Rheumatoid arthritis Flashcards
What markers are raised in RA?
Anti CCP (Specific) Rheumatoid Factor (Non specific)
What are some of the arthritic features of RA?
Symmetrical Polyarthritis Smaller joints - MCPs, PIPs of hands and feet Pain Swelling Deformity Prolonged morning stiffness (>1hr) Eases with exercise
What are some of the deformities associated with RA?
Swan neck - (DIP hyperflexion with PIP hyperextension)
Boutonniere - (PIP flexion with DIP hyperextension
Z - Thumb
Ulnar deviation of fingers
Dorsal subluxation of ulnar styloid
Describe the nodules associated with RA
Called rheumatoid nodules
Firm, non tender. Can be mobile or fixed
Commonly occur on the elbows, fingers and lungs
What are some of the other signs of RA in the hands? Excluding deformity, pain and nodules
Carpal tunnel syndrome
Raynaud’s syndrome
Tenosynovitis eg De Quervain’s (Effects tendons on lateral side of wrist near to thumb)
What are some of the immune complications of RA?
Lymphadenopathy
Amyloidosis
Vasculitis
What are some of the cardiac complications of RA?
Pericarditis
Pericardial effusion
What are some of the pulmonary complications of RA?
Rheumatoid nodules in the lung Fibrosing alveolitis (Lower zones) Pleural effusions (Exudate)
What are some of the opthalmic complications of RA?
Scleritis/Episcleritis
Secondary Sjogren’s Syndrome
What is Felty’s syndrome?
RA + Splenomegaly + Neutropenia
What is the diagnostic criteria for RA?
Need 4/7 of; Morning stiffness >1hr, >6 weeks Arthritis >3 joints Arthritis of hand joints Symmetrical Rheumatoid nodules \+ive Rheumatoid factor Radiographic changes
What diseases can cause a microcytic anaemia?
RA DM RCC Hepatoma Polymyalgia rheumatica *Iron deficiency is the most common cause*
What investigations can be done in a patient with suspected RA?
FBC - Anaemia, Raised CRP/ESR, Raised platelets
70% have +ve RF, if -ve called seronegative rheumatoid
High titre RF associated with severe disease
Anti CCP
ANA +ive in 30%
X-Ray
USS
MRI
What is the conservative management of RA?
Physiotherapy
Occupational therapy - Splints, Aids
Referral to rheumatologist - earlier the better as DMARDs can slow progression, only prescribed by specialists
Regular exercise
How can you monitor RA?
DAS28
RF
X-Rays
What is the medical management of RA?
DMARDs Biologics *Use early!* NSAIDs Steroids if exacerbations once reviewed by rheumatologist
What is important when managing a RA patient?
To manage their CV risk as well as RA accelerates the development of atherosclerosis
What is the surgical management of RA?
Ulna stylectomy
Joint prosthesis
What are the common side effects of all DMARDs?
Myelosuppression causing Pancytopenia
What are the side effects of Methotrexate?
Hepatotoxic
Pulmonary fibrosis
Highly teratogenic
What is the mode of action of Methotrexate?
Interferes with purine metabolism causing to accumulation of adenosine, inhibiting T cells and B cells
Interferes with folic acid and DHFR - Not main action in RA
Given once a week
What are the side effects of Sulfasalazine?
Hepatotoxic
Decreased sperm count
Stevens johnson syndrome
What is the mode of action of Sulfasalazine?
Metabolises the Mesalazine (5-ASA/5-aminosalicylic acid)
Mode of action not understood
Can be used in pregnancy
What are the two compunds combined to make Sulfasalazine?
Sulfapyridine (Antibiotic compound)
Salicylate (Anti-inflammatory compound)
What are the side effects of Hydroxychloroquine?
Retinopathy
Seizures
Not recommended in pregnancy
What is the mode of action of Hydroxychloroquine?
Reduces the activation of dendritic cells and the inflammatory process
Can also be used to treat malaria
What are some of the other DMARDs?
Gold - Can cause nephrotic syndrome
Penicillamine - Taste change, drug induced lupus
When are biologics prescribed?
In severe RA when there is no response to DMARDs
Need to screen for TB first as Anti TNF so will cause activation of TB if present
What are some of the side effects of biologics?
Increased infections - TB, opportunistic, Sepsis
Increased risk of lymphoma
Increased risk of some neurological diseases
What are some of the commonly used bioloigics?
Infliximab (Anti TNF)
Rutiximab (Anti CD20)
Adalimumab (Anti TNF)
What are the differentials for RA?
Psoriatic arthritis (Nail changes, Plaques)
Jaccoud’s arthropathy (Deforming, non errosive)
Chronic crystal arthropathies
What are the radiographic changes of RA?
Soft tissue swelling
Peri-Articular osteopenia
Deformity/Subluxation
Reduced joint space
