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04 Locomotor And Trauma > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

Describe rheumatoid arthritis

What is it’s distribution

Who is predominantly affected?

HLA?

A
  • Symmetrical poltnetially deforming inflammatory polyarthritis
  • Affects small joints of hands and feet; can also affect hips, elbows, and knees
  • Young adults - women 3:1
  • HLA-DR4
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2
Q

If see rheumatoid picture, how describe in technical terms?

A

Symmetrical (deforming/destructive) polyarthropathy possibly with signs of active (teno)synovitis

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3
Q

Features on dorsal aspect?

A

Dorsum

  • Soft tissue swelling
  • Spindling of proximal joints; loss of valleys between knuckles
  • Palmar subluxation - prominent ulnar styloid
  • Ulnar deviation of MCPJs
  • Rheumatoid nodules
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4
Q

Palmar aspect? (4)

Pathophysiology of swan neck, z-thumb and boutonniere

A

Palmar

  • Erythema
  • Thenar wasting (carpal tunnel)
  • Fixed flexion
  • Specific - swan neck, button hole, z-thumb

Path

  • Rheumatoid tenosynovitis
  • Button - rupture of cenral slip of extensor expansion
  • Swan - rupture of lateral slip of extensor expansion - unopposed flexion
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5
Q

How demonstrate function?

Where else look if asked to examine the hands?

A

Write out name, pick up coin, do up buttons

On elbows - nodules, psoriasis and behind ears - gouty tophi, psoriasis etc.

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6
Q

What is rheumatoid factor?

What is its main use?

What are high titres associated with?

What is a better antibody?

A
  1. RF is IgM against own IgG - present more as get older
  2. Helps with prognosis, but lots of people with classic rheumatoid are seronegative
  3. Progressive disease
  4. Anti-CCp - cyclic citrulinated peptide (collagen derived) - 95% specificity and 70% sensitivity; present in 40% seronegative RA
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7
Q

What is seronegative RA?

How many patients are seronegative?

Do they have any antibodies?

A

Absence of RF but identical disease presentation

1/3 - much less likley to have extra-articular features

Non-classical e.g. IgG to IgG

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8
Q

How do you manage RA?

A

MDT - esp Physio and OT; ROM exercises

NSAIDs

Low dose corticosteroids possible while waiting for DMARDs to work

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9
Q

What does DMARD stand for?

Examples of DMARDs

Start early and treat aggressively!

A

Disease modifying anti-rheumatic drugs

Methotrexate

Sulphasalazine

Gold compounds

Penicillamine

Chloroquine

Leflunomide

Anti-TNf e.g. infliximab

Other biological agents e.g. rituximab

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10
Q

What is mechanism of action of MTX?

Other than RA, what else used in?

Contraindications to treatment?

A

Dihydrofolate reductase inhibitor that prevents folate reduction –> reduces amount of important cofactor in DNA synthesis. i.e. interferes with DNA synthesis

Psoriasis, Crohn’s, Cancer (different dose)

Severe blood disorders, immunodeficiency, pregancy/trying to get pregnant M+F, breastfeeding

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11
Q

MTX

Common side-effects

Serious side-effects

What drugs increase levels and therefore toxicitiy?

Dose?

A

Mucositis, GI upset, skin reactions

Bone marrow suppression, Hepatotoxicity, neurotoxicity, pulmonary fibrosis/pneumonitis

NSAIDs, trimethoprim, Co-trimoxazole

~10mg once weekly, always give with folic acid 5mg

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12
Q

MTX

What blood tests need to be done pre-Rx?

How should someone on MTX be monitored?

A
  • FBC, U+E, creatinine, LFT, CXR
  • FBC fortnightly for 6/52 after each dose change, then monthly
  • LFT fortnightly
  • U+E 6-12 monthly, unless suspect bigger problem
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13
Q

With patient on MTX, what are red flags that should lead to discussion with doctor?

A
  • Any sign of infection, rash or oral ulceration
  • Signs of blood dyscrasia - e.g. abnormal bruising, infection
  • WBC <4, NPhils <2, Plt < 150, MCV > 105
  • > 2 fold rise in AST/ALP
  • Rise within normal rage should suggest further investigation
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14
Q

When use sulphasalazine

How long does it take to become effective?

What is DRESS?

Monitoring?

A
  1. 1st/2nd choice in mild/mdoerate disease
  2. 3 months
  3. Drug rash, eosinophilia, systemic symptoms –> hypersensitivity reaction that can be induced by sulfa
  4. 3 monthly, blood profile, LFTs etc. because can cause GI upset, BMS, deranged LFTs
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15
Q

Indications for steroids in RA?

>10 side effects?!!

A
  • Control of acute flare; adjunct; tide over while DMARD takes effect
  1. Increased appetitie –> weight gain
  2. Hyperglycaemia/DM
  3. Cushings –> addisonian crisis on withdrawal
  4. Osteoporosis
  5. Psychosis
  6. Bruising
  7. Skin thinning
  8. Infection
  9. Ulcers
  10. Delayed wound healing
  11. Glaucoma/cataracts
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16
Q

Gold - main risk?

Hydroxychloroquine - best for?

What used in 2-5% of patients?

What is MOA of leflunomide and when use?

A

BMS and Nephrotic syndrome

SLE - not really used in RA

Azathiprine or cyclosporin A

Pyrimidine antagonist - used after MTX but before CyA

17
Q

what is TNF alpha?

Give examples of anti-TNF agents - when are they used?

What are absolute CI, and what must be checked beforehand?

Other targets? When use?

A

Acute phase Immune Cytokine produced predominantly by macrophages; intrinsically involved in RA mediated inflammation

Infliximab, Adalimumab (self adminster), Etanercept, Certolizumab; Used if ≥2 2nd line agents fail; Also used in Psoriatis ± Arthritis, ank spond, Crohn’s, Behcets

Previous TB - can be reactivated; and any current severe infection. Check beforehand full haem/bio profile, autoantibodies and also Demyelination (can be effect of treatment)

CD-20 Bcell receptor - Rituximab. In those on MTX who fail with TNF biological

18
Q

Atlanto-axial subluxation

Why does it occur?

What is consequence? If occurs suddenly?

What consideration required pre-op?

A
  • Due to rheumatoid tenosynovitis causing weakening
  • Odontoid peg can slip back, causing compression of spoinal cord - progressive spatic tetraparesis
  • If compresison is sudden - risk of cardiac arrest cos of vagus stimulation
  • Lateral upper cervial spine x-ray in moderate flexion (? + open mouth view)
19
Q

X-ray changes seen in RA? spades

A

Soft tissue swelling

Peri-articular OP

Absence of osteophytes

Deformity

Erosions

Subluxation

20
Q

Extra-articular manifestations of RA

facebooks

A

Felty’s - splenomegaly and pancytopaenia

Atlanto-axial subluxation

Caplan’s - coal miners

Effusions - e.g. pleural

Blood - anaemia

Olecranon bursitis

Oral dryness - sicca

Kidney s- amyloid, gold, penicillamine

Sensory neuropathy

04 Locomotor And Trauma (8 decks)

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