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Adult Clinical Medicine > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

What is RA

A
  • Chronic, symmetric, systemic disease that primarily targets the synovium
  • May have extra-articular manifestations

*can present in a variety of ways

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2
Q

Complicaitons of RA

A
  1. Leads to synovial inflammation and proliferation
  2. Loss of articular cartilage seen on xray
  3. Erosion of juxta-articular bone/osteopenia
  4. Tendon and ligament destruction

*usually triggered by something to cause the autoimmune response

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3
Q

Who does RA effect?

A
  1. Affects 1% of the adult population
  2. Females: Males (3:1)
  3. Can present in any age
    - Women: Most commonly in late childbearing years
    - Men: 50-80 years of age
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4
Q

What is the etiology of RA

A

*Etiology is unclear–environmental, genetic, or infectious

  1. 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
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5
Q

Synovial-based disease

A

RA

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6
Q

Describe the pathophysiology of RA

A
  1. Unknown antigen activates/injures synovial microvascular endothelial cells
  2. Synovial inflammation and hypertrophy: CD4+ T cells, macrophages, B cells, and plasma cells
  3. Release of inflammatory cytokines by synovial macrophages: IL-1, TNF-alpha*, IL-6**
  4. Cytokines induce fibroblasts and chondrocytes to produce PGE2, collagenase, and proteinases resulting in cartilage and bone destruction
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7
Q

Presentation of RA

A
  1. Insidious onset over weeks to months (if <6 weeks think of reactive arthritis, gout, or pseudogout)
  2. Symmetric Joint Involvement
  3. Small joints first – MCPs, PIPs, MTPs (DOES NOT INVOLVE DIPs)
  4. Then wrists, knees, elbows, ankles, hips and shoulders
  5. Pain and swelling
  6. Stiffness -Morning stiffness for at least 1 hour; gel phenomenon–> improves with activity**
    Others:
  7. Fatigue
  8. Low grade fever
  9. Wt. loss
  10. poor sleep
  11. Dry eyes/mouth
  12. affects on ADLs
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8
Q

Why are occiptal HA a problem/concern in RA

A

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)

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9
Q

What is the primary care screening tool for RA

A
  1. Significant discomfort with squeezing the MCP and MTP joints (Positive Squeeze test)
  2. Presence of 3 or more swollen joints
  3. More than 1 hour of morning stiffness
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10
Q

Signs of RA on PE

A
  1. assess joints for: (tender, synovitis, erythema, warmth) ((typically warm but not red))
  2. Deformities/ ulnar deviation that is not correctable
  3. Crepitus
  4. Decrease ROM
  5. Tenosynovitis (can be in any tendor- extensor or volar aspect of arms)
  6. Nodules -By areas w/ pressure (elbows)
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11
Q

What joints are often involved in RA?

A
  1. Small joints first – MCPs, PIPs, MTPs
  2. Then wrists, knees, elbows, ankles, hips and shoulders
  3. C-spine
  4. Spine
  5. Shoulder
  6. Elbow
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12
Q

RA in the spine puts you at risk for:

A

Compression fracture due to osteoporosis

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13
Q

RA in the elbow puts you at risk for:

A
  1. Bursitis
  2. Nerve entrapment due to synovitis
  3. nodules

**numbness in 4th and 5th digit–> ulnar nerve entrapment

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14
Q

Describe hand/wrist manifestations of RA

A
  1. Nodules,
  2. synovitis,
  3. ulnar deviation,
  4. swan neck deformities,
  5. subluxation
  6. Tenosynovitis leading to:
  7. triggering,
  8. nerve entrapment, or
  9. tendon rupture
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15
Q

describe complications of RA in the hip and knee

A

Hip:

  • Bursitis
  • Avascular necrosis of the femoral head due to GCs

Knee:
-synovial cyst/baker cyst

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16
Q

describe complications of RA in the ankles and foot

A
  1. Synovitis,
  2. cock-up toe deformities,
  3. hallux valgus,
  4. pes planus-> leads to plantar fasciitis ,
  5. tarsal tunnel (tingling in feet)
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17
Q

What labs should you order with RA

A
  1. CBC (normocytic anemia, elevated platelets)
  2. ESR (chronic) and CRP (acute)
  3. +/- Synovial fluid
  4. Anti-CCP
  5. RF
  6. 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
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18
Q

Describe the use of synovial fluid analysis in RA

A
  • Not pathognomonic for RA
  • Inflammatory with two-thirds WBC being neutrophils
  • (do for gout, pseudogout, septic)
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19
Q

