Rheumatoid arthritis Flashcards
female to male ratio
3:1
what is ra and stages
immune system attack the joint
proliferative synovitis leading to cartilage loss and bone erosions
- synovitis: inflamed and thickened- bony erosions start
- pannus
- pannus: granulation tissue and vascularisation
- produces fluid - fibrous ankylosis: fuse connective tissue due to pannus there= reduced mobility
- bony ankylosis
- bone erosions: osteoclasts & granulation tissue =gradual complete loss mobility
factors associated to a poorer prognosis for RA 6
female disability at presentation involvement of MTP joints x-ray damage at presentation smoking positive RF or ACPA
key pathophysiological features of RA
synovitis
cartilage loss
bone erosions
auto-immune
what is the major haplotype assoc. to RA
HLA-dr4
what causes RA
genetic predisposition+environment stimuli eg smoking (damages epithelial so make ab), trauma, stress infection, menopause, post-partum
pathophysiology of RA
- dendritic cells stimulate T cells (th17)
- t cell stimulate B cells to produce AB (rf and acpa)
- synovial macrophages activated by immune complexes
- synovial fibroblasts promotes swelling and damage
- osteoclast activation by RANKL and chondrocytes by cytokines drive cartialge/ bone degrade
- neoangiogenesis- inflamed synovium becomes vascularised
- increases cytokines
which cytokine causes the acute phase response and systemic effects in RA
il6 goes to liver causing the anaemia, fatigue and reduced cognitive function
what is the abnormal tissue that forms in RA replacing articular cartilage called
pannus
what causes the formation of pannus
formed by hypoxic tissue undergoing neoangiogenesis
-causes excess fluid production as releases MMP that degrade catilage and cause bone destruction
what makes up a RA nodule
central area= fibrinoid material
surrounded by proliferating mononuclear cells
function of TNF in RA
stimulate IL1 il8 and il10 activate macrophages increases IL6, PROSTAG Activate osteoclast via il1 promote MMP production
most common affected joints of RA
mcpj pipj wrist elbow shoulder knee back
presentation of RA
polyarthritis symmetrical morning stiffness swelling post-inactivity gelling systemic symptoms: fatigue chronic >6 weeks lung fibrosis
importance of detecting lung fibrosis in ra
can’t use methotrexate
criteria for diagnosis of RA 2010
score >6 -num joints affected and size 1 large=0 2-10 large=1 1-3 small=2 4-10 small=5 -serology rf/acpa=0 low=2 high=3 -duration symptoms <6=0 >6=1 -acute phase reactants esr and crp 0 or 1
what is pallindromic RA
intermittent comes and goes more
examination of RA
swelling
synovial thickening
squeeze test pain
mcp/ pip not dipj
hand deformities of RA
swan neck boutonniere z thumb dorsal subluxation wrist radial deviation wrist ulnar deviation mcpj triggering of fingers swelling at wrists
what is boutonniere and swan neck
boutonniere= flexion pip and hyperextension DIP
swan neck- flexion pip and hyperextension dip
z deformity is
hyperextension thumb ipj
foot examination RA
- dorsal subluxation of MTPJ
- calluses (exposed mtp heads)
- claw
- hammer toe
- calcaneovalgus (eversion)
what is claw and hammer tow
claw: extension at mtp, flexion at pipj
hammer: flexion at piph
extra-articular features of RA
- weight loss
- fatigue
- fever
- susceptibility to infection
- osteop
- muscle wasting
- tenosynovitis
- anaemia
- lymphatic: splenomegaly
- nodules
- ocular: episleritis
- vasculitis
- cardiac: itis
- pulmonary: nodules/ effusions/ fibrosis
- neuro: compressions
- amyloidosis
indicator for risk of rheumatoid nodules
seropositive patient
what causes the systemic features of RA
serositis
granulomas
nodule formation
vasculitis
definition of scleritis, scleromalacia, keratoconjunctivits
scleritis: redness
scleromalacia: thickening of sclera
keratoconjunc: dry eyes
investigations for RA
raised ESR/ CRP ACPA+ RF+ USS or MRI not x-ray
monitoring disease damage and activity
DAS 28 x-ray for erosions early morning stiffness pain scale tenderness
rheumatoid erosion progression 2
joint space narrowing
marginal erosions
DAS 28 components 4
1.count number tender joints
2.count number swollen joints
3. measure ESR
4.rate pain /100
calculate
mangement progression for RA
metot+steroid combined DMARD anti-TNF other immunoglobulin (alongisde ANALGESIA)
What drugs should be avoided in pregnancy and when should they be stopped 6
methotrexate leflunomide mycophenylate 3 months prior cyclophosphamide gold penicillamine
safe drugs to use in pregnancy with ra 4
hydroxychloroquine
sulf
aza
ciclosporin
anaglesic of choice in pregnancy
paracetamol
how long can NSAIDs and cox2 inhibitors be used for
up until the last trimester
risks of steroids in pregnancy
maternal hypertension
drugs that are ci for breast feeding
methotrexate leflunomide cyclophosphamide ciclosporin aza sulf hydroxy
what must be taken when on methotrexate 2
folic acid 5mg day after
contraceptive
surgery for RA
synovectomy of sheath for pain
later stages: arthroplasty, arthrodesis, osteotomy
x-ray findings in progressive Ra disease
periarticular erosions
loss of joint space
subluxation
juxta-articular osteoporosis
history ra
morning stiffness >30 mins
improves with use
bilateral symptoms
systemic upset
