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MSK and Soft Tissue > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

What is Rheumatoid Arthritis?

A

Chronic, symmetric, erosive synovitis of peripheral joints (wrists, MCPs, MTPs). Characterised by a number of extra articular features.

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2
Q

What is the pathophysiology of RA?

A
  • Hypertrophy of synovial membrane
  • Activated rheumatoid synovium (pannus) grows into andover the articular surface.
  • Inflammatory mediators trigger release of MMPs and colalgenases
  • Destruction of articular cartilage and subchondral bone
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3
Q

What are the theories explaining the relapsing remitting pattern of RA?

A
  • Sequestered Ag

- Molecular mimicry

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4
Q

What is the sequestered antigen theory of relapsing remitting pattern of RA?

A

-During inflammation, immune complexes are deposited at avascular cartilage-bone junction; ICs are released as further cartilage breaks down –> inflammatory cascade.

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5
Q

What is the molecular mimicry theory of RA relapsing remitting?

A

Cartilage damage -> altered cartilage resembles undefined offending agent – > triggers inflammatory cascade.

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6
Q

Epidemiology of RA?

A
  • 1% adults
  • 3F:1M
  • Onset 20-40
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7
Q

What are the genetic predispositions to RA?

A

-HLA-DR4/DR1 association

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8
Q

Joint involvement in RA?

A

Symmetric

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9
Q

Signs and symptoms of RA?

A
  • Morning stiffness
  • Joint swelling, tenderness
  • Loss of motion, instability, deformity, crepitus
  • Constitutional symptoms
  • extra-articular features
  • Complications of chronic synovitis
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10
Q

What are the complications of chronic synovitis?

A
  • Signs of mechanical joint damage: dec ROM, instability, deformity, crepitus
  • Joint deformities
  • Atlanto-axial and subaxial subluxation
  • Ruptured Baker’s cyst
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11
Q

What are the syndromes of RA?

A
  • Sjogrens: keratoconjunctivitis sicca, xerostomia (dry eyes and mouth)
  • Caplan’s: multiple pulmonary nodules and pneumoconiosis
  • Felty’s: arthritis, splenomegaly, neutropenia
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12
Q

Poor prognostic factors in RA?

A
  • Young age of onset
  • High RF titre
  • Elevated ESR
  • Activity >20 joints
  • Presence of EAF
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13
Q

Ix in RA work up?

A
  • RF
  • anti-CCP (cyclic citrullinated peptide)
  • FBE
  • ESR
  • CRP
  • Imaging: Xray / US for hands
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14
Q

Goals of RA therapy?

A

Remission or lowest possible disease activity:

  • relieve pain and stiffness
  • maintain function and lifestyle
  • prevent or control joint damage
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15
Q

What is the RA window of opportunity?

A

Early treatment with DMARDs within first 3mo of disease may allow better control / remission

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16
Q

Behavioural / lifestyle treatments of RA?

A
  • Exercise: isometrics, gentle ROM exercises during flares)

- Job modification if required

17
Q

When should DMARDs be started?

A

As soon as possible

18
Q

First line DMARD in RA?

A

Methotrexate; start asap unless CIx

19
Q

Onset of action for methotrexate?

A

8-10weeks

20
Q

What DMARDs can be added on to methotrexate therapy?

A
  • Hydoxychloroquine
  • Sulfasalazine
  • Leflunomide
21
Q

What are the biologic agents DMARDs?

A
  • TNF Inhibitors: etanercept, adalimumab, inflixamab
  • B cell inhibitor: rituximab
  • Cell adhesion inhibitor: abatacept
  • IL6 inhibitor: tocilixumab
22
Q

Systemic corticosteroid use in RA?

A

-Low dose 5-10mg/d for short term improvement in symptoms if NSAIDs ineffective to bridge gap until DMARD effect

23
Q

Considerations in initiating prolonged corticosteroid therapy?

A
  • baseline DEXA scan

- consider bone supportive pharmacologic therapy if using >3mo at >7.5mg/day

24
Q

What are the typical features of inflammatory joint pain?

A
  • Acute or subacute pain
  • May worsen quickly
  • Better after movement
  • Worse after rest
  • Swelling often prominent
  • Stiffness may last hours
  • Usually worse in morning
25
Q

What are the typical features of mechanical joint pain?

A
  • Chronic pain (months- years)
  • Slowly worsening
  • Worse with movement
  • Relieved with rest
  • Not much swelling
  • Little stiffness (10-15min)
26
Q

What is the treatment strategy of RA Mx?

A
  • NSAIDs
  • DMARDs
  • Corticosteroids
  • Analgesics
27
Q

What are the side effects of corticosteroids?

A
  • Weight gain
  • Osteoporosis
  • AVN
  • Cataracts, glaucoma
  • PUD
  • Susceptibility to infection
  • Easy bruising
  • Acne
  • HTN
  • Hyperlipidemia
  • Hypokalemia, hyerglycemia
  • Mood swings
28
Q

What are the RA disease activity measures?

A
  • Pt and Dr global assessment
  • Swollen and tender joint count
  • Measures of inflammation (ESR, CRP)
29
Q

Imaging for disease damage measure in RA?

A 
MRI more sensitive than XR: XR often not required in early Mx.
Look for:
-synovitis
-cartilage damage
-bone oedema
-bone erosions

MSK and Soft Tissue (33 decks)

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