Rheumatoid arthritis Flashcards
RA affects any joint with a ___
synovium
F:M of RA
F3:1M
HLA ___ mediates RA
potential triggers =//_
DR4
smoking, infection stress
vertebral joint that has a synovium
C1/2
joint in the hand that doesn’t have a synovium and therefore isnt affected by RA
DIPJ
pannus =
=> __+__ erosion
in RA
macrophages and fibroblast-like mesenchymal cells, macrophages and mast cells etc
bone and cartilage
pathogenesis of RA : APC > ___ > activate __ (produce ++_ > chondrocytes =>__) + ___ (produce + > chondrocytes => __) => inflam and erosion
T cells
Macrophages - TNFα, IL1+6 => MMPs
B cells - RF + IL6 => MMPs
therapeutic window for best results in RA treatment
first 3 months
RA criteria relies on these 4 things
joint distribution (number affected)
serology
duration (>6wk)
inflammatory markers
Ix for diagnosis of RA
Hx + exam (clinical diagnosis) bloods (anaemia and raised platelets) inflam markers (CRP/ESR + PV) autoIg imaging
RA can present with this ___
= hip and shoulder pain worse in morning
polymyalgia rheumatica
if back of wrist swells in RA = ____ of ___
extensor tenosynovitis (extensor carpi ulnaris)
autoIgs in RA:
most specific =
RF anti CCP (cyclic citrullinated peptide) - most specific
anti-CCP doesnt ___ after Rx of RA and so is just ___
decrease
diagnostic
+ve anti CCP RA is more likely to be ____ and associated with ___
aggressive
erosion
anti-CCP Ig is associated with ___ as it citrullinates peptides in the ___ and causes Ig production
smoking
lung
baseline imaging for RA =
xray
xray findings of late RA
soft tissue swelling
periarticular osteopenia
erosions
imaging that has increased sensitivity for early synovitis and can catch subclinical inflammation in RA
In RA also used to make ___ changes
US
treatment changes
imaging that can see bone marrow oedema, distinguish synovitis from effusions and monitor activity of RA =
only used if ___ as is __
MRI
other tests are ineffective
costly
RA: DAS28 parameters =
used to __
number of tender and swollen joints (out of 28)
ESR+CRP
patients evaluation
monitoring activity of RA
DAS28 score of __ means RA is aggressive
> 5.1
DAS28 score of __ means RA is in remission
<2.6
treatment of RA broadly speaking =
DMARDS + steroids and NSAIDs
DMARDS =
which is first line?
principle of therapy for RA =
methotrexate (1st line)> + sulfasalazine > + hydroxychloroquine
others = leflunomide, gold injection + azathioprine
rapid escalation until remission
starting dose of methotrexate =
maximum =
must give ___ supplement with it
15mg/wk
25mg/wk
folic acid
dose of sulfasalazine =
avoid in __+__
40mg/kg/day
septrin allergy and G6PD deficiency
dose of hydroxychloroquine =
for ___ RA
200-400mg/day
palindromic
if on DMARDS then regularly monitor (4)
LFTs
FBC
CXR
contraception (teratogenic)
drug that causes an allergic pneumonitis as a possible side effect
methotrexate
only start biologics for RA if
2 DMARDS = no response
and DAS28 >5.1 on 2 occasions 4 wks apart
if giving biologics for RA screen for (5)
avoid
latent tb, HIV, hep B+C, VZV
live attenuated vaccines
biologics used in RA anti TNF = t cell receptor blocker = B cell depleter IL6 blocker Jak 2 inhibitor =
infliximab, adalimumab, etanercept, certolizumab, golimumab = TNF abatacept = T rituximab = B tocilizumab = IL6 tofacitinib = Jak2
see RA patient every ___ until remission and then every ___
1-3 months
3-6 months
if possible atlanto-axial subluxation get __+__ xrays
flexed and extended
marginal joint erosion is the hallmark of
RA
