Rheumatoid Arthritis Flashcards
What are 5 typical features of rheumatoid arthritis?
- Swollen, painful joints in hands and feet
- Stiffness worse in the morning
- Gradually worse with larger joints becoming involved
- Presentation usually insidiously develops over few months
- Positive ‘squeeze test’ - discomfort on squeezing across metacarpal or metatarsal joints
How do the symptoms of rheumatoid arthritis usually develop?
insidious over a few months, gradually worsening with larger joints getting involved
What are 2 hand features of rheumatoid arthritis?
swan neck and boutonnière deformities
When do swan neck and boutonière deformities often appear in rheumatoid arthritis?
late features - unlikely to present in recently diagnosed patient
In addition to the gradual worsening of symptoms over months in rheumatoid arthritis, what are 2 other ways it may present?
- Acute onset with marked systemic disturbance
- Relapsing/ remitting monoarthritis of different large joints (palindromic rheumatism)
What do NICE say is the most important way to diagnose rheumatoid arthritis?
clinical diagnosis more important than criteria, such as those defined by American College of Rheumatology
What is a key set of criteria that may be used to aid diagnosis of rheumatoid arthritis?
2010 American College of Rheumatology criteria
What are the 2 features of the target population for the American College of Rheumatology criteria?
- patients have at least 1 joint with definite clinical synovitis
- with the synovitis not better explained by another disease
What score is needed for a definite diagnosis of rheumatoid arthritis based on the American College of Rheumatology criteria?
6/10
What are the 4 aspects of American College of Rheumatology criteria?
- A: Joint involvement
- B: Serology (at least 1 test result is needed for classification)
- C: Acute phase reactants (at least 1 test result needed for classification)
- D: Duration of symptoms
What are the 4 points to part A: joint involvement of the American College of Rheumatology criteria?
- 1 large joint: 0
- 2-10 large joints: 1
- 1-3 small joints (with or without involvement of large joints): 2
- 4-10 small joints (with or without involvement of large joints): 3
- 10 joints (at least 1 small joint): 5
What are 3 parts to part B: serology of the American College of Rheumatology criteria?
- Negative rheumatoid factor and negative anti-citrullinated peptide antibody: 0
- Low positive RF or low positive ACPA: 2
- High positive RF or high positive ACPA: 3
What are 2 parts to part C: acute-phase reactants of the American College of Rheumatology criteria?
- Normal CRP and normal ESR: 0
- Abnormal CRP or abnormal ESR: 1
What are 2 parts to part D: duration of symptoms of the American College of Rheumatology criteria?
- <6 weeks: 0
- > 6 weeks: 1
What are 3 early x-ray findings in rheumatoid arthritis?
- Loss of joint space
- Juxta-articular osteoporosis
- Soft-tissue swelling
What are 2 late x-ray findings in rheumatoid arthritis?
- Peri-articular erosions
- Subluxation
What are 7 poor prognostic features of rheumatoid arthritis?
- Rheumatoid factor positive
- anti-CCP antibodies
- poor functional status at presentation
- HLA-DR4
- x-ray: early erosions (e.g. after 2 years)
- extra-articular features e.g. nodules
- insidious onset
What do sources suggest is the gender associated with a poor prognosis in rheumatoid arthritis?
female
What type of antibody is rheumatoid factor?
usually IgM
How does rheumatoid factor act in the patient’s body?
it’s a circulating antibody, usually IgM, which reacts with the Fc portion of the patient’s own IgG
What are 2 tests that are able to detect rheumatoid factor?
- Rose-Waaler test: sheep red cell agglutination
- Latex agglutination test (less secific)
Which is the more specific test at detecting rheumatoid factor?
Rose-Waaler test: sheep red cell agglutination
What proportion of patients with rheumatoid arthritis are rheumatoid factor positive?
70-80%
In addition to RA what are 7 conditions associaed with a positive RF?
- Sjogren’s syndrome
- Felty’s syndrome
- Infective endocarditis
- SLE
- Systemic sclerosis
- General population: 5%
- rarely: TB, HBV, EBV, leprosy
When may anti-CCP antibody be detectable in relation to the onset of RA?
may be detectable up to 10 years before development
What role may anti-CCP antibody play in the future?
may allow early detection of patients suitable for aggressive anti-TNF therapy
What are the sensitivity and specificity of anti-CCP?
- 70% sensitivity - similar to RF
- 90-95% specificity - much higher than RF
When does NICE suggest you should test a patient for anti-CCP antibodies?
in patients you suspect have RA who are rheumatoid factor negative
What are 8 of the possible respiratory problems that may be seen in patients with rheumatoid arthritis?
- Pulmonary fibrosis
- Pleural effusion
- Pulmonary nodules
- Bronchiolitis obliterans
- Complications oof drug thearpy e.g. methotrexate pneumonitis
- Pleurisy
- Caplan’s syndrome
- Infection (possibly atypical) secondary to immunosuppression
What is Caplan’s syndrome?
massive fibrotic nodules with occupational coal dust exposure
What proportion of rhuematoid arthritis patients have eye problems?
25%
What are 5 of the ocular manifestations of rheumatoid arthritis?
- keratoconjunctivitis sicca
- episcleritis (erythema)
- scleritis (erythema and pain)
- corneal ulceration
- keratitis
What is the most common ocular manifestation of rheumatoid arthritis?
keratoconjunctivitis sicca
What are 2 iatrogenic eye problems seen in rheumatoid arthritis?
- steroid-induced cataracts
- chloroquine retinopathy
What is the overall management of rheumatoid arthritis once diagnosis is made?
should start ombination of disease-modifying drugs (DMARD) as soon as possible
also require analgesia, physiothearpy and surgery
What do NICE guidelines recommend for the initial DMARD therapy for rheumatoid arthritis?
recommend DMARD monotherapy ± short-course of bridging prednisolone
What are the 2 ways that NICE recommends monitoring response of RA to treatment?
