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Stage 2: Inflammation > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

What is the peak age of onset for RA?

A

35-45 years

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2
Q

Which gender is more affected by RA?

A

Females

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3
Q

What imaging techniques do you use in RA?

A

Ultrasound, doppler, MRI, X ray

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4
Q

What will you see in an ultrasound in RA e.g. finger side on?

A
  • Synovial hypertrophy

- Joint lining should be flat on the bone but it is being pushed up bu lots of inflammatory cells

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5
Q

What will you see in a doppler in RA?

A
  • Red/yellow indicates blood vessels

- Demonstrates angiogenesis (blood flow should not be live this in a normal joint)

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6
Q

What might you see in an MRI of carpal bones in RA?

A

It should be bright white however there are multiple punched out areas that are black indicating eroded bone

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7
Q

What would you normally see in a hand examination of someone presenting with a new diagnosis of RA?

A

Swelling of PIPs incl. thumbs

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8
Q

What clinical features might you see on hands of someone with established RA?

A
  • Chronic inflammation and swelling along MCP joints
  • Fingers start to deviate outwards towards the ulnar side/5th digit due to erosion and damage of MCP joints
  • Swan neck deformity - hyperextension of PIP and flexion of DIP
  • Boutonniere deformity - flexion of PIP and hyperextension of DIP
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9
Q

What is one of the first investigations you would do in someone with RA?

A

X ray (simple, cheap, no harm to patient)

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10
Q

What can you see on a hand X ray of someone with RA?

A

Bony erosion changes - can see where bone has eroded (less defined edges)

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11
Q

How can feet be affected in RA?

A
  • Swelling and damage of the MTP joint

- Rheumatoid foot disease (more rare now)

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12
Q

Which spine can be involved in RA (other spines v rarely involved)?

A

Cervical

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13
Q

How can the cervical spine be affected in RA?

A
  • Can get erosion of the odontoid peg of the atlas which sits on the axis
  • Spine should move in complete alignment and when you get damage of the odontoid peg, you can get forward movement of the atlas over the axis when the head moves forwards
  • Problem bc spinal cord runs all the way down the front of the vertebrae and any movement on it can cause cord compression
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14
Q

Where else in the body can be affected by RA other than joints?

A
  • Anywhere (systemic inflammation)
  • Main organs affected = eyes, lungs, skin
  • Chronic inflammation can cause amyloidosis e.g. in kidney
  • Neuropathy, respiratory, CV
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15
Q

Describe rheumatoid nodules

A
  • Often painless
  • Tend to occur in areas of friction e.g. elbows, fingers
  • Occur in people who have had long standing erosive disease who are often anti-CCP and RF positive
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16
Q

What are two features of rheumatoid lung disease?

A
  • Chest nodules

- Pulmonary fibrosis in people with long standing disease

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17
Q

What imaging can be used to see chest nodules?

A

X ray or CT (clearer)

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18
Q

What can happen to (chest) nodules in RA?

A

Fat necrosis

- Tissue within these soft tissue nodules can sometimes get absorbed way so they can often look like little cavities

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19
Q

How can RA affect the eye and how do these conditions present?

A

1) Scleritis or episcleritis - eye pain, watering and redness over sclera
2) Corneal ulcers (white blob in iris) - feeling of grittiness in eye, pain, blurred vision
3) Necrotising scleritis - worst case scenario, recurrent episodes of scleritis, sclera starts to thin and can have perforation of sclera (v painful)

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20
Q

What skin condition can people with long standing RA rarely get?

A

Small vessel vasculitis affecting vessels that supply the skin - rheumatoid vasculitis with skin involvement

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21
Q

What two conditions are patients with RA at increased risk of?

A

CVD (incidence and fatality) and cancer (28% increased incidence)

22
Q

Why are RA patients at increased risk of CVD?

A

1) Traditional risk factors are more prevalent in those with RA
2) The inflammatory process of RA (constant cytokine release and inflammatory cells in body) has a direct impact on the vascular bed, leading to premature atherosclerosis

23
Q

Why are RA patients at increased risk of cancer?

A

Bc the immune system is not behaving normally and not doing the normal surveillance

24
Q

Which types of cancers are more common in people with RA?

A
  • Lung cancers

- Non-Hodgkin lymphomas

25
Q

What are the 4 DMARDs which are the main drugs used in RA?

A

1) Methotrexate
2) Leflunomide
3) Sulfasalazine
4) Hydroxychloroquine

26
Q

What are the benefits of using combination of therapies?

A
  • Reduced radiographic progression
  • Patients have better impacts at 12 months
  • No significant difference in toxicity
27
Q

What are the aims of treatment in RA (incurable disease)?

