenous
Rest are subcutaneous

27
Q

Which biologics are NON-anti-TNF?

A
  1. Rituximab
  2. Tocilizumab
  3. Abatacept
28
Q

When are biologics used?

A
  • When response to conventional DMARDs have been ineffective (Biologics are more effective than conventional DMARDs)
  • In severe rheumatoid arthritis
29
Q

What are the risks of using Biologics?

A
  1. Infections
    - e.g. Tuberculosis (seek medical attention if persistent cough, weight loss and fever develop)
  2. Blood disorders
    - Seek attention if symptoms such as fever, sore throat, bruising or bleeding develop
  3. Cancer
    - e.g. Skin cancer
30
Q

How often are
biologics DMARDs monitored for effectiveness?

A

every 6 m

31
Q

What should all patients be evaluated for before starting treatment with biologics?

A

TB

32
Q

Treatment - bridging

A

Conventional DMARDs have a slow onset of action and can take 2–3 months to take effect.
Bridge with CS when rapid suppression is needed
Short-term CS should also be given to rapidly decrease inflammation during flare-ups.

33
Q

Interactions - increased risk of blood disorders

A

Phenytoin
Trimethoprim/co-trimoxazole
Clozapine (neutropenia)

34
Q

Interaction - NSAIDs

A

NSAIDs cause vasoconstriction of afferent renal arteriole
NSAIDs reduced renal excretion = MTX toxicity

35
Q

Interactions - Increased risk of hepatotoxicity

A

Isotretinoin
Phenothiazine antipsychotics
Rifampicin
Ketoconazole

PR - MUSCULOSKELETAL (7 decks)

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