Rheumatoid arthritis

Question 1

Rheumatoid arthritis

Answer 1

a chronic systemic inflammatory disease whose major manifestation is synovitis of multiple joints

Question 2

What is the prevalence of RA and age of onset

Answer 2

1% and can begin at any age

Question 3

Clinical presentation

Answer 3

symmetric swelling of multiple joints, tenderness and pain, stiffness >30 mins prominent in the am, recurring after daytime inactivity, and severe after strenuous activity

Question 4

Common joints affected in RA

Answer 4

PIP joints of fingers, MCP, wrists, knees, ankles, and MTP most often

Question 5

20% of pts have

Answer 5

subcutaneous rheumatoid nodules, commonly over bony prominences but also in bursae and tendon sheaths

Question 6

Labs

Answer 6

Anti-CCP (most specific), RF, ANA

Question 7

Rheumatoid factor

Answer 7

IgM ab directed against the Fc fragment of IgG, can occur in other autoimmune diseases including hep C, syphilis, TB, present in 70-80% of pts w/ established RA, not as sensitive in early stages

Question 8

Imaging

Answer 8

specific, obtained during first 6 months, but usually normal, earliest changes occur in wrists or feet, later diagnostic changes of uniform joint space narrowing and erosions develop

Question 9

Treatment objectives

Answer 9

reduce inflammation, preservation of function, prevention of deformity, joint rest, ice/heat, exercise, wt loss

Question 10

Treatment success

Answer 10

requires early, effective pharm intervention, DMARD should be started as soon as diagnosis is certain

Question 11

NSAIDs

Answer 11

provide symptomatic relief but do not prevent erosions or alter progression, only use in conjunction with other meds

Question 12

Corticosteroids

Answer 12

low doses produce anti-inflammatory effect in RA and slow rate of articular erosion, multiple side effects limit long-term, often used as bridge for DMARDs to take effect

Question 13

Methotrexate

Answer 13

initial synthetic DMARD, tolerated well and beneficial in 2-6 weeks

Question 14

Side effects of methotrexate

Answer 14

gastric irritation, stomatitis, cytopenia, bone marrow suppression, hepatotoxicity

Question 15

Lab monitoring with methotrexate

Answer 15

base line liver, monitor every 3 mon, CBC, HCG, kidney fun, glucose

Question 16

Sulfasalazine

Answer 16

second line drug, do not give if ASA sensitive

Question 17

Side effects of sulfalazine

Answer 17

neutropenia/ thrombocytopenia in 10-25%, HEMOLYSIS WITH g6pd DEFICIENCY

Question 18

monitoring for sulfalazine

Answer 18

G6PD, CBC every 2-4 weeks for first 3 months then every 3 mon

Question 19

Leflunomide

Answer 19

pyrimidine synthesis inhibitor

Question 20

Side effects of leflunomide

Answer 20

diarrhea, rash, alopecia, hepatotoxicity, wt loss, teratogenic

Question 21

Antimalareals

Answer 21

hydroxychloroquine sulfate is antimalarial agent often used, monotherapy only in mild disease, often in combo with DMARDs

Question 22

Side effects of antimalareals

Answer 22

pigmentary retinitis which leads to visual loss, opthalmologic exam once/year

Question 23

Minocycline

Answer 23

more effective than placebo, reserved for early mild cases, MOA unclear

Question 24

TNF inhibitors

Answer 24

frequently added when pts do not respond to DMARDS or poor prognosis, etanercept, infliximab, abalimumab, golimumab, certilzumab pegol

Question 25

TNF inhibitor cautions

Answer 25

increases risk of serious bacterial infection and granulomatous infection, reactivation of TB, should stop if develop fever, extreme caution in CHF

Question 26

Course and prognosis

Answer 26

Months-years, deformities occur, ulnar deviation, boutonniere deformity, swan neck deformity, valgus deformity of knee, volar subluxation of MTPs

Question 27

Adverse effects of RA

Answer 27

mortality associated with RA is largely due to CVD