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Rheumatoid arthritis Flashcards

1
Q

Is it a monoarthritis, oligoarthritis or a polyarthritis?

A

Polyarthritis

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2
Q

Is the inflammation symmetrical or asymmetrical?

A

Symmetrical

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3
Q

What is the relative prevalence between men and women?

A

3:1 women to men, except after menopause when it is equal

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4
Q

What is the most common age of onset?

A

30-50

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5
Q

What aspects of history are relevant?

A

Family- increased incidence in first degree relatives
Social- smoking
Past medical- other forms of bronchial stress

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6
Q

Describe the pathophysiology of Rheumatoid arthritis

A

An erosive arthritis leading to synovitis and joint destruction
TNF-alpha is overproduced due to macrophages interacting with T and B lymphocytes
TNF-alpha causes the overproduction of IL-6

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7
Q

What is the cause of the swelling?

A

Change from normal synovium which is a few cells thick to greatly thickened synovium containing a variety of inflammatory cells

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8
Q

Why is rheumatoid factor produced in the body?

A

Physiological response to remove immune complexes in the body

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9
Q

What does clinical testing look for in terms of rheumatoid factor?

A

IgM rheumatoid factor

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10
Q

Is IgM rheumatoid factor diagnostic of RA?

A

No, seronegative RA occurs with persistently negative rheumatoid factor tests

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11
Q

What is indicated by persistently high titre of IgM rheumatoid factor in early disease?

A

More active synovitis
More joint damage
Greater diability
An indication for early use of DMARDS

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12
Q

What factor might predict a poorer prognosis in early rheumatoid arthritis?

A 
older age
female
symmetrical small joint involvement
morning stiffness more than 30 mins
More than 4 swollen joints
Cigarette smoking
Co-morbidity
CRP more than 20g/dL
Positive rheumatoid factor and anti-citrullinated peptide antibodies
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13
Q

Which joints are affected by pain and stiffness usually?

A

MCPs, PIPs and MTPs

DIPs spared

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14
Q

What other joints can be affected?

A

Wrists, elbows, shoulders, knees and ankles

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15
Q

When is the pain worst?

A

In the morning

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16
Q

How does activity affect the pain?

A

Reduces it

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17
Q

What other symptoms can be present?

A

Fatigue

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18
Q

What disease can be mimicked by RA? How can you tell the difference?

A

Polymyalgia rheumatica

Reduce the steroid dose and the synovitis becomes apparent

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19
Q

What might be found on joint examination in RA patients?

A

Warm, tender, swollen joints - basically inflammation
Muscle wasting
Limited range of movement
Patient can close a fist despite pain unlike in osteoarthritis

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20
Q

What are 6 other forms of presentation of RA?

A 
Palindromic rheumatism
Transient
Remitting
Chronic, persistent
Rapidly progressive
Seronegative RA
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21
Q

Describe the presentation of palindromic rheumatism

A

Consists of short lived episodes of acute monoarthritic attacks (24-48 hrs)
Joint becomes red, swollen and acutely inflamed
Further attacks can occur in the same joint or in different joints
1/2 of these patients go on to develop other forms of RA within months or years
RF or ACPA detection predicts the likelihood of developing other forms of RA

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22
Q

Describe the presentation of transient RA

A

Self-limiting
Lasts less than a year and leaves no permanent joint damage
Seronegative for RF and ACPA

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23
Q

Describe the presentation of remitting RA

A

Arthritic activity is present for many years but then remits, leaving minimal joint damage

24
Q

Describe the presentation of chronic/persistent RA

A

Most common form
Can be either Seropositive or seronegative for RF
It has a relapsing and remitting course
Seropositive patients develop greater joint damage and long-term disability and ad such warrant earlier and more aggressive treatment

