Rheumatoid arthritis Flashcards
1
Q
Define
A
Chronic systemic inflammatory disease with symmetrical, deforming, peripheral polyarthritis
2
Q
Predisposing
A
- Genetic risk
- Environmental risk
- Autoimmune risk
3
Q
Pathophysiology
A
- Perivascular inflammaT
infiltrate (T, B, dendritic, macroP) - Neovascularisation, hemosiderin
- Organising fibrin covering synovium
and in joint space (rice bodies) - neutrophils in synovium (TH17 + number)
- osteoclasts subchondral: cysts,’erosions
osteoporosis - pannus erodes cartilage
- Eventually bridging two bones->ossifies
4
Q
Radiographic features
A
- Soft tissue swelling
- Joint space narrowing
- Erosions
- Periarticular osteoporosis
- Subluxation of joints
5
Q
Manifestation of rheumatoid vasculitis
A
Digital arteries--> peripheral ulcers, gangrene Vasa nervorum-->peripheral neuroathy Leukocytoclastic venitis--> purpura, ulcer, nail bed infarcts
6
Q
Clinical features
A
- Aged 50-55
- Female commonly
- Joint pain/swelling, symmetrical, small joints
- Morning stiffness
- Fatigue, fever, weight loss
- Pericarditis, pleurisy
7
Q
Examination
A
- Swollen MCP, PIP, wrist, MTP
- Tenosyovitis, bursitis
- Ulnar deviation
- Boutonniere and swan neck deformity
- Z deformity thumb
- Atlanto-axial subluxation
- Nodules
- Lymphadenopathy
- Vasculitis
- Fibrosing alveolitis
- Raynauds, carpal tunnel
- Peripheral neuropathy
- Splenomegaly
- Episcleritis, scleromalacia, keratoconjunctivitis
- Osteoporosis
8
Q
Investigations
A
- RF->positive in 60-70% of patients
- anti-CCP->positive in 70%
- Radiographs
- FBC->anemia, +PLT
- +ESR/CRP
9
Q
Diagnostic criteria
A
For classification purposes, patients are said to have RA if they satisfy at least 4 of these 7 criteria (criteria 1 to 4 must have been present for ≥6 weeks):
- Morning stiffness: lasting ≥1 hour before maximal improvement.
- Arthritis of 3 or more joint areas: simultaneously have had soft tissue swelling or fluid, observed by a physician. The 14 possible areas are right or left proximal interphalangeal (PIP), metacarpophalangeal (MCP), wrist, elbow, knee, ankle, and metatarsalphalangeal (MTP) joints.
- Arthritis of hands: at least 1 swollen area in a wrist, MCP, or PIP.
- Symmetric arthritis.
- Rheumatoid nodules: subcutaneous nodules over bony prominences or extensor surfaces or in juxta-articular regions observed by a physician.
- Serum rheumatoid factor.
- Radiographic changes: typical changes in posteroanterior hand and wrist radiographs; must include erosions or unequivocal bony decalcification localised in or most marked adjacent to the involved joints.
10
Q
Management
A
- Refer early to rheumatologist
- Score disease activity with DAS28
- Early use of DMARDS and biologic agents
- Steroids for acute exacerbations->don’t delay diagnosis
- NSAIDS for analgesia->try several if one doesn’t work.
In early, give fish oil + paracetamol + NSAID - Regular exercise, weight loss, diet, smoking cessation, reduce alcohol->Reduce CV risks. Consider BP/lipid management
- Regular monitoring for drug toxicity and osteoporosis and atherosclerosis->BMD, lipids, glucose, BP, BMI,waist circumference
FBC
LFTs
Opthalmologist (hydroxychloroquine) - Assess fatigue, sleep, relationships, work, social
- Patient education
- Referrals: rheumatologist, orthopedics, physiotherapist, occupational therapist, social worker
11
Q
Indicators of poor prognosis
A
- High RF and anti-CCP
- Sustained +ESR, CRP
- > 20 swollen joints
- Early functional impairment
- Erosions of imaging
12
Q
DMARD options
A
- Methotrexate + folic acid
2. Hydroxychloroquine, sulfasalazine if methotrexate contraI/not tolerated
13
Q
Biologics
A
Use if remission not acheived with DMARDS
- Abatacept
- Adalimumab
- Certolizumab
- INfliximab
14
Q
Symptom management
A
- NSAID
- Fish oil
- Paracetamol
- Codeine or tramadol
- Amitryptiline
15
Q
Causes of anemia
A
- Chronic disease
- Autoimmune hemolysis
- Feltys
