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MSK > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

What joints are mainly affected by RA

A

Peripheral joints
e.g. MCP, PIP, wrists
NOT the DIP though as too small and not enough synovium

Has to be joints with sufficient synovium as this is what gets inflamed
Larger joints like elbow and shoulder can also be affected

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2
Q

RA is usually symmetrical - true or false

A

True
e.g. both hands would be affected
Also typically polyarticular - multiple joints

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3
Q

What is the main structure involved in RA

A

The synovium

Lies inside of a synovial joint capsule

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4
Q

Which joints in the body are synovium lined

A

Hand, wrists, shoulders, C1, C2, TMJ, hip, knees, feet (MTPs) and ankles

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5
Q

What is the main antibodies involved in RA

A

Rheumatoid factor

Anti-CCP (more specific)

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6
Q

Describe the inflammatory process in RA

A

The synovium gets inflamed and becomes a spongy mass with increased blood flow
This brings even more inflammatory cells to the area
If not treated it can stimulate osteoclasts which erode the bone leading to deformity

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7
Q

What is a pannus

A

Thickened synovium due to granulation tissue

Brought on by inflammation

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8
Q

How is early RA defined

A

Less than 2 years since symptoms started

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9
Q

What is the significance of the first 3 months of RA presentation

A

This is therapeutic window of opportunity
If you catch the disease and start treating it you can alter progression and make it less aggressive - prevent bone damage/erosions

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10
Q

How can you diagnose RA

A 
History and examination are key 
Routine blood tests 
Inflammatory markers 
Autoantibody test - RF and anti-CCP
Imaging
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11
Q

What results may you see in a FBC on someone with RA

A

Anaemia - due to chronic inflammation, bone marrow is under stress
Will be normochromic and normocytic
High platelets - non-specific marker of inflammtion

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12
Q

What are some common systemic symptoms of RA

A

SOB

Chest pain

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13
Q

What are the clinical signs of RA

A

Prolonged morning stiffness - longer than 1hr - which eases with movement
Involvement of small joints of hands and feet.
Symmetric distribution.
Positive compression tests of MCP and MTP joints.
Trigger finger
Systemic symptoms

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14
Q

What are some common joint signs of RA

A

Swelling - feels spongy
Tenderness
Symmetrical involvement
Not able to make fists (due to tendon involvement)

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15
Q

What is tenosynovitis

A

Inflammation of a tendon
Common in the extensor tendon
Can become swollen and sore
If not treated the tendons fray and tear

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16
Q

Describe anti-ccp antibodies

A

Very specific for RA - 98%
Can be present before symptoms appear
Patients will remain positive for the antibody even after treatment
Related to disease activity and more likely to be associated with erosion - worse prognosis

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17
Q

Describe how X-rays are used in RA

A

Done in all patients
May see soft tissue swelling, periarticular osteopenia (early disease) and/or erosions (late)

Disadvantage is absence of findings in early disease

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18
Q

Describe how US is used in RA

A

More sensitive than X ray
More likely to spot synovitis in early disease - shows increased blood flow associated with inflammation
Can differentiate between synovial effusions secondary to OA and
synovitis secondary to RA
Detects more MCP erosions

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19
Q

Describe how MRI scans are used in RA

A

Most sensitive investigation - gold standard
However very expensive so used sparingly
Can monitor disease activity, detect erosions early, asses tendon integrity and distinguish synovitis

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20
Q

What is the DAS28 score

A

A score that assesses disease activity in RA
Investigates 28 joints in the body
Also includes how patient feels on a scale and an inflammatory marker (CRP or ESR)

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21
Q

What are the thresholds for the DAS28 score

A

> 5.1 Active disease.
3.2- 5.1 Moderate disease.
2.6-3.2-Low disease activity.
Less than 2.6 Remission.

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22
Q

Give an overview of RA management

A 
Recognise early 
refer to rheumatology 
Start on DMARDs - early and aggressive in therapeutic window
Treat symptoms with NSAIDs and steroids
Multidisciplinary approach
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23
Q

Describe the steps of RA treatment

A

Step 1 - NSAID for symptoms
Step 2 - add steroid
Step 3 - add first DMARD
Step 4 - add another DMARD etc

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24
Q

How are steroids used in RA

A

Improve symptoms and reduce radiological damage
Used in combination with DMARDs - bridge as DMARD takes effect
Given orally, IM or IA
Not used long term due to side effects

25
Q

Name 4 common DMARDs

A

Methotrexate
Sulfasalazine
Hydroxychloroquine
Leflunomide

26
Q

What DMARD is first line

A

Methotrexate

27
Q

In what order are DMARDs given

A 
1st = Methotrexate
2nd = Sulfasalazine (used second line or alongside MTX)
3rd = Hydroxychloroquine (never used alone as weak)
28
Q

