Rheumatoid arthritis Flashcards
What is the reduced life-expectancy in RA
7-10 years - CV disease
Which alleles confer susceptibility in Anti-CCP positive RA
HLA-DRAB1*01 HLA-DRAB1*04 HLA-DRAB1*15 CTLA4 STAT4
Which alleles confer susceptibility in Anti-CCP negative RA
HLA-DRAB103
HLA-DRAB113
IRF5
STAT 4
Which environmental risk factor increase risk in lung?
Smoking
Which environmental risk factor increase risk in mouth?
Periodontal disease
Which environmental risk factor increase risk in GIT?
Microbiome
What are Rheumatoid Factors?
Antibodies directed against Fc portion of human IgG
What are Anti-CCP antibodies?
Highly specific antibodies against citrullinated proteins that are the hallmarks of the immune response to RA
What manifestations are associated with ACPA?
More severe and destructive disease
RA-related interstitial lung disease and CVD
Which epigenetic factors interact/trigger?
Synovial fibroblast-like synoviocytes
Which are the major cytokines involved in pathogenesis
TNF
IL-17A/F
IL-1
IL-6
What signalling factor mediates bone damage?
RANK ligand
What are the clinical features?
Asymmetric, insidious onset
Morning stiffness
Small joints first
Which joints are typically spared?
DIPs
What is Palindromic rheumatism?
Articular pain then swelling and erythema
Symptoms wrose for hours to a few days
Then resolve in reverse sequence
What percentage of pt with palindromic rheumatism go onto dev RA?
50%
What is more common in elderly?
Stiffness ? synovitis
What is RS3PE?
Remitting, seronegative, symmetric synovitis with pitting oedema syndrome
What are the clinical and serological features of RS3PE?
Oedema of dorsum of hand or foot (boxing glove appearance)
Tenosynovitis
Seronegative for RF and ACPA
What is the underlying concern with RS3PE?
Can be paraneoplastic
Which direction does the wrist deviate?
Radially
Which direction do the fingers deviate at the MCPs?
Ulnar
Which direction do the finger joints go with Swan neck?
PIP herniates in volar direction
Flexion at DIP
Which direction do the finger joint go with Boutonniere deformity?
PIP flexion to rupture of extensor tendons
DIP extension
(opposite to swan neck)
Which foot joint is effected first in feet?
5th MTP commonly
What are the derm manifestations
Rheumatoid nodules
Vasculitis
Ulcers
Neutrophilic dermatosis
What are the ophthalmic manifestations
Episcleritis
Scleritis
Perilimbic ischaemic ulcers
Secondary Sjogren’s syndrome
What are the pulmonary manifestations?
Pleuritis Pleural effusions Nodules NSIP/UIP Bronchiectasis
What are the CV manifestations?
Premature atherosclerosis
Pericarditis, pericardial effusion
What are the radiographic characteristics?
Periarticular soft tissue swelling Juxta-articular osteoporosis Marginal erosions Joint space narrowing Symmetric involvement Deformities
What does Power Doppler positivity portend?
Progression to erosive disease
When do you consider biological DMARDs?
Active disease after two or more conventional DMARDs for 6 months
What is the ACR70 response rate of methotrexate?
20-40%
What dose cut off such subcut MTX be considered?
15mg/week
What AEs for MTx?
Nausea Ulcer Abnormal LFTs Cytopenia Pneumonitis Teratogenicity
How much EtOH can be consumed without increasing risk of transaminitis?
<14units per week
How is methotrexate excreted?
Renally
Which medication shouldn’t MTx be combined with
Trimethoprim
What is hte ACR70 response rate of sulfalazine
8%
Common AEs of ssz?
Hypersensitivity reaction Nausea Diarrhoea Agranulocytosis Drug-induced lupus Azoospermia
AE of hydroxychloroquine?
Hyperpigmentation
Retinopathy
Myopathy and cardiomyopathy
What is hte mech of leflunomide?
Inhibit DHODH (dihydroorate dehydrogenase)
AE of leflunomide?
Diarrhoea (~25%) Hypertension Hypersensitivity LFTs and pneumonitis esp. when w MTx Leukocytopenia Teratogenicity Peripheral neuropathy
Which biologics inhibitor TNF?
Infliximab Etanercept Adalimumab Golimumab Certolizumab
What is the ACR70 response rate of TNFi
20%
Which TNFi is safest in pregnancy?
Certolizumab
What relative contraindications are their for TNFi
SLE Demyelinating disorder Infections CCF Pregnancy
TNFi AE
Infection Malignancies - skin and lymphoma Demyelinating conditions Lupus-like syndrome Hepatic Dermatologic reaction
What is the mechanism of abatacept?
CD80 and CD86 inhibitor
What is the mech of tocilizumab
IL-6 receptor inhibitor
Which biologic effects CRP?
Tocilizumab
Which medications are the JAK inhibitors?
Tofacitinib and baricitinib
Which infection in particular do you get with JAK inhibitors?
Herpes zoster
