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Musculoskeletal > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

how is rheumatoid arthritis defined?

A

symmetrical inflammatory arthritis affecting mainly the peripheral joints

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2
Q

What is the ratio of females to males with rheumatoid arthritis?

A

3:1

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3
Q

What percentage of the UK population currently have RA?

A

1%

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4
Q

What genetic factor is thought to mediate RA?

A

HLA-DR4

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5
Q

What are the potential triggers that could cause RA?

A

infections
stress
cigarette smoking

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6
Q

What joints does RA affect?

A 
Hand joints
wrists
elbows
shoulders
TMJs
C1/C2
hips
knees
ankles
feet
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7
Q

What time frame would be described as early RA?

A

less than 2 years since symptom onset

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8
Q

What two structures in the joint are affected by RA?

A

Synovium and tenosynovium

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9
Q

What are the clinical features of RA?

A

Prolonged morning stiffness.

Involvement of small joints of hands and feet.

Symmetric distribution.

Positive compression tests of metacarpophalangeal(MCP) and metatarsophalangeal(MTP)joints.

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10
Q

What autoantibodies are associated with RA?

A

Rheumatoid factor(Rheumatoid IgM)

Antibodies to cyclic citrullinated peptide
Anti-CCP antibodies

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11
Q

Describe the pathogenesis of RA

A
  • Spongy mass of inflammatory cells in synovium
  • Attracts blood cells and cytokines
  • End result is inflamed synovium which activates osteoclasts
  • Osteoclasts dissolve bone, causing erosion and joint damage
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12
Q

What imaging is used in the diagnosis of RA?

A

Plain x-rays of hands and feet.

Ultrasound scanning.

MRI scans.

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13
Q

What can be seen on an X-Ray with RA?

A

Soft tissue swelling .

Periarticular osteopaenia.

Erosions.

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14
Q

What is the disadvantage of X-Rays in RA?

A

Absence of findings in early disease

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15
Q

Why are ultrasound scans potentially more useful than X-Rays

A

Can detect upto 7 times more MCP erosions than plain x-ray in early RA.

Useful in making treatment changes

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16
Q

Why are MRIs potentially more useful than an X-Ray in RA?

A

Integrity of tendons can be assessed
distinguish synovitis from effusions
detect erosions earlier
monitors disease activity

17
Q

What scoring system is used to asses disease activity in RA?

A

Disease Activity Score 28(DAS 28)

**due to 28 joints potentially being affected (does not count feet)

18
Q

What are the boundaries for disease activity on the DAS28 score

A

> 5.1 Active disease.

  1. 2- 5.1 Moderate disease.
  2. 6-3.2-Low disease activity.

Less than 2.6 Remission.

19
Q

Describe the stages of treatment in RA

A 
Aspirin/NSAIDs
\+ steroids
\+ DMARD 1
\+ DMARD 2
\+ DMARD 3

once in remission - gradually withdraw Tx

20
Q

What steroid injections can be used in RA?

A

3 IM injections of 120 mg methylprednisolone every 4 weeks

If fewer than 5 joints involved = Intra-articular injections

21
Q

What DMARDs are used in RA?

A

Methotrexate
Sulfasalazine
Hydroxychloroquine

*can be used in combination

22
Q

What is the drawback of using Hydroxychloroquine alone?

A

Does not prevent erosions

23
Q

How is methotrexate used to treat RA?

A

Start at 15 mg/week with rapid escalation .

Maximum dose 25 mg/week.

Folic acid 24 hours after MTX dose.

24
Q

Why is regular monitoring required when patients are on DMARDs?

A

Bone marrow suppression.
Infection.
Liver function derangement.
Pneumonitis in case of methotrexate.

25
Q

What biological agents are used to treat RA and what feature of the immune response do they block?

A

Anti TNF agents - Infliximab,Etanercept,Adalimumab

T cell receptor blocker - Abatacept

B cell depletor - Rituximab

IL-6 blocker - Tocilizumab

JAK 2 inhibitors - Tofacitinib

26
Q

What criteria must be met for a patient to be started on biologic agents?

A
  • Failure to respond to 2 DMARDs including Methotrexate

- DAS 28 greater than 5.1 on two occasions 4 weeks apart.

27
Q

What is co-prescribed with biologics?

A

Methotrexate

28
Q

What infections must be screened for when using biologic agents?

A

Screen for latent or active TB ,Hep B/C, HIV, Varicella zoster.

29
Q

What type of vaccine must be avoided in Biologics patients?

A

Avoid live attenuated vaccines.

30
Q

What clinical sign is seen in the hands of patients with severe RA?

A

Swan-neck deformitiy of fingers
ulnar deviation of MCP joints
Boutonniere deformity of the Thumb

31
Q

What can C1-C2 involvement cause?

A

Atlanto-axial subluxation and instability

=> when leaning head forward, only atlas moves instead of whole spine

Musculoskeletal (27 decks)

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