Rheumatoid Arthritis Flashcards
What type of disease is RA?
What does it target?
- Autoimmune, chronic systemic
- Inflammatory disease, symmetrical
- Targets synovial tissues, diarthrodial joints
- Polyarthritis, extra-articular features
- Idiopathic
Systemic features of RA
- systemic sx
- non specific labs
- constitutional sx
• Fatigue, fever, anemia
• Elevated acute phase reactants (ESR, CRP)
• Constitutional symptoms – malaise, myalgia,
depression
• Affected joints are swollen, warm and tender over PIP and MCP joints
Immunopathology/pathogenesis of RA (two)
- RF produced by RA synovium. RF’s fix complement. Complement consumed in RA joint; recruit PMN’s.
- Anti-cyclic citrullinated peptides
“B” lymphocytes produce autoantibodies, cytokines (TNF alpha, IL-1, IL6), pro-inflammatory cytokines synovial proliferation, increase synovial fluid, leads to ___ that invades cartilage and bone.
leads to pannus in RA
Lab tests to order for RA dx
- ESR/CRP
- RF
- ACCP
- ANA
- Hepatitis panel
- CBC
What two imaging tests should be ordered in RA - to detect what?
EROSION DETECTION!
• X-rays of hands and feet – detect symmetrical involvement of MCP/MTP joints; erosions
• CT – more sensitive detecting erosions
4 treatment progressions of RA
- Begin NSAID for pain control
- Early use of DMARD
- May need low dose of steroid for a few weeks
- Monitor progress and toxicity
Three types of Rheumatoid Synovitis
Bursitis, tendinitis, synovitis
Significant cause of mortality in RA
! Heart disease (60%) - CAD, HF, pericarditis due to endothelial damage from chronic inflammation !
- Malignancy (20%)
- Infection (9.4%)
- Renal disease (7.8%)
- GI disease (4%)
Who should be tested for RA? Classification criteria
What is definite RA?
- Have at least one (1) joint with definite clinical synovitis
- With synovitis not better explained by another disease
A score > 6/10 = definite RA
Serology + APR + Duration of Symptoms
Describe articular manifestations of RA.
- Typically starts in hands/feet (MCP, PIP, MTP)
- Later = larger joints, wrists, knees, elbows, ankles, hips, shoulders
Part of spine that is affected by RA
C1-C2
define swan neck and boutonniere
• Swan neck (hyperextension of PIP joints)
• Boutonniere (button hole
deformity) (hyperflexion of PIP joints)
Rheumatoid nodules = RF+/-?
RF+ always
Baker cysts
RF nodules in knee/popliteal
**Describe clinical manifestations of RA - describe the PE of joints, what type of joints, what time of day? Is this abrupt or insidious?
- Pain, swelling, warmth in multiple small joints (less than 3) of hands and/or feet
- Morning stiffness greater than one (1) year
- Less than 10% have abrupt onset of disease
**Dx of RA is active signs of inflammation for at least __ weeks.
six
**Extra-Articular Manifestations of RA
- more common in what type of RA patient
- what are the manifestations?
- More common in RF positive or Anti-CCP positive
* Skin – subcutaneous nodules; extensor surface of forearm
What is this:
Tender reddish purple papule; leads to necrotic, non-healing ulcer
pyoderm gangrenosum
What is this:
Purpura, petechial, splinter hemorrhages, digital infarct
Rheumatoid vasculitis
What is RA + pneumoconiosis + pulm nodules?
CXR hyperlucency.
What is it due to?
Felty Syndrome. Nodular densities after exposure to coal or silica dust.
What is keratoconjuctivitis sicca?
Extra-articular manifestation of RA due to a secondary Sjogrens Syndrome or SLE (Dry eyes)
- dry eyes, damage to eye surface
- dry mouth, increased tooth decay
Tests for Sjogrens
- Ro/SS-a, La/SS-B (both associated with salivary gland involvement)
- Schirmers test (tear test)
- Slit-lamp exam
Tx for Sjogren’s Syndrome
Anti – Inflammatory &
Immunosuppressive
What is:
• RA
• Splenomegalia
• Neutropenia/anemia/thrombocytopenia
Feltys Syndrome
While there is NO SINGLE finding on PE or lab that is pathogneumonic, describe lab findings in RA
- RF positive
- Anti-CCP antibody (remember – 15%-20% of RA patients are negative for these antibodies)
- Inc. ESR or CRP parallels activity of disease
- Anemia (NC-NC, chronic)
- Thrombocytosis (acute phase reactant)
- ANA+ (30% of RA patients)
- Hyperglobulinemia
- Leukopenia / Granulocytopenia
- Low glucose in body fluids
- Synovial fluid – 2/3 PMN’s; WBC’s 5000 – 100,000/mm3
Tx of RA
Non-biologic DMARDs
Biologic DMARDs
(which can be used in pregnancy?)
No cure - treat early and to keep in remission; PT/OT
DMARD + bridging therapy (NSAIDs, then CS)
Non-biologic DMARDs:
- *PREG? YES, then use **antimalarial (hydrochlorquine) and sulfasalazine
- *PREG? NO, then use MTX, leflunomide (pyrimidine antag)
Biologic DMARDs:
(immunosuppressants etanercept, infliximab, adalimumab, rituximab)
-ANALGESICS are necessary to control pain
**Define progression of RA management
- Define extent of joint and extra-articular involvement
- Full dose of NSAID
- Early use of DMARD
- Add a biologic agent
- Low does steroids – flares/bridge
- Adequate pain management
- Monitor progress/toxicity
RA is MC secondary cause of what?
Sjogren’s (anti-SSA/B, speckled)
