rheumatoid arthritis Flashcards
extraarticular manifestations of RA
neurologic: cervical myelopathy
hematologic: anemia of chronic disease, neutropenia, splenomegaly, Felty’s syndrome, large granular lymphocyte leuukemia, lymphooma
GI: vasculitis
skeletal: osteoporosis
ocular: ketaoconjunctivitis sicca, episcleritis, scleritis
oral: xerostomia, periodontitis
pulmonary: pleural effusions, pulmonary nodules, interstitial lung disease, pulmonary vasculitis, organizing pneumonia
cardiac: pericarditis, ischemic heart disease, myocarditis, cardiomyopathy, arrhythmia, mitral regurgitation
renal: membranous nephropathy, secondary amyloidosis
endocrine: hypoandrogenism
skin: rheumatoid nodules, purpura, pyoderma gangrenosum
nodules in RA
subcutaneous nodules, common
found in skeleton subject to repeat trauma (forearm, sacral prominence, Achilles); also lungs, pleura, pericardium, or peritoneum
- nodules typically benign, although can be ass w/ infection, ulceration and gangrene
secondary Sjögren’s syndrome
found in RA
- presence of keratocnjunctivitis sicca (dry eye)
- xerostomia (dry mouth)
pulmonary complications of RA
- most common: pleural disease (exudative pleural effusions)
- can also develop interstitial lung disease
cardiac complications of RA
- pericarditis
- cardiomyopathy (from myocarditis, CAD, or diastolic dysfunction)
- mitral regurg
vasculitis in RA
- seen in longstanding disease, + RF, and hypocomplementemia
- overall, rare
- petechiae, purpura, digital infarcts, gangrene, livedo reticularis
hematologic complications in RA
- normochromic, norrmocytic anemia that corresponds to inflammation (ESR, CRP)
- platelets may be elevated as acute phase reactant
risk of cancer in RA
- increased risk of lymphoma, usually diffuse large B-cell lymphoma
conditions associated with RA
- CVD (higher CAD, atherosclerosis, CHF)
- osteoporosis (inflammation –> generalized bone loss; also steroids and immobility)
- hypoandrogenism: low testosterone may play people at greater risk of RA, or RA may cause low testosterone
environmental factors contributing to RA
smoking
? EBV
criteria for diagnosing RA
joint involvement, serology, acute-phase reactants, duration of symptoms
RF vs anti-CCP
both have sensitivity ~80%
anti-CCP has sensitivity off 95%
utility of synovial fluid analysis in RA
confirms inflammatory arthritis (as opposed to OA) and excluding infection or crystal-induced arthritis
remission in RA
10% of pts will undergo spontaneous remission w/i 6 months (usually seronegative pts)
categories of RA treatment
- NSAIDs
- glucocorticoids (prednisone, methylpred)
- conventional DMARDs
- biologic DMARDs
NSAIDs for RA
analgesic and anti-inflammatory effect
chronic use should be minimized because of side effects (gastritis, PUD, renal dysfunction)
glucocorticoids for RA
- achieve rapid control before DMARDs kick in
- management of acute disease flares
- chronic administration for those unresponsive to DMARDs
side effects of glucocorticoids and prevention
osteoporosis, PUD
bisphosphonate for any pt getting >5mg/d for more than 3 months
what makes a DMARD? examples of conventional DMARDs
ability to slow or prevent structural progression of RA
- hydroxychloroquine, sulfasalazine, methotrexate, leflunomide
- delayed onset of action til 6-12 wks
first choice DMARD + mechanism of action
methotrexate
- stimulates adenosine release from cells, producing an anti-inflammatory effect
side effects + monitoring of hydroxychloroquine
serious: irreversible retinal damage, cardiotoxicity, blood dyscrasia
common: nausea, diarrhea, headache, rash
monitoring: eye exams every year
side effects and monitoring of sulfasalazine
serious: granulocytopenia, hemolytic aneemia (with G6PD deficiency)
common: nausea, diarrhea, headache
monitoring: CBC ~monthly
side effects and monitoring of methotrexate
serious: hepatotoxicity, myelosuppression, infection, interstitial pneumonitis, pregnancy category X
common: nausea, diarrhea, stomatitis / mouth ulcers, alopecia, fatigue
monitoring: CBC, Cr, LFTs
side effects and monitoring of leflunomide
serious: hepatotoxicity, myelosuppression, infection, pregnancy category X
common: alopecia, diarrhea
monitoring: CBC, Cr, LFTs
types of biologic DMARDs
- anti-TNF agents (infliximab, etanercept, adalimunab, golimumab, certolizumab)
- abatacept: CD28 receptor antagonist
- anakinra: IL-1 receptorr antagonist
- rituximab: antibody against CD20
- tocilizumab: antibody against IL-6
approach to treatment of RA
- methotrexate alone
- combinations: methotrexate, sulfasalazine, and hydroxychloroquine (triple therapy); methotrexate and leflunomide; methotrexate and biologic
articular signs of RA
symmetric wrists, MCP and PIP to start flexor tendon tenosynovitis swan-neck deformity butonniere deformity Z-line deformity
