Rheumatoid arthritis 2 Flashcards
How is the cervical spine affected in RA?
painful stiffness of the neck is often muscular but may be something more sinister
Why does atlanto-axial subluxation occur in RA?
Rheumatoid synovitis affects the synovial joints of the cervical spine and bursa separate the odontoid peg from the anterior arch of the atlas and its retaining ligaments
Synovitis leads to joint destruction, damages the ligaments and causes atlanto-axial or upper cervical vertebral instability
Subluxation and swelling may damage the spinal cord producing pyramidal and sensory signs
How does atlanto-axial subluxation present?
painful stiffness of the neck
neurological signs, particularly sensory deficits
In late RA, difficulty walking, weakness of the legs or loss of control of the bladder/bowel may be due to spinal cord compression and is a neurosurgical emergency
How is should atlanto-axial subluxation be assessed?
MRI is the best way to visualise this but lateral flexed and extended neck x-rays can show instability
Why should RA patients have their cervical spine imaged before surgery/upper GI endoscopy?
check for instability and reduce the risk of spinal cord injury during intubation
What are the two main aims of RA treatment?
induce remission and prevent progression/damage
control symptoms
How are NSAIDs used in the treatment of RA?
to improve pain and stiffness
How are steroids used in RA?
PO pred or IM depot steroid
may be on steroids for up to 6 months to cover until DMARDs become effective
also help with pain and swelling
Remember to tail off and not stop suddenly
What are DMARDs?
Disease modifying anti rheumatic drugs are capable of suppressing disease activity and may slow joint damage
examples include methotrexate (taken once weekly) and then sulfasalazine and then hydroxychloroquinine can be added for triple therapy
How do DMARDs work?
reduced synovitis therefore improve function and reduce permanent joint damage
slow acting (may take 3-6 months to have their full effect)
effective in 70% of patients
treatment can be escalated until control of synovitis is achieved
What are the SEs and monitoring needed in DMARDs?
regular blood tests: FBC, U&Es, LFT
must keep up to date with vaccinations, and be aware of atypical infections
What are the biological therapies used in RA?
- aimed at blocking TNF activity
- work quickly
- given by injection
- most commonly infliximab, etanercept and adalumimab
- effective in 70% patients
- MORE effective if coprescribed with methotrexate
What are the SEs of biological therapies?
- require monitoring with regular blood tests
- main SE is increased risk of serious and non-serious infection particularly TB
How effective is biological therapy?
Complete remission is achieved in some patients
They are expensive but should be used first line in conjunction with methotrexate
When are injectable corticosteroids used?
have rapid onset of action and are widely used intra-articularly
v effective
