Rheumatoid Arthritis Flashcards
sero positive or negative
seropositive inflammatory arthropathy
define RA
symmetrical inflammatory arthritis affecting mainly the peripheral joints, which if untreated can lead to joint damage and irreversible deformities leading to loss of function
epidemiology
women>men. can occur in any age group. the prevalence is increased in smokers
aetiology
cause is unknown, potential triggers include smoking, infections and stress
is there a genetic predisposition
yes - HLA-DR4 mediated
pathology
immune response is initiated against the synovium which lines the synovial joints and some tendons.
inflammatory pannus forms and then attacks and denudes cartilage leading to joint destruction.
what joints in the spine are lined by synovium
C1 and C2
what phalangeal joint is not lined by synovium
DIP
what can happen to the tendons
can rupture and soft tissue damage can occur - joint instability and subluxation
what scoring system is used for diagnosis
ACR/EULAR
what is early RA defined as
less than 2 years since symptom onset
when is the therapeutic window of opportunity
first 3 months
clinical features
prolonged morning stiffness that improves with exercise
symmetrical synovitis (doughy swelling)
involvement of small joints of hands and feet
what is a compression test
positive for MCP and MTP
painful if joints are squeezed
what is it called when synovitis occusr in tendon sheath
tenosynovitis
name some more features of RA
tenosynovitis
trigger finger
carpal tunnel syndrome (compression of medial nerve by synovial tissue bilaterally)
polymyalgia rheumatica
what is palindromic rheumatism
RA that comes and goes, patient is fine between episodes
name 2 late features in aggressive/untreated disease
swan neck deformity
Boutonniere’s
describe the nodules that can be found as an extra articular manifestation
rheumatoid nodules found on extensor surfaces or areas of frequent mechanical irritation
describe other organ features
lung - pleural effusions, interstitial fibrosis or pulmonary nodules
CVS morbidity and mortality increased
occular involvement
Caplan’s syndrome
rheumatoid arthritis and pneumoconiosis
combination of inhaled dust and disturbed immunity of RA that manifests as intrapulmonary nodules
occurs particularly in coal worker’s pneumoconiosis
auto antibodies
rheumatoid factor
anti-CCP
anti-CCP antibodies after treatment and associations
can remain positive despite treatment, also associated with current or previous smoking
inflammatory markers
CRP, ESR and PV normally raised
imaging options
x ray
US
MRI
x ray
at onset of disease will show no joint abnormality
can sow peri articular osteopaenia (bone thinning), soft tissue swelling, joint space narrowing and erosions later in disease
US
useful in detecting synovial inflammation if there is uncertainty
useful for making treatment changes
MRI
bone marrow oedema can precede erosion in inflammatory joint disease
can distinguis synovitis from effusions
detect erosions early
monitor disease activity
but expensive
what are the aims of treatment
relieving symptoms and preventing disease progression
when should DMARD therapy be commenced
within 3 months of symptom onset
steroids can be used in the time that DMARDs take to have effect
what scoring system is used to determine whether patients qualify for therapy
DAS 28 score
composite score of tender and swollen joint count, CRP/ESR and visual analogue score
what DAS 28 score suggests remission
<2.6
what DAS 28 score suggests active disease
>5.1
- 2-5.1 moderate
- 6-3.2 low
outline treatment
DMARDs given - methotrexate is first line
steroids, NSAIDs, analgesia given while DMARD is taking time to work
if DMARD doesnt work (patient has tried 2 different types) patient may qualify for biologic therapy
what does DMARD therapy include
methotrexate is first line
also sulphasalazine, hydroxychloroquine, leflunomide
what side effects can DMARDs have
mostly IS
can inc risk of infection and cause bone marrow suppression
regular blood monitoring is therefore required
what effect on pregnancy do DMARDs have
methotrexate is teratogenic - must be stopped 3 months before conceiving, and appropriate contraception advised. has no effect on fertility however
sulphasalazine can be used throughout pregnancy
if patient doesnt respond to DMARD therapy
biological therapy - anti - TNF alpha drugs
what can untreated RA lead to
joint damage and deformities: swan necking and Boutonniere’s
atlanto-axaial subluxation resulting in cervical cord compression
trigger finger
tendon becomes swollen and inflamed and catches in the tendon sheath - difficult to move and clicking sensation
what is the first line DMARD
methotrexate
sulphasalazine is added on
how is patient disease monitored
DAS 28 score
what must be taken with methotrexate
folic acid
adverse effects of methotrexate
pneumonitis
teratogenic
alcohol intake must be limited as methotrexate also affects the liver
rash/mouth ulcers
what qualifies patients for biologic therapy
disease doesnt respond to DMARD therapy - 2 drugs tried
DAS 28 score > 5.1
what are the adverse affects of biologic drugs
reactivate latent TB
inc risk of skin cancer
inc risk of infection
