Rheumatoid Arthritis

Question 1

List some useful polyarthritis diagnostic tests.

Answer 1

CBC with differential and platelets looking for chronic inflammation or anemia

ESR (mo)/CRP (days)

Cr (kidney function) LFTs, CK and UA

+/- X-rays, CCP, RF, ANA, lyme/GC in sp. scenarios

Question 2

Who typically gets RA?

Answer 2

females more then men, peak onset in the 3-5th decade

*important to diagnose early and refer for treatment

Question 3

Describe the diagnostic rheumatoid arthritis.

Answer 3

synovitis w/p alternative cause 
smaller joints
higher titers of RF and CCP (most specific)
increased ESR/CRP
duration >6weeks

Question 4

Describe how the genetic component of RA contributes to the disease.

Answer 4

HLA-DRB1 0401 “shared epitope” causes impaired presentation of self with CD4+ T cells and production of autoantibodies

risk is increased dramatically if patient smokes (36x)

Question 5

Describe histologically joint damage of RA.

Answer 5

TNFa is central in the cascade, IL-1 and IL-6 cause hypertrophy of inflammatory cells
leads to marginal erosions mediated by matrix metaloproteinases and hyperplasia of the synovial membrane caused by inflammatory cells

Question 6

What signs may you see on PE that would support diagnosis of RA?

Answer 6

rheumatoid nodules at phalangeal joints, ulnar joint and others
ulnar deviation with MCP subluxation
PIP synovitis

Question 7

What are extra-articular manifestations of RA?

Answer 7

mild/common:
rheumatoid nodules
iron deficiency anemia
Raynaud's
Sjogren- dryness

moderate/severe/rare:
scleritis, interstitial lung disease
pericarditis, pleuritic
vasculitis
Felty syndrome (splenomegaly and neutropenia)

**premature cardio-vascular disease

Question 8

List 4 disease modifying anti rheumatic drugs (DMARDs)

Answer 8

methotrexate
leflunomide
sulfasalazine
hydroxychloroquine

“triple therapy” includes MTX, SSZ and HCQ response comparable to anti-TNF meds

Question 9

What is the mechanism and risks of methotrexate?

Answer 9

PO/IM weekly with folic acid QID

blocks purine synthesis via dihydrofolate reductase step

toxicities: oral ulcers, GI upset, fatigue, cytopenias, pneumonitis, cirrhosis (esp. w/EtOH), infection risk, TERATOGENIC

monitor CBC, liver, kidney, baseline Hep B, C, CXR

Question 10

What is the mechanism and risks of leflunomide?

Answer 10

PO QID

blocks pyrimidine/purine synthesis

toxicities similar to MTX, + HTN, monitor like MTX

cholestyramine is used as binder to remove drug from circulation due to long half-life

Question 11

What is the mechanism and risks of hydroxycholoroquine?

Answer 11

works as a mild antimalarial that stabilizes lysosomes, decreases IL-1 and cell destruction

ocular toxicity (requires visual field testing), pigment and neuromyopathy

Question 12

What is the mechanism, risks and major advantage of sulfasalazine?

Answer 12

its metabolism releases an anti-inflammatory as well as an antibiotic portion

toxicity includes GI upset, liver toxicity, caution with G6PD deficiency

can be safely used in pregnancy or with alcohol

Question 13

List the antibody as well as receptor blocking anti-TNFa agents. (5 FDA approved)

Answer 13

infliximab
adalimumab
golimumab
certolizumab

entanercept

Question 14

What are the risks of TNFa inhibition?

Answer 14

infection (likely low fever response, atypical organism or disseminated TB)

heart failure or demyelination excerbation

malignancy- non melanoma skin cancer +/- lymphoma

Question 15

List biologics that work through CTLA-4, AntiCD20, Anti IL-6 and JAK inhibitor mechanisms.

Answer 15

CTLA-4 abatacept- blocks T-cell costimulation
AntiCD20 rituximab- naive B cell depletion
anti IL-6 tocilizumab
JAK inhibitor tofacitinib

Question 16

What are the risks of biologics?

Answer 16

common: injection or infusion reactions (ice and benydryl to tx.)

predispose to infection (tx with non-live vaccinations)

malignancy risk for non-melanoma skin cancer

Question 17

What preventive care should you think about in a patient with RA?

Answer 17

immunizations
pregnancy planning
exercise/funcitonal assessment
depression screening
osteoporosis screening
CAD prevention 
tobacco avoidance
C-spine clearance assessment before surgery

hold biologics if septic joint is suspected

Question 18

What are the hallmarks of fibromyalgia?

Answer 18

diffuse chronic pain

can include: migrating burning, tender skin +/- flares
fatigue and sleep disruption common
ROS globally positive for pain: headaches, IBS, TMJ

Question 19

Discuss diagnostic and treatment recommendations for fibromyalgia.

Answer 19

dx: exclude secondary causes of fatigue or pain: TSH, Ca, Vit D, OSA, Hep C

tx: sleep regulation, gentle exercise and mindfulness practices
non-narcotic pain medications (TCAs, cyclobenzaprine, gabapentin, duloxetine, pregabalin)
NO steroids