Rheumatoid Arthritis Flashcards
What is rheumatoid arthritis?
Autoimmune condition causing chronic inflammation of the synovial membrane of joints, tendon sheaths and bursa
What is rheumatoid arthritis?
Autoimmune condition causing chronic inflammation of the synovial membrane of joints, tendon sheaths and bursa
What joints are typically affected by rheumatoid arthritis?
Multiple small joints symmetrically
What are some risk factors for having rheumatoid arthritis?
Female
Smoking
Obesity
HLA DR4 gene
What are the 2 autoantibodies that are normally positive in patients with rheumatoid arthritis?
Rheumatoid factor
Anti-CCP (anti cyclic citrulinated peptide)
How does Rheumatoid factor lead to pathology in patients with rheumatoid arthritis?
Rheumatoid factor attaches to the Fc portion of the patients own IgG leading to systemic inflammation
How does rheumatoid arthritis typically present?
Middle aged female
Morning stiffness of joints > 60mins
Joint pain
Overall malaise/fatigue
Swollen joints
What are the 3 general changes that happen to joints due to rheumatoid arthritis?
Pain
Stiffness
Swelling
What are the most commonly affected joints with rheumatoid arthritis?
MCPJs
PIPJs
Wrist
MTPJs
How does an osteoarthritic joint feel different to a rheumatoid arthritic joint?
Osteo = hard
Rheumatoid = soft, boggy and painful
What is palindromic rheumatism?
When theres self limiting epsiodes of inflammatory arthritis (pain, swelling and stiffness of joints) that resolve. Joints appear normal between episodes.
If Rheumatoid factor and anti-CCP is elevated it likely means it will develop to full Rheumatoid arthritis
What are some deformities of the hand that can be caused by advanced rheumatoid arthritis?
Z shaped deformity to thumb
Swan neck deformity
Boutonnière deformity
Ulnar deviation of fingers at MCP joints
What is swan neck deformity?
Hyperextended PIP
Flexed DIP
What is boutonnière deformity?
Flexed PIP
Hyperextended DIP
(Opposite to swan neck)
What is the pathophysiology of boutonnière deformity?
Flexed PIP
Hyperextended DIP
Central slip of extensor tendon gets damaged leading to the lateral slips migrating to the volar aspect of the hand leading to Flexion at the PIP but hyperextension at the DIP
What changes to the spine can you have as a result of rheumatoid arthritis?
Atlantoaxial subluxation
Where synovitis damages the ligaments around the Odontoid peg of the axis C2 so it can shift
What is a dangerous complication of atlantoaxial subluxation due to RA?
Spinal cord compression
What are some extras articular manifestations of rheumatoid arthritis?
Pulmonary fibrosis
Feltys syndrome
Sjögren’s syndrome (sicca)
Anaemia of chronic disease
CVS disease
Eye manifestations
Rheumatoid nodules
Amyloidosis
Carpal tunnel
What is feltys syndrome/triad?
Rheumatoid arthritis
Neutropenia
Splenomegaly
What are some eye manifestations of rheumatoid arthritis?
Keratoconjunctivitis sicca (Dry eye syndrome)
Episcleritis
Scleritis
Keratitis
Cataracts (secondary to steroids)
Retinopathy
What DMARD can cause retinopathy?
Hydroxychloroquine
What is the criteria for diagnosing rheumatoid arthritis?
Morning join stiffness and pain
Duration > 6weeks
Elevated CRP and ESR
Serology for Anti-CCP and Rheumatoid factor
How is the classification criteria for diagnosing rheumatoid arthritis scored?
Score 6 or more = Definte rheumatoid arthritis
What investigations do you do if you suspect a patient might have rheumatoid arthritis?
Routine bloods
CRP + ESR
Rheumatoid factor
Anti-CCP
Hand X-ray to check for bone changes
Ultrasound to identify synovitis (inflammation of joints)
What are some changes you might see on x-ray in a pateitn with rheumatoid arthritis?
Loss of joint space
Erosions of bone
See through bones (oestopenia)
Soft tissue swelling
What is the management for a patient presenting with rheumatoid arthritis?
Short term corticosteroids (PO or IM) to settle flare
Then manage with DMARDs
If ineffective with just one can try a combination of DMARDs
If a combination of DMARDs fails move to biologics
Can give NSAIDs for pain relief but can cause side effects and complications
What is the first line DMARD given for rheumatoid arthritis?
What are some others?
Methotrexate
Sulfasalazine
Leflunomide
What is the mildest DMARD that can be used to treat mild rheumatoid arthritis or palindromic rheumatism?
Hydroxychloroquine
What are some combination DMARDs that can be used if 1st line mono therapy DMARDs are ineffective?
Azathioprine
Mycophenolate
Cyclophosphamide (dangerous)
Cyclosporin
When is methotrexate not the first line DMARD given in rheumatoid arthritis?
Patient is PREGNANT
Leflunomide also not suitable
Why is methotrexate not the first line drug if pregnant?
Its teratogenic
Inhibits Dihydrofolate reductase which inhibits the synthesis of folic acid
What are the safest DMARDs that can be given to Rheumatoid arthritis patients who are pregnant?
Sulfasalazine
Hydroxychloroquine
What supplement should be given to patients on methotrexate?
Folic acid
What is are some examples of biologics that can be used for rheumatoid arthritis?
Infliximab
Rituximab
What are some side effects to methotrexate?
Bone marrow suppression + leukopenia
Teratogenic
Interstitial lung disease
Liver toxicity
Moth ulcers and mucositis
How much folic acid is taken a week when on methotrexate?
5mg once a week
How dos Leflunomide act as a DMARD?
Immunosuppressant that interferes with pyrimidine production
What are some side effects of Leflunomide?
Hypertension
Peripheral neuropathy
Teratogenic
Bonemarrow suppression + leukopenia
Liver toxicity
Mouth ulcers and mucositis
What are the side effects of Sulfasalazine?
Orange urine (like Rifampicin)
REVERSIBLE MALE INFERTILITY
Bone marrow suppression
What are the side effects of hydroxychloroquine?
Retinal toxicity (reduces visual acuity so damage to macular)
Blue grey skin pigmentation
Hair bleaching
What are some side effects of rituximab?
Night sweats
Thrombocytopenia
What is the scoring system used to monitor the effectiveness of treatment of rheumatoid arthritis?
DAS-28
What does the DAS-28 scoring system take into account?
How patient feels (swollen, pain joints)
How many joints involved (…/28)
ESR and CRP results
What DAS-28 score is considered in remission for Rheumatoid Arthritis?
Less than 2.6
How can a complication of rheumatoid arthritis mimic a DVT?
Can lead to the rupture of a bakers cyst that looks like the swollen calf you get with a DVT
Why is cyclophosphamide usually only reserved for life/limb threatening events?
What is the reversal for this?
Can cause Haemorrhagic cystitis
Treated with MESNA
What eye issue can hydroxychloroquine cause?
Bullseye maculopathy
