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.
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
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)
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
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.