25
Describe the presentation of rapidly progressive RA
``` Disease progression over a few years Rapidly leading to severe joint damage and severe disability Usually seropositive Systemic complications are seen Very difficult to treat ```
26
Describe the presentation of seronegative RA
Affects the wrists first, then the fingers Less symmetrical Better long-term prognosis but can lead to severe disability Can be confused with psoriatic arthritis
27
What investigations need to be done? What would these investigations show?
Bloods - may show normocytic anaemia ESR/CRP - varies by degree of disease activity, good for monitoring Serology - RF and ACPA x-rays - show soft tissue swelling in early disease USS and MRI - better at showing early erosion and synovitis Aspiration of joint - cloudy (white cells) Doppler USS - effective in deciding the need for DMARDS
28
What is the aim of therapy for a patient with RA? How should they be managed?
To induce remission and allow them to live a normal life Reassure the patient that this is possible Encourage them to stay at their job Refer early to a rheumatologist within 3 months of onset
29
Describe the use of Drug therapy in patients with RA
Aim to reduce DAS28 score to less than 3 Use NSAIDs and analgesics to control symptoms, especially pain Steroids are not used long term but are used to treat acute exacerbations and difficult symptoms Early use of DMARDS and biologics to improve long term outcome Anti-TNF-alpha therapy
30
What is the purpose of using NSAIDs in RA patients?
To relieve night pain and morning stiffness
31
What are the side effects of NSAIDs?
indigestion, skin rashes, PUD, gastric erosions
32
When might you add a PPI to the treatment of a patient taking NSAIDs?
If they have indigestion or are over 65
33
How might additional pain relief be given if NSAIDS aren't enough?
Paracetamol or a combination of codeine and paracetamol
34
What is the purpose of using corticosteroids in patients with RA?
Early use of these drugs slows down the course of the disease
35
How are corticosteroids used in the treatment of RA?
IM depot methylprednisolone 80-120mg can be tried for inducing remission Oral corticosteroids on doses of 5-7.5mg are given as a maintenance therapy - not long term Concomitant Vit D and bisphosphonates need to be given to reduce fracture risk from osteoporosis due to the steroids
36
What is the purpose of giving DMARDs in RA?
``` Early treatment (within 6 weeks to 6 months of onset) improves outcome of disease Reduces the increased CVS risk in RA ```
37
How are DMARDs given in RA?
Combination therapy of 3 to 4 drugs used initially and then reduced after remission
38
What are the common side effects of DMARDs?
neutropenia, sepsis, rash, nausea, vomiting, diarrhoea
39
How is methotrexate used in RA?
Drug of choice- weekly dose starting with 7.5-10mg increasing to about 15-25mg FBCs and liver biochemistry should be monitored Drug takes 1-2 months to take effect
40
What side effects and cautions must be remembered for methotrexate?
Should not be used in pregnancy Conception should be delayed until the patient is 6 weeks off the drug Need to rule out TB before administering the drug Pulmonary toxicity and pneumonitis - watch out for dry cough, SOB and fever - to test do lung function tests - restrictive pattern Do not give folic acid
41
How is sulfasalazine used in RA?
(It is a combination of sulfapyridine and 5-ASA) Dose starts at 500fsdkf and increased to 2-3mg daily 50% of patients respond within the first 3-6 months
42
What side effects and cautions must be considered for sulfasalazine?
Better tolerated in pregnancy than others Risk of leucopenia and thrombocytopenia Oligospermia Contraindicated in someone who has an aspirin allergy Drug induced lupus
43
How is hydroxychloroquine used in RA?
Used in mild disease or in combination therapy | 200-400mg daily
44
What side effects and cautions must be considered when giving hydroxychloroquine?
Retinopathy is possible but rare - arrange annual macular check as retinopathy is irreversible Arrhythmias
45
What are the benefits of giving TNF-alpha blockers in RA?
They are known to stop joint erosion and heal joints in some - not seen in DMARDs
46
Name a TNF-alpha blocker used in RA?
Infliximab
47
How are TNF-alpha blockers used in RA?
Used after at least 2 DMARDs have failed | Usually given in combination therapy to avoid loss of efficacy of DMARDs due to anti-drug antibody formation
48
What cautions are to be taken when giving TNF-alpha blockers?
Should not be used in patients with severe heart failure Treat TB Careful monitoring of LFTs in HBV and HCV patients
49
How is rituximab used in RA?
Produces significant improvement in RF positive patients due to B cell lymphopenia This drug is used more in haematological cancers Mainly helps in patients who have failed to respond to TNF-alpha blockers
50
Name 3 DMARDs used in RA
Methotrexate, sulfasalazine, hydrochloroquine
51
Name 3 biologicals used in RA?
TNF-alpha blockers - infliximab, rituximab
52
What are the possible complications of RA?
Septic arthritis - may not display the typical features of septic arthritis in an immunosuppressed patient, any effusion of sudden onset needs to be aspirated - usually staph aureus Amyloidosis - associated with carpal tunnel syndrome and subcutaneous nodules
53
How is septic arthritis treated?
Aspiration and antibiotics
54
What are the differentials for early RA?
Seronegative spondyloarthropathies Post viral arthritis - Hep B, rubella, erthrovirus Polymyalgia rheumatica Acute nodal osteoarthritis (DIPs involved)
55
What are the possible non-articular manifestations of RA?
Subcutaneous nodules - over pressure points (elbows, finger joints) Bursitis Tenosynovitis - swelling of flexor tendons causing stiffness +/- trigger finger Sjogren's syndrome Eye - scleritis, episcleritis CVS - pericarditis, endocarditis Amyloidosis atlantoaxial subluxation - cervical cord compression Resp - pleural effusion, ILD Vasculitis Anaemia

Rheumatology (4 decks)

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