rheumatoid arthritis Flashcards
The peak incidence of rheumatoid arthritis is between the _______ and _________decades of life?
Fourth and Fifth
Is Rheumatoid arthritis more common in males or females?
2.5 times more common in females
How many weeks of symptoms have to be present before a diagnosis of rheumatoid arthritis can be made?
6 weeks
Does RA include morning stiffness, fatigue and gradual improvement of stiffness as day goes on?
Yes
Is RA symmetrical and polyarticular (affecting more than one joint)?
Yes
have inflammatory synovitis (palpable/touchable synovial fluid)
What joints does RA usually affect?
wrists
MCP
PIP joints
What joints does RA NOT affect?
DIPs of the fingers
thoracolumbar spine
IPs of the toes
What do the nodules with RA typically look like?
subcutaneous or periosteal at pressure points (along where people lie on their arms)
What percentage of people will be positive for the rheumatoid factor serological test at 6 months? at 2 years?
50% at 6 months
85 % at 2 years
T/F a low titer for RF is not specific but a high titer early is a bad sign?
TRUE
What four serological markers are used for diagnosis of RA?
RF (rheumatoid factor)
Anti-CCP (Anti-cyclic citrullinated peptide antibody)
Sed rate (ESR)
CRP
If RF and Anti-CCP are positive there is a higher correlation with _____________ disease?
erosive
Marginal spacing and joint space narrowing on X-ray are also a ______________ sign of RA?
positive
With the new RA diagnosing criteria, how many points are needed for a diagnosis of RA?
6 out of 10 points
- *must have at least one joint with definite clinical synovitis
- ** the synovitis present can’t be explained by another disease condition
How many points do you get for joint swelling in 4-10 small joints?
3 points
How many points do you get for joint involvement in 2-10 large joints?
1 point
How many points do you get for joint involvement in 1 large joint?
0 points
Typically RA is not associated with large joints
How many points do you get for joint involvement in 1-3 small joints?
2 points
How many points do you get for joint involvement greater than 10 joints with at least one small joint?
5 points
How many points for next following questions:
Negative RF and negative anti-CCP?
0 points
duration of symptoms over 6 weeks
1 point
High positive RF and High positive anti-CCP
3 points
Low positive RF OR low positive anti-CCP
1 point
Normal CRP and normal ESR?
0 point
Abnormal CRP OR abnormal ESR?
1 point
What is the major cell type in synovial fluid?
Neutrophils
Synovial fluid in RA is over or under produced?
Overproduced
What is it called when synovial fluid becomes old and thickened?
Pannus
What are the major cell types of Pannus?
T-Lymphocytes
Macrophages
What type of hemorrhages can be seen with RA in the fingers and nail beds?
Splinter Hemorrhages
What are some systemic conditions patients can have with RA?
fatigue Raynauds phenomenon pleuritis or pericarditis vascularitis interstitial lung disease dry eyes and mouth
What do you do with patient once diagnosis of rheumatoid arthritis has been made?
refer them to rheumatology for mangement
How often do you need to monitor the patient for adverse effects of the medications?
At least every 2 months
Are NSAIDs used for RA patients and do they prevent disease progression
Yes NSAIDS are used for symptomatic relief and improved function
they DONT change disease progression
What consideration must be taken into account with prolonged prednisone use in patient?
Consider prophylactic osteoporosis medication
T/F Intraarticular steroid injections can be used for specific joints treatments?
TRUE
What are some DMARDs used for RA?
plaquenil (hydroxychloroquine)
sulfasalazaline
methotrexate (highly effective single DMARD)
leflunomide
azathioprine
cyclophosphamide
cyclosporine
They only have a moderate effect but they are low cost
DMARDs= disease modifying anti rheumatic drugs
Which medication is the GOLD standard drug for treatment of RA?
Methotrexate
Methotrexate can cause ________ and __________ suppression.
Hepatotoxicity
Bone marrow
What labs need to be checked when patient is taking methotrexate and how often?
Liver function tests need to be checked every 8 weeks after established but initially every 2-3 weeks with beginning medication
Once patient goes a year without elevated liver enzymes patients can come in every 12 weeks.
patients need to be seen 3-6x/year for monitoring.
What two diseases are contraindicated for the use of methotrexate and why>
Type 2 Diabetes mellitus
Obesity
**due to increased risk of hepatic fibrosis
T/F patients taking methotrexate are at increased risk of developing lymphoma?
TRUE (autoimmune disease increases risk with or without medication)
What drugs are the TNF inhibitor biologics used for RA?
tumor necrosis factor inhibitors Remicade (given IV in office) Embrel Humira Cimzia (newer biologic) Simpomi Cimzia and Simpomi are given 1x/month SQ
Tumor necrosis factor is present in the ________. It causes __________, ______________ and __________.
present in the synovial fluid TNF causes: bone erosion pain/joint swelling (synovitis) joint space narrowing (cartilage degradation)
When the B cell is activated what does it cause to happen?
B cell activation produces the release of the anti necrosis factor, IL-1 and IL-6 which leads to inflammation and destruction of the joint.
Before initiating the TNF inhibitors need to use which drugs first?
Plaquenil
Sulfasalazine
azathioprine
*** in combination with methotrexate
When would you switch the patient to TNF inhibitors?
When bone erosion starts to occur in patient.
Which key feature is NOT included in the diagnosis of rheumatoid arthritis?
A. symptoms lasting longer than 6 weeks
B. morning stiffness
C. thoracolumbar spine pain
D. symmetrical pain and swelling in the hands
C. thoracolumbar spine pain NOT feature of RA
What diagnostic test would you want to order to confirm suspicion of diagnosis of RA? A. rheumatoid factor RF B. anti-CCP C. x-ray of the hands D. all of the above
D. All of the above.
Why is early diagnosis essential? Please choose the best statement.
A. The more involved the pain and swelling at baseline, the worse the future will be for the patient.
B. Early intervention can make a difference in long-term progression of the disease.
C. Seropositive disease is more aggressive, causing erosions and structural damage to the bone.
D. All of the above
D. all of the above.
What other systems can RA affect besides the joints? A. Cardiac system B. Pulmonary system C. Vascular system D. All of the above
D. All of the above.
What is the first-line treatment of RA? A. Methotrexate B. TNF C. Inhibitors D. Cyclophosphamide E. Actemra
A. methotrexate
According to the BeSt trial
A. Monotherapy is the best way to start treatment
B. Combination therapy provides earlier clinical improvement and less progression of joint damage after a year compared to initial monotherapies
C. Monotherapy is just as effective as combination treatment in rapidly eliminating clinical symptoms
B. Combination therapy provides earlier clinical improvement and less progression of joint damage after a year compared to initial monotherapies
According to the New England Journal of Medicine paper, triple therapy with MTX, sulfasalazine, and Plaquenil is noninferior to treatment with Enbrel and methotrexate. Is this true, and if so, why is this important?
Triple therapy is more cost effective then combination therapy with MTX and Enbrel. The TNF medications are biologics, and they are very costly ($30,000 to $40,000 per year). Use of TNF inhibitors should be used after failure of triple therapy for that reason. But of course if there are side effects, we would move in that direction sooner rather then later.
