Rheumatoid Arthritis Flashcards
What is rheumatoid arthritis?
- A chronic systemic inflammatory disease characterised by a symmetrical, deforming, peripheral polyarthritis.
- It increases the risk of cardiovascular disease by 2-3 fold
- The prevalance is higher in smokers
How does rheumatoid arthritis present?
- Morning stiffness (>30 mins)
- Swelling
- Joint pain typically of the small joints (except DIPJs) in a symmetrical manner
- Normally a polyarticular condition (affects a great number of joints)
- Can get rheumatoid nodules (often on elbows or knuckles and sometimes lungs) which are prognostic for bad outcomes as often develop extra articular pathologies and are RF +ve
- Can get extra-articular presentations with:
- Weight loss
- Fever
- Fatigue
- Pericarditis
- Lung fibrosis
- Lymphadenopathy
- Episcleritis
- Scleritis
- Felty’s syndrome (RA + splenomegaly + neutropenia)
- Peripheral neuropathy
- Vasculitis
- Carpal tunnel syndrome
Extra-articular manifestations affect 40% of RA patients.
What are the extra-articular presentations of rheumatoid arthritis?
- Weight loss
- Fever
- Fatigue
- Cardiac
- Pericarditis
- IHD
- Pericardial effusion
- Lungs
- Lung fibrosis
- Lymphadenopathy
- Eye
- Episcleritis
- Scleritis
- Scleromalacia
- Felty’s syndrome (RA + splenomegaly + neutropenia)
- Peripheral neuropathy
- Vasculitis
- Carpal tunnel syndrome
- Osteoporosis
- Amyloidosis (rare)
What are the early signs of rheumatoid arthritis?
- Inflammation, no joint damage
- Swollen MCP, PIP, wrist or MTP joints
- often symmetrical
What are the later signs of rheumatoid arthritis?
- Joint damage and deformity
- Ulnar deviation
- Swan neck deformity
- Boutonneires deformity
- Z deformity of hands
- Dorsal wrist subluxation
- Hand extensor tendons may rupture
- Foot changes are similar
- Larger joints may be involved
- Altanto-axial joint subluxation may threaten the spinal cord
What are investigations for rheumatoid arthritis?
- Rheumatoid factor is postive in 70%
- High titres are associated with severe disease, erosions and extra-articular disease
- Anticyclic-citrillinated peptide antibodies
- These are more specific for RA and sensitive too
- They may also predict disease progression
- Anaemia of chronic disease
- Raised platelets
- Raised ESR
- Raised CRP
- X rays
- Soft tissue swelling
- Juxta-articular osteopenia
- Decreased joint space
- Most changes are seen later
- Ultrasound and MRI
- Both can identify synovitis more accurately and have greater sensitivity in detecting bone erosins than conventional X-rays
How is rheumatoid arthritis managed?
- Conservatively
- Refer to rheumatologist before irreversible destruction
- Physiotherapy/Occupational therapy
- Medically
- DMARDS - early use improves long term outcomes
- Methotrexate
- Sulfasalazine
- Hydroxychloroquine
- Steroids - reduce symptoms and inflammation rapidly
- Oral prednisolone
- IM depot methylprednisolone
- NSAIDs - symptoms relief, no effect on long term outcomes
- DMARDS - early use improves long term outcomes
- Surgically
- relieves pain
- improves function
- prevents deformity
RA increases the risk of some diseases. What are they?
Cardiovascular and cerebrovascular diseases as atherosclerosis is accelerated in RA
What modifiable factor increases the symptoms of RA?
Smoking
How does RA affect quality of life?
- Depression, disability and pain are all important quality of life predictors
- RA affects all three of these so be mindful about the impact of the disease on their relationships, work and hobbes
- Consider therapies and support groups for patients - holistic care
What is the diagnostic criteria for RA?
What changes can be seen on X ray of someone with RA?
- Soft tissue swelling
- Extra-articular osteopenia
- Marginal atrophic erosions
- Joint space narrowing (no osteophytes or sclerosis so looks dark)
- LESS
- Loss of joint space
- Erosions
- Soft tissue swelling
- Soft bones (osteopenia)
Where are rheumatoid nodules found?
What are they a sign of?
- Elbows or knuckles
- Lungs
- Cardiac
- They are prognostic for bad outcomes as often develop extra articular pathologies and are RF +ve
What are the side effects of methotrexate?
- Nausea
- Hepatotoxicity (monitor LFTs)
- Hair thinning
- Reduce appetite
- Insomnia
- Pneumonitis
- Lung fibrosis
What is the mode of action of methotrexate?
- It inhibits DHFR (dihydrofolate reductase)
- This leads to reduced tetrahydrofolate production which is needed as a co-factor for thymidylate synthase
- Therefore there is reduced thymidine production which leads to thymidine less cell death
What is the gold standard of RA treatment?
Methotrexate
What are the contraindications of methotrexate?
- Contraindicated if already have severe lung disease/fibrosis therefore CXR before starting
- Highly teratogenic (advice to child bearing age women to stop 3 months prior to trying for children)
- Renally excreted therefore can lead to toxicity if renal compromise
How is methotrexate administered?
- It is given weekly PO, IM or SC (not PO can avoid nausea)
- Start within 3 months of persistent symptoms
- Can take 6-12 weeks for symptomatic benefits
- It is taken with folic acid, up to 6 times a week (each day except day they take the MTX) and can reduce nausea too.
- Should not be taken with Trimethoprim as both inhibit folate.
- Require LFTs, U&Es (to ensure it will be excreted effectively) and FBC (to check for neutropenia).
- Anyone on any immunosuppressant should receive annual skin surveillance to check for skin pigmentation changes
What is the mode of action of sulfasalazine?
- It inhibits T cell proliferation, IL-2 production and neutrophil chemotaxis
What are the side effects of Sulfasalazine?
- Nausea
- Vomiting
- Myelosuppression
- Alopecia
- Rash
- Reduced sperm count
- Oral ulcers
- GI upset
What are the side effects of hydroxychloroquine?
Retinopathy
Annual eye screen required
When are biological agents prescribed?
- When at least 2 DMARDs have been trialled but the disease is still active
- After pre-treatment screening for TB, hepatitis B/C and HIV
- By specialists
Name the 4 types of biological agents used for severe active RA? Give an example of each one.
- TNF-alpha inhibitor = Infliximab
- 1st line
- B cell depletion = Rituximab
- Used when DMARDs and TNF-alpha has failed
- IL2 & IL6 inhibitor = Tocilizumab
- Used when TNF-alpha has failed or its contraindicated
- Inhibition of T cell co stimulation = Abatacept
- Used when DMARDs and TNF-alpha has failed
Which biological agent can be used as monotherapy in RA?
TNF-alpha, infliximab
Used where methotrexate is contraindicated
What are the side effects of biological agents?
- Serious infection
- Reactivation of TB
- Hepatitis B
- Worsening heart failure
- Hypersensitivity
- Injection site reactions
- Blood disorders
- Skin cancers
- Reversible SLE-type illness may evolve
