Rheumatoid arthritis Flashcards
What is Methotrexate?
Methotrexate is an antimetabolite that inhibits dihydrofolate reductase, an enzyme essential for the synthesis of purines and pyrimidines. It is considered an ‘important’ drug as it can be very effective in controlling disease, but the side effects may be potentially life-threatening.
What are the indications for Methotrexate?
Methotrexate is indicated for inflammatory arthritis (especially rheumatoid arthritis), psoriasis, and some chemotherapy for acute lymphoblastic leukaemia.
What are the adverse effects of Methotrexate?
Adverse effects include mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis.
What is the most common pulmonary manifestation of Methotrexate?
The most common pulmonary manifestation is pneumonitis, which typically develops within a year of starting treatment.
What are the symptoms of Methotrexate-induced pneumonitis?
Symptoms include non-productive cough, dyspnoea, malaise, and fever.
What precautions should women take regarding pregnancy after Methotrexate treatment?
Women should avoid pregnancy for at least 6 months after treatment has stopped.
What precautions should men take regarding pregnancy after Methotrexate treatment?
Men using Methotrexate need to use effective contraception for at least 6 months after treatment.
How should Methotrexate be prescribed?
Methotrexate should be taken weekly, and FBC, U&E, and LFTs need to be regularly monitored.
What is the starting dose of Methotrexate?
The starting dose of Methotrexate is 7.5 mg weekly.
What should be co-prescribed with Methotrexate?
Folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after the Methotrexate dose.
What interactions should be avoided with Methotrexate?
Avoid prescribing trimethoprim or co-trimoxazole concurrently, as they increase the risk of marrow aplasia. High-dose aspirin also increases the risk of Methotrexate toxicity.
What is the treatment of choice for Methotrexate toxicity?
The treatment of choice is folinic acid.
What is Methotrexate?
Methotrexate is an antimetabolite that inhibits dihydrofolate reductase, an enzyme essential for the synthesis of purines and pyrimidines. It is considered an ‘important’ drug as it can be very effective in controlling disease, but the side effects may be potentially life-threatening.
What are the indications for Methotrexate?
Methotrexate is indicated for inflammatory arthritis (especially rheumatoid arthritis), psoriasis, and some chemotherapy for acute lymphoblastic leukaemia.
What are the adverse effects of Methotrexate?
Adverse effects include mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis.
What is the most common pulmonary manifestation of Methotrexate?
The most common pulmonary manifestation is pneumonitis, which typically develops within a year of starting treatment.
What are the symptoms of Methotrexate-induced pneumonitis?
Symptoms include non-productive cough, dyspnoea, malaise, and fever.
What precautions should women take regarding pregnancy after Methotrexate treatment?
Women should avoid pregnancy for at least 6 months after treatment has stopped.
What precautions should men take regarding pregnancy after Methotrexate treatment?
Men using Methotrexate need to use effective contraception for at least 6 months after treatment.
How should Methotrexate be prescribed?
Methotrexate should be taken weekly, and FBC, U&E, and LFTs need to be regularly monitored.
What is the starting dose of Methotrexate?
The starting dose of Methotrexate is 7.5 mg weekly.
What should be co-prescribed with Methotrexate?
Folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after the Methotrexate dose.
What interactions should be avoided with Methotrexate?
Avoid prescribing trimethoprim or co-trimoxazole concurrently, as they increase the risk of marrow aplasia. High-dose aspirin also increases the risk of Methotrexate toxicity.
What is the treatment of choice for Methotrexate toxicity?
The treatment of choice is folinic acid.
What are some respiratory complications of rheumatoid arthritis?
Pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy
What are the ocular complications associated with rheumatoid arthritis?
Keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, chloroquine retinopathy
What is a common complication of rheumatoid arthritis related to bone health?
Osteoporosis
How does rheumatoid arthritis affect heart health?
It carries a similar risk of ischaemic heart disease as type 2 diabetes mellitus
What is an increased risk associated with rheumatoid arthritis?
Increased risk of infections
What mental health issue is commonly associated with rheumatoid arthritis?
Depression
What is Felty’s syndrome?
A condition that includes rheumatoid arthritis, splenomegaly, and low white cell count
What is a less common complication of rheumatoid arthritis related to protein deposits?
Amyloidosis
What is more important for the diagnosis of rheumatoid arthritis according to NICE?
Clinical diagnosis is more important than criteria defined by the American College of Rheumatology.
What is the target population for the 2010 American College of Rheumatology criteria?
Patients who have at least 1 joint with definite clinical synovitis and with the synovitis not better explained by another disease.
What is the minimum score needed for a definite rheumatoid arthritis classification?
A score of 6 out of 10 is needed for definite rheumatoid arthritis.
What does RF stand for in the context of rheumatoid arthritis?
RF stands for rheumatoid factor.
What does ACPA stand for?
ACPA stands for anti-cyclic citrullinated peptide antibody.