A

1) Relief of symptoms
2) Conservation and restoration of function in affected joints (may involve surgery)
3) Suppression of active progressive disease using medication and other methods
4) Reduce morbidity and loss of QoL associated with RA

28
Q

Which is the stronger NSAID that a doctor may prescribe if the patient was already taking NSAIDs (and paracetamol)?

A

Naproxen

29
Q

What are the benefits of using NSAIDs?

A
  • Less toxic?

- Used easily unlike MTX/steroids which need to be monitored

30
Q

Describe modern RA treatment (traditional = symptom treatment, less aggressive, NSAIDs)

A
  • Limit joint destruction reducing the amount of surgeries
  • Early aggressive treatment to aim for remission
  • MTX used early (incl. in elderly and young)
  • Combination therapy e.g. DMARDs, NSAIDs
  • Increasing use of biologics/biosimilars
31
Q

What are the symptoms of RA?

A
  • Joint pain and swelling (sore if touch)

- Early morning stiffness (due to drop in cortisol levels)

32
Q

What topical treatment can be used to treat RA?

A

Capsaicin containing cream

  • First time activates sensory nerves
  • After first time works to desensitise them, improving pain
33
Q

What outcome measure is used in RA at every clinic appointment?

A

DAS28 (disease activity score 28 joint count)

34
Q

Describe the 4 components of DAS28

A

1) 28 tender joint count
2) 28 swollen joint count
3) ESR/CRP (blood test)
4) Their assessment of how their global health is on a scale of 0-100 (best to worst)

35
Q

Describe how the DAS28 score is used?

A
  • Gives an overriding image of how bad their RA is
  • Score from 0-10
  • Escalate therapy if score is > 5.2 (v high)
  • Remission target = 2.7
  • Weighted towards swollen joint count and blood test so if someone is feeling bad bc of other cause, won’t drive DAS28 up
36
Q

Why is infliximab used less frequently and what is used instead?

A
  • Bc it is IV formulation

- Replaced by s/c options (other 4 TNF options) e.g. adalimumab pens

37
Q

What is the IL-6 inhibitor used in RA and how does it work?

A

Tocilizumab

  • Binds to IL-6 receptor so stops IL-6 binding and stops a lot of its effects
  • Given s/c in a pen similar to TNF inhibitors
38
Q

Describe the action and use of rituximab

A
  • Mab targets CD20 molecule expressed on the surface of B cells
  • Causes apoptosis and depletion of B cells
  • Tends to affect the B cells that are terminally differentiated so doesn’t affect population, only the effector B cells
  • Efficacy persists long after drug clearance
  • Only effective in seropositive patients (anti-CCP and RF positive)
39
Q

What drugs are used to treat RA?

A

NSAIDs, topical treatments, steroids (incl. injected into joint), DMARDs, anti-TNF therapy (adalimumab), rituximab, tocilizumab

40
Q

What is RA?

A

Inflammatory arthritis

41
Q

How quickly should patients with suspected RA be referred to specialist care?

A

Within 3 working days, to start on treatment asap to reduce future treatment and disease progression

42
Q

What is a key early symptoms of RA?

A

Joint pain/tenderness (arthralgia), no swelling

43
Q

Describe the joint involvement in RA

A
  • Symmetrical proximal polyarticular small joint inflammatory arthritis
  • Mainly MCP and PIP
  • DIP almost universally spared
44
Q

What % of inflammatory arthritis is RA?

A

70-80%

45
Q

What are RA patients seropositive for?

A

Rheumatoid factor and anti-CCP

46
Q

What is the difference between OA and RA?

A

1) OA - bone ends rub together, thinned cartilage

2) RA - swollen inflamed synovial membrane, bone erosion

47
Q

What is RA?

A

A chronic inflammatory systemic autoimmune disease which mainly manifests in joints but has extra-articular involvement

48
Q

What is an inflammatory arthropathy?

A

An autoimmune disease that causes inflammation of the musculoskeletal system

49
Q

Describe the presentation of septic arthritis

A
  • Red, swollen, hot, painful joint
  • History of systemic infection
  • Generally monoarthritis (one joint affected) - should be septic until proven otherwise
  • Emergency presentation, need urgent treatment
  • High mortality
  • Need to be admitted with at least 2 weeks of IV abx and then month of oral abx
50
Q

What is the difference between arthralgia and arthritis?

A 
Arthralgia = joint pain 
Arthritis = join inflammation
51
Q

What might you take a fluid sample of to analyse arthritis?

A

Synovial fluid analysis

Stage 2: Inflammation (39 decks)

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