Patients on DMARDs need regular monitoring - true or false

A

True
Drugs have many side effects
MTX - LFT and FBC

29
Q

What are some side effects of Methotrexate

A 
Nausea, vomiting and diarrhoea
Rash
Mouth ulcers 
Alopecia
Increased infection risk

Liver function derangement - check LFT regularly
Bone marrow suppression Can cause pneumonitis - allergic inflammatory reaction

30
Q

What are biologic agents

A

Specialised drugs that inhibit parts of the immune pathway such as cytokines and cells
Can be used in RA

31
Q

What is the major risk with biologic agents

A

Increased infection risk as immune system is inhibited

Can reactivate latent TB etc

32
Q

How are people recommended for biologic treatment

A

Expensive treatment so must meet certain criteria

Failure to respond to 2 DMARDs and a DAS28 greater than 5.1 on 2 occasions

33
Q

What are the main complications of untreated RA

A

Severe joint damage and deformity

e.g. swan necking

34
Q

What signs of RA may be seen on imaging

A 
Soft tissue swelling 
Periarticular osteopaenia
Bone demineralisation - darker on x-ray 
Inflammatory pannus - can destroy bone 
Joint deformity and erosions
Ankylosis - joint fusion
35
Q

What causes the soft tissues to swell in RA

A

Synovial proliferation and reactive joint effusion

36
Q

What causes bone demineralisation in RA

A

Hyperaemia

Results in periarticular osteoporosis (around joint)

37
Q

Which joints commonly fuse in RA

A

Sacro-iliac

Spine

38
Q

Why isn’t it good if you see RA features on X-ray

A

Mostly show bone and joint damage that’s already happened
Hard to pick up early changes
By this stage its often too late to modify or prevent the disease

39
Q

What are the seronegative arthritis’

A

Psoriatic arthritis - affects small joint of hands and feet
Ankylosing spondylitis
Reiter’s syndrome - affects lower limb joints

40
Q

What early arthritic signs can be seen on US

A

Thickening of synovium Increased blood flow

41
Q

What early arthritic signs can be seen on MRI

A

Bone marrow oedema

Early inflammation and bone erosion

42
Q

Why do patients with RA get early morning stiffness

A

Increased viscosity of synovial fluid secondary to
inflammation
Eases with movement

43
Q

Which age groups can be affected by RA

A

RA can affect any

age group and even children

44
Q

RA is more common in men - true or false

A

False

More common in women - 3:1

45
Q

Smokers

are more likely to be more resistant to treatment in RA - true or false

A

True

Also more likely to have anti-CCP antibodies

46
Q

Rheumatoid factor may be positive in which other conditions

A

Sjogren`s syndrome, vasculitis, infections and

malignancy

47
Q

Which joints are typically the first to erode in RA

A

The 5th MTP joint in the foot and the ulnar styloid in the wrist
Hand and feet X-ray are typically used as the baseline as a result

48
Q

Which other tablet must be taken alongside methotrexate

A

Folic acid
MTX prevents it from entering cells
MTX given as a weekly dose followed by folic acid at least 24 hours later on the other 6 days

49
Q

Methotrexate is contraindicated in which patients

A

Severe lung disease - due to pneumonitis risk
Women of childbearing age not on contraception - highly teratogenic
Alcoholics - hepatotoxic so they are higher risk

50
Q

Sulfasalazine is contraindicated in which patients

A

Those with with allergy to septrin
G6PD deficiency

Best avoided in autoimmune diseases like SLE as can cause drug induced lupus

51
Q

List side effects of sulfasalazine

A 
Diarrhoea
Rash
Mouth ulcers
Headache 
It can cause
cytopaenias and liver abnormalities
52
Q

Hydroxychloroquine is used alone in RA

A

False - used as triple therapy with MTX and sulfa

However
in autoimmune diseases like SLE and Sjogren`s, it has been shown
to reduce fatigue, improve arthralgia and reduce progression of the
disease and is used in isolation.

53
Q

List side effects of hydroxychloroquine

A

GI side effects and rash

Very rarely maculopathy - patient must get annual eye tests

54
Q

Why must people be screened for TB before starting biologics

A

Risk of reactivation due to drug effect on immune system

Comprimises the granuloma containing the TB as held together by TNF - therefore anti-TNF high risk

55
Q

What is the major contraindication to starting biologic therapy

A

Any active infection

56
Q

How long do DMARDs typically take to work

A

12 weeks

Steroids are given as a bridge

57
Q

When are RA patients given long term steroids

A

If they have severe organ involvement such as lung or kidney involvement

58
Q

List some side effects of steroids

A

cataracts, diabetes, weight gain, osteoporosis (consider bone protection) etc

59
Q

Why must older patients with RA have DEXA screening

A

Risk of osteoporosis due to osteoclastic activation by

inflammatory cytokines seen in RA

MSK (21 decks)

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