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RHEUMATOLOGY > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

what is RA

A

autoimmune condition that causes chronic inflammation in the synovial lining of the joints, tendon sheaths and bursa

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2
Q

what does RA tend to affect

A

multiple small joint symetrically across both sides of the body - symmetrical polyarthritis

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3
Q

what are risk factors of RA

A

F>M
smoking
obesity
FHx

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4
Q

what is the most common gene associated with RA

A

HLA-DR4

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5
Q

What antibodies are associated with RA

A
  • Fc portion of IgG (RF)
  • anti citrullinated cyclic peptide (anti-CCP)
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6
Q

What is the pathophysiology of RA

A
  • citrullination of self antigens which are then recognised by T&B cells that produce antibodies (RF and anti-CCP)
  • stimulated macrophages and fibroblasts release TNFa
  • inflamm cascade —> proliferation of synoviocytes which results in the typical ‘boggy’ joint swelling
  • these grow over the cartilage and lead to restriction of nutrients and cartilage is damaged
  • activated macrophages stimulate osteoclast differentiation contributing to bone damage
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7
Q

What are features of a typical history of RA

A
  • hx > 6 weeks
  • morning stiffness > 30 mins
  • commonly c/o fatigue or malaise
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8
Q

What may be present O/E in RA

A
  • soft tissue swelling and tenderness first
  • Z-shaped deformity to the thumb
  • ulnar deviation/palmar subluxation of MCPs
  • swan-neck & Boutonnière deformity
  • rheumatoid nodules on elbow
  • check median nerve - carpal tunnel association
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9
Q

Give 5 relevant investigations into RA and state their findings

A
  • RF & anti-CCP antibodies
  • FBC - normocytic anemia
  • WCC if concerned re septic arthritis
  • inflamm markers e.g. CRP, ESR
  • X-ray changes apparent in established but need USS/MRI for early disease
  • USS!!
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10
Q

What are 5 treatment options for RA

A
  • initially DMARD monotherapy e.g. methotrexate but consider combo DMARDs
  • steroids acutely - PO/IM or intra-articular
  • symptom control w NSAIDs + PPI cover if no contraindications
  • if diseases persists, consider biologics e.g. anti-TNF
  • non drug: OT/PT, podiatry, psychological
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11
Q

What type of patients do extra-articular manifestations of RA normally present in

A

RF + patients with severe articular disease

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12
Q

What are extra-articular manifestations of RA

A
  • 3Cs – Carpal tunnel syndrome, elevated Cardiac risk (CVD), Cord compression (due to atlanto- axial subluxation)
  • 3As – Anaemia (normochromic & normocytic), Amyloidosis (very rare now due to improved treatment, can cause nephrotic syndrome and CKD), Arteritis (rare now due to improved treatment, can cause nail fold infarcts, cutaneous vasculitis & mononeuritis multiplex)
  • 3Ps – Pericarditis (uncommon), Pleural disease (common), Pulmonary disease (common) e.g. bronchiectasis, bronchiolitis obliterans, fibrosis
  • 3Ss – Sjögren’s (common), Scleritis/episcleritis (uncommon), Splenic enlargement (together with neutropaenia = Felty’s syndrome, rare)
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13
Q

what are the distinguishing features of inflammatory vs mechanical disease

A
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14
Q

What might polarised light microscopy reveal in gout and pseudo-gout

A
  • gout: negatively birefringent needle shaped crystals
  • pseudo-gout: positively birefringement rhomboid shaped crystals
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15
Q

What are the adverse effects of methotrexate (5)

A
  • nausea most common
  • oral ulcers, hair thinning
  • hepatitis, cirrhosis
  • pneumonitis
  • bone marrow suppression
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16
Q

What are the adverse effects of hydroxychloroquine

A
  • GI disturbance most common
  • retinal pigmentation and loss of vision which is rare but screening needed
  • no blood tests required
17
Q

What are the adverse effects of sulfasalazine

A
  • GI upset
  • rash
  • hepatitis
  • bone marrow suppression
18
Q

What are the adverse effects of azathioprine

A
  • GI upset most common
  • bone marrow suppression
19
Q

What are the adverse effects of cyclophosphamide (3)

A
  • bone marrow suppression
  • infertility
  • inc risk of cancer
20
Q

What are the adverse effects of ciclosporin (2)

A
  • renal impairment
  • HTN
21
Q

What are the adverse effects of leflunomide

A
  • GI upset
  • HTN
  • bone marrow suppression
  • hepatitis
22
Q

what are the 3 joint symptoms of RA

A
  • pain
  • stiffness
  • swelling
23
Q

what are the most commonly affected joints in RA

A
  • MCPJ
  • PIPJ
  • wrist
  • MTPJ
  • also ankle, knee, hips, shoulders, cervical spine not lumbar
24
Q

what might the joints feel like on palpation in RA

A
  • tenderness and synovial thickening
  • ‘boggy’ feeling
25
Q

what are associated systemic symptoms of RA

A
  • fatigue
  • weight loss
  • flu-like illness
  • muscle aches and weakness
26
Q

how can disease activity of RA be monitored

A
  • HAQ measures functional ability and the response to treatment
  • DAS28 involves assessing 28 joints and assigning points for: swollen joints, tender joints, ESR/CRP result
27
Q

in women experiencing a symptom flare for RA during pregnancy, which drugs would be offered and which wouldn’t

A
  • hydroxychloroquine and sulfasalazine (+ extra folic acid)
  • methotrexate and leflunomide are teratogenic!
28
Q

what is the function of TNF

A

cytokine involved in stimulating inflammation

29
Q

what are the 4 main biologics to remember for treating RA

A
  • adalimumab
  • infliximab
  • etanercept (above 3 are TNF-inhibitors)
  • rituximab (monoclonal antibody that targets CD20 proteins on the surface of B cells)
30
Q

what are the risks of monoclonal antibodies

A
  • cause immunosuppression
  • increasing risk of infection
  • risk of certain cancers e.g. skin
  • reactivation of latent TB
31
Q

how does leflunomide work

A

immunosuppresant which interferes w the production of pyrimidine (important component of RNA/DNA synthesis)

32
Q

how does hydroxychloroquine work

A

suppresses immune system by interfering w TLR
- disrupts antigen presentation
- increases the pH in lysosomes of immune cells

RHEUMATOLOGY (14 decks)

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