Rheumatoid Arthritis Flashcards
longstanding complication of RA with sensation of head falling off dropattacks and painless paresthesias of hands and feet
C1-C2 subluxation Can have inflammation that leads to attenuation of transverse ligament that normally limits posterior motion of odontoid process of C2 vertebrae.
Pre op testing
Get flexion and extension XR of neck prior to surgery in case of C1-C2 subluxation atlantoaxial subluxation (important for intubation)
If abnormal XR of neck in RA pt, order what test next?
MRI, if significant subluxation get surgery
preferred therapy for RA (or initial monotherapy)
methotrexate weekly
How to measure RA disease activity?
CDAI or clinical dx activity index
maximum dose for methotrexate
methotrexate 25 mg weekly
how to titrate methotrexate in patients with RA
CDAI score, development of joint damage by radiography or U/S (sees erosions earlier than XR)
Is prednisone useful in tx of RA
Helpful if used WITH methotrexate but long term side effects are large not helpful if primary therapy
What is the role of NSAIDs in RA?
helpful in treating pain and swelling but not disease modifying and doesn’t slow pregoression of dx. Only used for temporary symptom control while methotrexate or other therapies work
Do we use mychophenolate mofetil in RA?
no, not a DMARD and no benefit compared to placebo
Prognostic factors for erosive RA
positive anti CCP antibody and RA
early development of multiple joint inflammation
radiographic erosions
severe functional limitations
lower socioeconomic status and less education
elevated ESR and CRP persistent
joint inflammation >12 weeks
people who have anti CCP antibodies and have higher titers with RA mean
they probably will have poor funcitonal outcomes and more radiographic progression so should be on a more aggressive DMARD compared to other pts to treat their RA
clinical features of RA?
insidious onset, multiple joint pain,
stiffness and swelling morning stiffness lasting hours,
improves with activity
small joints PIP MCP MTP but no DIP
can see monoarthritis in knees and elbows (which occurs later)
what is seen on physical exam with pt who has RA?
affected joints are tender, swollen, limited ROM.
tenosynovitis of palms (trigger finger)
rheumatoid nodules (on elbows)
cervical joint can lead to spine subluxation
Lab imaging results for RA pts
positive anti CCP
high IgM RF
high ESR and CRP
XR with soft tissue swelling and joint space narrowing and boney erosions.
can RA serology be negative and still have disease
yes. diagnosis is based on a point system so if number of joints, ESR/CRP are high, clinical history and physical exam are concerning can treat like RA. Serology can be negative in early disease.
If RA patient is unable to tolerate methotrexate or doesn’t improve on methotrexate alone what do you give?
TNF alpha inhibitor (check tuberculin test prior to starting)
when do we give rituximab in the treatment of RA?
third line tx
in pts who are resistant to usual DMARD therapy (methotrexate or combo with TNF alpha inhibitor)
when do we use sulfasalazine and hydroxychloroquine for RA
for mild disease or in combination with methotrexate in highly active RA dx.
not used alone for moderate to severe dx.
when would you get orthopedic surgery evaluation for RA?
- when have joint pain because of severe functional disability and impending tendon rupture.
- when there’s been longstanding RA and functional limitations not explained by inflammatory aspect of dx. If ESR and CRP are neg and no joint effusions or tenderness but has severe joint dx.
However total joint replacement and soft tissue release and joint fusion only lasts about 10-15 years after.
who should we avoid TNF alpha inhibitors in?
CHF pts.
Could use cautiously in NYHA class 1 and 2 but absolutely contraindicated in 3 and 4.
neck pain radiating to occipital region, slow progressive quadriparesis, painless sensory deficits in hands or feet and respiratory dysfunction (vertebral artery compression)
clinical features of rheumatoid cervical myelopathy
signs of RA cervical myelopathy
protruding anterior arch of atlas, scioliosis with loss of cervical lordosis upper motor neuron signs (spastic paresis, hyperreflexia and Babinski sign) and Hoffman sign
Risk factors for cervical subluxation related to RA
late onset RA< elevated C reactive protein, rapidly progressive peripheral joint dx and early subluxation of peripheral joints.
why do we see cervical subluxation of C1-C2?
because this is the only joint that has synovial membrane. There can be synovitis with erosions that destroys adjacent ligaments anchoring C1 and C2 causing eventual subluxation of C1 relative to C2 most often anteriorly.
Best imaging study to order to see if there’s suspected subluxation
get spinal MRI to visualize the cervical spine for spinal cord compression, boney erosions and synovitis.
patients who have subluxation without signs of core compression should be treated
medically with neck collars and close monitoring of neck prevention
pts who have subluxation with signs of cord compression need
surgery for spinal stabilization
methotrexate toxicity presentation
stomatitis and megaloblastic anemia or small oral ulcers that are non healing
how long does stomatitis last and what are its effects
can persist for days to weeks and can interfere with eating and lead to premature discontinuation of MTX
how what supplement should be given with MTX
give folic acid 1mg/day with dose increase to 5mg/day based on symptoms. Folic acid improves stomatitis and toxicity from MTX
if someone doesn’t improve with folic acid and is on MTX and has stomatitis what to do next?
need to discontinue MTX
common side effects of MTX
fever,
rash in once a week MTX fever can be caused by MTX but needs to be excluded.