What is the scoring for 1 large joint in the joint involvement category?
0
What score is given for 2 - 10 large joints in the joint involvement category?
1
What score is given for 1 - 3 small joints (with or without involvement of large joints)?
2
What score is given for 4 - 10 small joints (with or without involvement of large joints)?
3
What score is given for 10 joints (at least 1 small joint)?
5
What is the scoring for negative RF and negative ACPA in the serology category?
0
What score is given for low-positive RF or low-positive ACPA?
2
What score is given for high-positive RF or high-positive ACPA?
3
What is the scoring for normal CRP and normal ESR in the acute-phase reactants category?
0
What score is given for abnormal CRP or abnormal ESR?
1
What score is given for symptoms lasting less than 6 weeks?
0
What score is given for symptoms lasting more than 6 weeks?
1
What is rheumatoid factor (RF)?
Rheumatoid factor (RF) is a circulating antibody (usually IgM) that reacts with the Fc portion of the patient’s own IgG.
What is the recommended first-line antibody test for suspected rheumatoid arthritis?
Rheumatoid factor (RF) is recommended as the first-line antibody test for patients with suspected rheumatoid arthritis.
What tests can detect RF?
RF can be detected by the Rose-Waaler test (sheep red cell agglutination) and the latex agglutination test (less specific).
What percentage of rheumatoid arthritis patients have a positive RF?
RF is positive in 70-80% of patients with rheumatoid arthritis.
What is associated with high titre levels of RF?
High titre levels of RF are associated with severe progressive disease but are not a marker of disease activity.
What conditions are associated with a positive RF?
Conditions associated with a positive RF include Felty’s syndrome (around 100%), Sjogren’s syndrome (around 50%), infective endocarditis (around 50%), SLE (20-30%), systemic sclerosis (30%), and the general population (5%). Rarely, TB, HBV, EBV, and leprosy may also show positive RF.
What is the significance of anti-cyclic citrullinated peptide antibody?
Anti-cyclic citrullinated peptide antibody may be detectable up to 10 years before the development of rheumatoid arthritis.
What is the sensitivity and specificity of anti-CCP antibodies?
Anti-CCP antibodies have a sensitivity similar to RF (around 70%) and a much higher specificity of 90-95%.
What does NICE recommend for rheumatoid factor negative patients?
NICE recommends that patients with suspected rheumatoid arthritis who are rheumatoid factor negative should be tested for anti-CCP antibodies.
What imaging does NICE recommend for suspected rheumatoid arthritis?
NICE recommends performing x-rays of the hands and feet of all patients with suspected rheumatoid arthritis.
What percentage of rheumatoid arthritis patients have ocular manifestations?
25% of patients have eye problems.
What is the most common ocular manifestation of rheumatoid arthritis?
Keratoconjunctivitis sicca.
What are other ocular manifestations of rheumatoid arthritis?
Episcleritis, scleritis, corneal ulceration, keratitis.
What is a common iatrogenic effect of treatment for rheumatoid arthritis?
Steroid-induced cataracts.
What is another iatrogenic ocular issue related to rheumatoid arthritis treatment?
Chloroquine retinopathy.
What percentage of rheumatoid arthritis patients have ocular manifestations?
25% of patients have eye problems.
What is the most common ocular manifestation of rheumatoid arthritis?
Keratoconjunctivitis sicca.
What are other ocular manifestations of rheumatoid arthritis?
Episcleritis, scleritis, corneal ulceration, keratitis.
What is a common iatrogenic effect of treatment for rheumatoid arthritis?
Steroid-induced cataracts.
What is another iatrogenic ocular issue related to rheumatoid arthritis treatment?
Chloroquine retinopathy.
What are typical features of rheumatoid arthritis?
Swollen, painful joints in hands and feet; stiffness worse in the morning; gradually gets worse with larger joints becoming involved; presentation usually insidiously develops over a few months; positive ‘squeeze test’ - discomfort on squeezing across the metacarpal or metatarsal joints.
What are late features of rheumatoid arthritis?
Swan neck and boutonniere deformities are late features of rheumatoid arthritis and unlikely to be present in a recently diagnosed patient.
What are other presentations of rheumatoid arthritis?
Acute onset with marked systemic disturbance; relapsing/remitting monoarthritis of different large joints (palindromic rheumatism).
What are poor prognostic features in rheumatoid arthritis?
Poor prognostic features include: rheumatoid factor positive, anti-CCP antibodies, poor functional status at presentation, X-ray: early erosions (e.g. after < 2 years), extra articular features e.g. nodules, HLA DR4, and insidious onset.
Which gender is associated with a poor prognosis in rheumatoid arthritis?
Female gender is associated with a poor prognosis in rheumatoid arthritis according to both the American College of Rheumatology and recent NICE guidelines.
What are early x-ray findings in rheumatoid arthritis?
- Loss of joint space
- Juxta-articular osteoporosis
- Soft-tissue swelling
- Periarticular erosions
- Subluxation
