Rheumatoid arthritis Flashcards
Is it a monoarthritis, oligoarthritis or a polyarthritis?
Polyarthritis
Is the inflammation symmetrical or asymmetrical?
Symmetrical
What is the relative prevalence between men and women?
3:1 women to men, except after menopause when it is equal
What is the most common age of onset?
30-50
What aspects of history are relevant?
Family- increased incidence in first degree relatives
Social- smoking
Past medical- other forms of bronchial stress
Describe the pathophysiology of Rheumatoid arthritis
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
What is the cause of the swelling?
Change from normal synovium which is a few cells thick to greatly thickened synovium containing a variety of inflammatory cells
Why is rheumatoid factor produced in the body?
Physiological response to remove immune complexes in the body
What does clinical testing look for in terms of rheumatoid factor?
IgM rheumatoid factor
Is IgM rheumatoid factor diagnostic of RA?
No, seronegative RA occurs with persistently negative rheumatoid factor tests
What is indicated by persistently high titre of IgM rheumatoid factor in early disease?
More active synovitis
More joint damage
Greater diability
An indication for early use of DMARDS
What factor might predict a poorer prognosis in early rheumatoid arthritis?
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
Which joints are affected by pain and stiffness usually?
MCPs, PIPs and MTPs
DIPs spared
What other joints can be affected?
Wrists, elbows, shoulders, knees and ankles
When is the pain worst?
In the morning
How does activity affect the pain?
Reduces it
What other symptoms can be present?
Fatigue
What disease can be mimicked by RA? How can you tell the difference?
Polymyalgia rheumatica
Reduce the steroid dose and the synovitis becomes apparent
What might be found on joint examination in RA patients?
Warm, tender, swollen joints - basically inflammation
Muscle wasting
Limited range of movement
Patient can close a fist despite pain unlike in osteoarthritis
What are 6 other forms of presentation of RA?
Palindromic rheumatism Transient Remitting Chronic, persistent Rapidly progressive Seronegative RA
Describe the presentation of palindromic rheumatism
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
Describe the presentation of transient RA
Self-limiting
Lasts less than a year and leaves no permanent joint damage
Seronegative for RF and ACPA
Describe the presentation of remitting RA
Arthritic activity is present for many years but then remits, leaving minimal joint damage
Describe the presentation of chronic/persistent RA
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
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
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
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
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
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
What is the purpose of using NSAIDs in RA patients?
To relieve night pain and morning stiffness
What are the side effects of NSAIDs?
indigestion, skin rashes, PUD, gastric erosions
When might you add a PPI to the treatment of a patient taking NSAIDs?
If they have indigestion or are over 65
How might additional pain relief be given if NSAIDS aren’t enough?
Paracetamol or a combination of codeine and paracetamol
What is the purpose of using corticosteroids in patients with RA?
Early use of these drugs slows down the course of the disease
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
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
How are DMARDs given in RA?
Combination therapy of 3 to 4 drugs used initially and then reduced after remission
What are the common side effects of DMARDs?
neutropenia, sepsis, rash, nausea, vomiting, diarrhoea
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
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
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
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
How is hydroxychloroquine used in RA?
Used in mild disease or in combination therapy
200-400mg daily
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
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
Name a TNF-alpha blocker used in RA?
Infliximab
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
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
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
Name 3 DMARDs used in RA
Methotrexate, sulfasalazine, hydrochloroquine
Name 3 biologicals used in RA?
TNF-alpha blockers - infliximab, rituximab
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
How is septic arthritis treated?
Aspiration and antibiotics
What are the differentials for early RA?
Seronegative spondyloarthropathies
Post viral arthritis - Hep B, rubella, erthrovirus
Polymyalgia rheumatica
Acute nodal osteoarthritis (DIPs involved)
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
