Rheumatoid Arthritis Flashcards
What is RA
- Chronic, symmetric, systemic disease that primarily targets the synovium
- May have extra-articular manifestations
*can present in a variety of ways
Complicaitons of RA
- Leads to synovial inflammation and proliferation
- Loss of articular cartilage seen on xray
- Erosion of juxta-articular bone/osteopenia
- Tendon and ligament destruction
*usually triggered by something to cause the autoimmune response
Who does RA effect?
- Affects 1% of the adult population
- Females: Males (3:1)
- Can present in any age
- Women: Most commonly in late childbearing years
- Men: 50-80 years of age
What is the etiology of RA
*Etiology is unclear–environmental, genetic, or infectious
- Likely due to an unknown antigen(s) that trigger the response in a genetically susceptible patient
- Genetic susceptibility – 30 loci currently identified (HLA-DRB1 strongest)
- Antigens – viruses (Parvovirus*, EBV)
- Smoking or periodontal inflammation –> associated with anti-CCP
Synovial-based disease
RA
Describe the pathophysiology of RA
- Unknown antigen activates/injures synovial microvascular endothelial cells
- Synovial inflammation and hypertrophy: CD4+ T cells, macrophages, B cells, and plasma cells
- Release of inflammatory cytokines by synovial macrophages: IL-1, TNF-alpha*, IL-6**
- Cytokines induce fibroblasts and chondrocytes to produce PGE2, collagenase, and proteinases resulting in cartilage and bone destruction
Presentation of RA
- Insidious onset over weeks to months (if <6 weeks think of reactive arthritis, gout, or pseudogout)
- Symmetric Joint Involvement
- Small joints first – MCPs, PIPs, MTPs (DOES NOT INVOLVE DIPs)
- Then wrists, knees, elbows, ankles, hips and shoulders
- Pain and swelling
- Stiffness -Morning stiffness for at least 1 hour; gel phenomenon–> improves with activity**
Others: - Fatigue
- Low grade fever
- Wt. loss
- poor sleep
- Dry eyes/mouth
- affects on ADLs
Why are occiptal HA a problem/concern in RA
C1-C2 subluxation – erosion of the odontoid
Brainstem impingement
axis and atlas can erode and protude to the –> get Xray of C-spine to look for suplaxation)
What is the primary care screening tool for RA
- Significant discomfort with squeezing the MCP and MTP joints (Positive Squeeze test)
- Presence of 3 or more swollen joints
- More than 1 hour of morning stiffness
Signs of RA on PE
- assess joints for: (tender, synovitis, erythema, warmth) ((typically warm but not red))
- Deformities/ ulnar deviation that is not correctable
- Crepitus
- Decrease ROM
- Tenosynovitis (can be in any tendor- extensor or volar aspect of arms)
- Nodules -By areas w/ pressure (elbows)
What joints are often involved in RA?
- Small joints first – MCPs, PIPs, MTPs
- Then wrists, knees, elbows, ankles, hips and shoulders
- C-spine
- Spine
- Shoulder
- Elbow
RA in the spine puts you at risk for:
Compression fracture due to osteoporosis
RA in the elbow puts you at risk for:
- Bursitis
- Nerve entrapment due to synovitis
- nodules
**numbness in 4th and 5th digit–> ulnar nerve entrapment
Describe hand/wrist manifestations of RA
- Nodules,
- synovitis,
- ulnar deviation,
- swan neck deformities,
- subluxation
- Tenosynovitis leading to:
- triggering,
- nerve entrapment, or
- tendon rupture
describe complications of RA in the hip and knee
Hip:
- Bursitis
- Avascular necrosis of the femoral head due to GCs
Knee:
-synovial cyst/baker cyst
describe complications of RA in the ankles and foot
- Synovitis,
- cock-up toe deformities,
- hallux valgus,
- pes planus-> leads to plantar fasciitis ,
- tarsal tunnel (tingling in feet)
What labs should you order with RA
- CBC (normocytic anemia, elevated platelets)
- ESR (chronic) and CRP (acute)
- +/- Synovial fluid
- Anti-CCP
- RF
- HepC
* *Do not order an ANA (ONLY GET ANA TO confirm suspicion for SLE)
* *Do not need positive labs to confirm dx if hx and PE are suggestive
Describe the use of synovial fluid analysis in RA
- Not pathognomonic for RA
- Inflammatory with two-thirds WBC being neutrophils
- (do for gout, pseudogout, septic)
Describe the use of RF for RA
Only + in 50%-70%
Not unique to RA
If + correlates with more severe disease
Describe the use of anti-CCP for RA
- Confirmatory test for RF
- Present in 60-70%
- 90-98% specific for RA
- Correlate strongly with more aggressive/ erosive disease
- Can be present years before the diagnosis of RA
Describe common hand XRAY findings of RA
- Erosive/fused joints
- Pencil and cup deformity– eroding down into metacarpal
- bone remodeling/stepping off
- DIPs are normal
- Osteopenia near joint
What is the ACR diagnostic criteria for RA
Score >6
1. Joint involvement: (1 large joint=0, 2-10 large=1, 1-3 small=2, 4-10 small w/ or w/o large=3, >10 joints (at least 1 small)=5
- serology (-RF and antiCCP=0, low+ RF and antiCCP= 2, high+ RF and antiCCP=3)
- Acute phase reactants (normal CRP and ESR=0, or 1 if either abnormal)
- duration: (<6 weeks= 0, >6 weeks=1)
What are considered small and large joints?
