Rheumatoid Arthritis Flashcards by Callum Donoher

What is rheumatoid arthritis?

Autoimmune condition causing chronic inflammation of the synovial membrane of joints, tendon sheaths and bursa

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What is rheumatoid arthritis?

Autoimmune condition causing chronic inflammation of the synovial membrane of joints, tendon sheaths and bursa

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What joints are typically affected by rheumatoid arthritis?

Multiple small joints symmetrically

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What are some risk factors for having rheumatoid arthritis?

Female
Smoking
Obesity
HLA DR4 gene

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What are the 2 autoantibodies that are normally positive in patients with rheumatoid arthritis?

Rheumatoid factor
Anti-CCP (anti cyclic citrulinated peptide)

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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

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How does rheumatoid arthritis typically present?

Middle aged female
Morning stiffness of joints > 60mins
Joint pain
Overall malaise/fatigue
Swollen joints

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What are the 3 general changes that happen to joints due to rheumatoid arthritis?

Pain
Stiffness
Swelling

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What are the most commonly affected joints with rheumatoid arthritis?

MCPJs
PIPJs
Wrist
MTPJs

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How does an osteoarthritic joint feel different to a rheumatoid arthritic joint?

Osteo = hard

Rheumatoid = soft, boggy and painful

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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

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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

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What is swan neck deformity?

Hyperextended PIP
Flexed DIP

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What is boutonnière deformity?

Flexed PIP
Hyperextended DIP

(Opposite to swan neck)

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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

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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

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What is a dangerous complication of atlantoaxial subluxation due to RA?

Spinal cord compression

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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

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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