- CRP and
- disease activity using a composite score such as DAS28
What is the management of flares in RA?
usually managed with corticosteroids - oral or intramuscular
What are the 2 routes that corticosteroids may be administered for flares of RA?
oral or IM
What are 4 examples of DMARDs which can be used to treat RA?
- Methotrexate
- Sulfasalazine
- Leflunomide
- Hydroxychloroquine
What is the most widely used DMARD to treat RA?
methotrexate
What are 2 importants aspects of monitoring of methotrexate and why?
- FBC
- LFTs
due to risk of myelosuppression and liver cirrhosis
What are 3 important side effects of methotrexate?
- Myelosuppression
- Mucositis
- Pulmonary fibrosis
- Liver cirrhosis
- Pneumonitis
In addition to DMARDs what are 3 other drugs which can be used to manage RA?
- TNF-inhibitors
- Rituximab
- Abatacept
What are 3 examples of TNF inhibitors?
- Etanercept
- Infliximab
- Adalimumab
What is the current indication for a TNF-inhibitor in RA?
inadequate response to at least 2 DMARDs including methotrexate
What is etanercept, an example of a TNF-inhibitor, made from? How does it work?
recombinant human protein; acts as a decoy receptor for TNF-alpha
Via which route is etanercept, a TNF-ihibitor, administered?
subcutaneous administration
What are 2 adverse effects associated with etanercept?
- Demyelination
- Reactivation of tuberculosis
What is infliximab (TNF-inhibitor example) and how does it work?
monoclonal antibody; binds to TNF-alpha and prevents it from binding with TNF receptors
What is the route of adminisrtation of infliximab?
IV
What is one of the risks of infliximab?
reactivation of tuberculosis
What is the route of administration of adalimumab?
subcutaneous
What is rituximab and what is the mode of action to treat RA?
anti-CD20 monoclonal antibody
results in B-cell depletion
How is rituximab administered?
two 1g intravenous infusions given 2 weeks apart
What is a disadvantage of the use of rituximab?
infusion reactions are common
What is the mechaism of action of abatacept?
fusion protein that modulates a key signal required for activaiton of T lymphocytes
leads to decrease T-cell proliferation and cytokine production
How is abatacept administered?
given as an infusion
Which type of RA drug does NICE not currently recommend?
abatacept
What are 4 side-effects of sulfasalazine?
- Rashes
- Oligospermia
- Heinz body anaemia
- Interstitial lung disease
What are 3 side effects of leflunomide?
- Liver impairment
- Interstitial lung disease
- Hypertension
What are 2 side effects of hydroxychloroquine?
- Retinopathy
- Corneal deposits
What are 5 side effects of prednisolone?
- Cushingoid features
- Osteoporosis
- Impaired glucose tolerance
- Hypertension
- Cataracts
What is a side effect of gold when used to treat RA?
proteinuria
What are 2 side effects of penicillamide?
- Proteinuria
- Exacerbation of myasthenia gravis
What are 6 types of extra-articular complications of RA?
- Respiratory
- Ocular
- Osteoporosis
- Ischaemic heart disease
- Increased risk of infections
- Depression
What is a condition that RA’s risk of ischaemic heart disease is comparable to?
type 2 diabetes mellitus
What are 2 rare extra-articular complications of RA?
- Felty’s syndrome
- Amyloidosis
What are the 3 features of Felty’s syndrome?
- RA
- Splenomegaly
- Low white cell count
What advice should be given to patients with early or poorly controlled RA when it comes to conception?
should be advised to defer conception until their disease is more stable
What is sometimes seen with RA symptoms in pregnancy?
tend to improve in pregnancy, only resolve in small minotirty
tend to have a flare following delivery
What are the rules about methotrexate and pregnancy?
not safe: needs to be stopped at least 6 months before conception
What are the 2 DMARDs not safe in pregnancy?
methotrexate and leflunomide
What are 2 DMARDs that are considered safe in pregnancy?
- Sulfasalazine
- Hydroxychloroquine
What is said about TNF-alpha blockers in pregnancy?
studies suggest no significant increase in adverse outcomes
What is thought about the safety of corticosteroids in pregnancy?
low-dose corticosteroids may be used in pregnancy to control symptoms
What is said about the use of NSAIDs in pregnancy?
may b used until 32 weeks but after this should be withdrawn due to risk of early close of ductus arteriosus
Who should patients with RA be referred to in pregnancy and why?
obstetric anaesthetist: risk of atlanto-axial subluxation
What is the mechanism of action of methotrexate?
antimetabolite that inhibits dihydrofolate reductase; an enzyme essential for synthesis of purines and pyrimidines
What is said about men using methotrexate and conception?
advises men using methotrexate use effective contraception for at least 6 months after treatment
How is methotrexate taken?
weekly rather than daily
What blood tests should be done before and during treatment with methotrexate?
- FBC and U+Es and LFTs should be done before starting and weekly until therapy stabilised
- then monitor every 2-3 months
What must be co-prescribed with methotrexate and how is it taken?
folic acid 5mg once wekly taken more than 24hours after methotrexate dose
What is the starting dose of methotrexate?
- 5mg weekly
(2. 5mg tablets of methotrexate are prescribed)
What are 2 types of drug reaction with methotrexate?
- Trimethoprim or co-trimoxazole - increase risk of marrow aplasia
- High dose aspirin - increases risk of methotrexate toxicity secondary to reduced secretion
What is the treatment of choice for methotrexate toxicity?
folinic acid