Small joints: MCP, PIP, wrists
Large joints: everything else (hip, shoulder, knee)
What are poor prognosis factors?
- Functional limitations (ie. hand deformities)
- RF + or Anti-CCP +
- Erosions on x-rays
- Extra-articular disease
- Interstitial lung disease, vasculitis, scleritis, rheumatoid nodules
**escalate their treatment quicker
Rheumatoid nodules are strongly associated with __
RF+
*Can worsen with methotrexate therapy (usually go off methotrexate and switch to something else)
Describe Rheumatoid nodules
Firm, non-tender, subcutaneous and occur over pressure points areas like elbows
Tx of rheumatoid nodules
Can be removed if symptomatic or if in organs such as the lung (look for sx of SOB, cough)
Why is it important to dx RA quickly and early?
better outcomes
-erosions and deformity form in the 1st yr w/o tx
therapy for RA is directed to controlling ___
the synovitis which prevents joint injury
- Choice depends on the disease severity
- Irreversible damage
3 categories of drugs for the tx of RA
- DMARDs
- Biologic
- GCs
Give examples of DMARDs
- Methotrexate (PO and SQ)- chemo med (START W/ THIS)
- Sulfasalazine (PO)
- Leflumonide (PO)
- Hydroxychloroquine (PO)- anti-malaria med
SE of Methotrexate
- Hair loss
- mouth sores
- CHEMO SE
* *put on folic acid to help against these SE
SE of Sulfasalazine
- GI upset (NSAID properties)
2. aspermia (need wash out period of 3 months if they want to get pregnant)
SE of Lefluomide
- Skin lesion
2. hair loss
SE of hydroxychloroquine
- Vivid dreams
2. plaque on back on eye w/ HD
Describe how DMARDs are prescribed/managed
- Take 2-6 months to reach maximal effect (so need to give them something else for the interm)
- Usually used in combination with each other or Biologics
- Require regularly monitoring
- Methotrexate, Sulfasalazine and Leflunomide – labs every 6 weeks to 12 weeks
- Hydroxychloroquine – eye exams every year for retinal toxicity
What category of drugs? Etanercept (SQ), Adalimumab (SQ), Infliximab (IV) Rituximab (IV) Abatacept (IV and SQ) Tocilizumab (IV) Tofacitinib (oral) Anakinra (SQ--> feels like a bee sting)
Biologics
Must have PPD placed before initiation and if any exposure to TB prior to starting
Biologics
*Meds target TNF-alpha- and if you give them this med w/ latent TB then they can get dissemenated TB
Describe how biologics are prescribed/managed
- Take days to weeks to reach affects
- Greater efficacy if combined with methotrexate
- need PPD in place before initiation
Cons of biologics
- very costly,
- unknown long-term toxicities,
- increased risk of infection (hepatitis B)
Describe the use of Prednisone, NSAIDs, and intra-articular GCs for RA
Prednisone
- Rapid onset and slow x-ray progression
- Significant long-term side effects with oral prednisone
NSAIDs
- Symptomatic relief
- GI toxicity
Intra-articular
- Suppress inflammation for several months
- More commonly done in kids
Describe other tx modalities for RA
- PT
- Bone mass/DEXA Scans, Ca2+ + Vit. D.
- Stop smoking- can worsen dz
- Assess CV risk
- Monitor for infection
- flu shot
- Pneumovax, check Hepatitis B status
What vx can you get while on DMARDs
Once on DMARDs cannot get live vaccines (ie. need flu shot- non-active)
What is the max dose of Methotrexate you can prescribe?
25mg/week
How often do you get Xrays of hands and feet w/ RA
every year