GI complaints: are nausea/ upset stomach and can be relieved by PPI or H2 blockers
non healing ulcers and stomatitis.
what kind of rash is associated with MTX
rash is punctuate and macular which affects extremities but spares the trunk. usually will fade by the following week’s MTX dose.
life threatening toxicities with MTX are:
hepatocellular toxicity, or worsening hepatotoxicity in setting of viral hepatitis,
pulmonary damage,
myelosuppression and nephrotoxicity
what should be ordered on a pt who is going to get MTX
needs a CXR and a viral hepatitis panel prio to initiation
What labs should be followed in pts who get MTX:
CMP (liver and Cr), albumin, CBC with diff.
Prognosis of seronegative RA pts
have a somewhat less aggressive course
treatment of RA is with:
Role NSAIDs for acute flairs and treatment of RA
disease modifying antirheumatic agents
NSAIDS only provide pain relief but don’t actually prevent long term joint damage and functional impairment with RA
Prednisone may have some disease modifying effect and are often paired with methotrexate or others. Often used to rapidly improve RA symptoms while waiting for long term DMARDs to be come effective.
1st line DMARDs are
hydroxychloroquine, methotrexate, sulfasalazine, leflunomide
most often people use methotrexate but can use other agents single agent. Leflunomide is used when methotrexate is not tolerated.
hydroxychloroquine (lease potent) is used early in dx when dx activity score is low
synovitis, systemic inflammation, chronic symmetrical polyarticular joint pain and stiffness and elevated CRP and ESR
RA features
adverse effects of MTX
hepatotoxicity stomatitis
pulmonary fibrosis
cytopenia -
folate deficiency rash GI-N/V can see nephrotoxicity non classically works as an antifolate metabolite
doesn’t cause peripheral neuropathy
lefluomide adverse effects
hepatotoxicity,
fetal abnormalities
cytopenia
rarely it causes peripheral neuropathy
can see HTN
pyrimidine synthesis inhibitor (often used when methotrexate is not tolerated)
hydroxychloroquine adverse effects
Hepatotoxicity,
stomatitis,
hemolytic anemia
can see QT prolongation with this TNF and IL-1 suppressor
long term side effects is irreversible damage to the retina - need eye exam at initiation of med and then 5 years after that.
sulfasalazine adverse effects
hepatotoxicity,
stomatitis,
hemolytic anemia
can see TEN and
crystal induced AKI
Acts as TNF and IL-1 suppressor
TNF inhibitors (adalimumab, certolizumab, etancercept, golimumab, infliximab) side effects
infection, demyelination, CHF malignancy
Need to screen for TB and hep B and C prior to starting.
can potentially cause a SLE drug induced dx and a increased risk for lymphoma.
used in many diseases like RA, psoriasis, psoriatic arthritis, ankylosing spondylitis, and Behcet’s dx.
ACR classification for diagnosis of RA:
symptoms >6 weeks inflammatory arthritis >3 joints positive RF or anti CCP elevated ESR/CRP exclusion of other similar conditions: psoriatic arthritis, acute viral polyarthritis, polyarticular gout or CPPD dx, SLE)
can see marginal erosion of joints in RA
see underlying erosive RA
what is the Felty syndrome?
this is RA with splenomegaly and leukopenia seen with long established RA and has a positive RF
treatment of Rheumatoid arthritis
If there’s a positive TST or positive interferon gamma release assay prior to starting a TNF-alpha inhibitor in a RA pt what do you do?
need to treat for latent TB prior to starting TNF antagonist therapy
Before starting a TNF alpha inhibitor what vaccine would you give to a 50 year old woman with RA
give them the recombinant herpes zoster vaccine
recombinant - inactivated vaccine
However the 2019 made no comment on if we can safely give recombinant vaccine to someone with TNF alpha inhibitor.
Ok to give recombinant vaccine with someone who is on methotrexate.
side effect of leflunomide is
Major toxicity are:
severe hypertension
fetal toxicity
hepatoxocity - discontinue if there’s LFTs elevation regardless of symptoms.
DMARD that stops pyrimidine synthesis
considered 1st line agent for RA and can be used with conjunction with biologic or non biologic DMARDs.
felty syndrome is associated with:
neutropenia and splenomegaly
happens in people who have severe untreated RA and they are at risk for serious bacterial infection, lower extremity ulceration, lymphoma and vasculitis.
RA eye involvement:
most common symptom is dry eyes (keratoconjunctivitis sicca)
if they also have dry mouth + dry eyes = secondary Sjogren’s from RA
Less common is episcleritis - inflammation of superficial scleral vessels
Scleritis = inflammation of deep scleral vessels. is vision threatening as there’s thinning of sclera and can have perforation.
keratitis - corneal inflammation and can be ulcerative which iccurs at the periphery of corena
corneal melt - severe keratitis
both scleritis and keratitis need immediate referral to ophthlamologist.
pleural effusion of RA
see pleural effusions which are exudative and large
see low glucose and low pH
low complement levels and elevated levels of total protein, RF, and LDH
what causes majority of RA death?
CAD and atherosclerotic heart dx
interstitial lung dx.
pts who get pregnant and have RA often
2/3 will undergo remission of RA
1/3 will stay the same or get worse.
Rheumatoid medications that are absolutely contraindicated in pregnancy
methotrexate - STOP 3 months prior to pregnancy
leflunomide - extremely tetraogenic - need cholestyramine to remove drug from body and needs to be followed with drug level
mycophenolate mofetil - STOP 3 months prior to pregnancy
Rheumatoid medications that are safe to use in pregnancy:
hydroxychloroquine
sulfasalazine
tylenol
not teratogenic
Medications that are “iffy” and only should be used in pregnancy if benefit outweighs the risk and technically should be avoided:
NSAIDs
glucocorticoids
colchicine
opioids
tramadol
azathioprine
cyclosporine
cyclophosphamide
TNF alpha inhibitors
all the gout drugs.