Describe the use of RF for RA

A

Only + in 50%-70%
Not unique to RA
If + correlates with more severe disease

20
Q

Describe the use of anti-CCP for RA

A
  1. Confirmatory test for RF
  2. Present in 60-70%
  3. 90-98% specific for RA
  4. Correlate strongly with more aggressive/ erosive disease
  5. Can be present years before the diagnosis of RA
21
Q

Describe common hand XRAY findings of RA

A
  1. Erosive/fused joints
  2. Pencil and cup deformity– eroding down into metacarpal
  3. bone remodeling/stepping off
  4. DIPs are normal
  5. Osteopenia near joint
22
Q

What is the ACR diagnostic criteria for RA

A

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

  1. serology (-RF and antiCCP=0, low+ RF and antiCCP= 2, high+ RF and antiCCP=3)
  2. Acute phase reactants (normal CRP and ESR=0, or 1 if either abnormal)
  3. duration: (<6 weeks= 0, >6 weeks=1)
23
Q

What are considered small and large joints?

A

Small joints: MCP, PIP, wrists

Large joints: everything else (hip, shoulder, knee)

24
Q

What are poor prognosis factors?

A
  1. Functional limitations (ie. hand deformities)
  2. RF + or Anti-CCP +
  3. Erosions on x-rays
  4. Extra-articular disease
    - Interstitial lung disease, vasculitis, scleritis, rheumatoid nodules

**escalate their treatment quicker

25
Q

Rheumatoid nodules are strongly associated with __

A

RF+

*Can worsen with methotrexate therapy (usually go off methotrexate and switch to something else)

26
Q

Describe Rheumatoid nodules

A

Firm, non-tender, subcutaneous and occur over pressure points areas like elbows

27
Q

Tx of rheumatoid nodules

A

Can be removed if symptomatic or if in organs such as the lung (look for sx of SOB, cough)

28
Q

Why is it important to dx RA quickly and early?

A

better outcomes

-erosions and deformity form in the 1st yr w/o tx

29
Q

therapy for RA is directed to controlling ___

A

the synovitis which prevents joint injury

  • Choice depends on the disease severity
  • Irreversible damage
30
Q

3 categories of drugs for the tx of RA

A
  1. DMARDs
  2. Biologic
  3. GCs
31
Q

Give examples of DMARDs

A
  1. Methotrexate (PO and SQ)- chemo med (START W/ THIS)
  2. Sulfasalazine (PO)
  3. Leflumonide (PO)
  4. Hydroxychloroquine (PO)- anti-malaria med
32
Q

SE of Methotrexate

A
  1. Hair loss
  2. mouth sores
  3. CHEMO SE
    * *put on folic acid to help against these SE
33
Q

SE of Sulfasalazine

A
  1. GI upset (NSAID properties)

2. aspermia (need wash out period of 3 months if they want to get pregnant)

34
Q

SE of Lefluomide

A
  1. Skin lesion

2. hair loss

35
Q

SE of hydroxychloroquine

A
  1. Vivid dreams

2. plaque on back on eye w/ HD

36
Q

Describe how DMARDs are prescribed/managed

A
  1. Take 2-6 months to reach maximal effect (so need to give them something else for the interm)
  2. Usually used in combination with each other or Biologics
  3. Require regularly monitoring
    - Methotrexate, Sulfasalazine and Leflunomide – labs every 6 weeks to 12 weeks
    - Hydroxychloroquine – eye exams every year for retinal toxicity
37
Q 
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)
A

Biologics

38
Q

Must have PPD placed before initiation and if any exposure to TB prior to starting

A

Biologics

*Meds target TNF-alpha- and if you give them this med w/ latent TB then they can get dissemenated TB

39
Q

Describe how biologics are prescribed/managed

A
  1. Take days to weeks to reach affects
  2. Greater efficacy if combined with methotrexate
  3. need PPD in place before initiation
40
Q

Cons of biologics

A
  1. very costly,
  2. unknown long-term toxicities,
  3. increased risk of infection (hepatitis B)
41
Q

Describe the use of Prednisone, NSAIDs, and intra-articular GCs for RA

A

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
42
Q

Describe other tx modalities for RA

A
  1. PT
  2. Bone mass/DEXA Scans, Ca2+ + Vit. D.
  3. Stop smoking- can worsen dz
  4. Assess CV risk
  5. Monitor for infection
  6. flu shot
  7. Pneumovax, check Hepatitis B status
43
Q

What vx can you get while on DMARDs

A

Once on DMARDs cannot get live vaccines (ie. need flu shot- non-active)

44
Q

What is the max dose of Methotrexate you can prescribe?

A

25mg/week

45
Q

How often do you get Xrays of hands and feet w/ RA

A

every year

Adult Clinical Medicine (26 decks)

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