Rheumatoid Arthritis Flashcards
What is RA?
- Autoimmune condition which causes chronic inflammation of synovial lining of joints
What is the pattern of joint manifestation in RA?
*dont include sx. focus more on distribution of disease
- At least 6 weeks
- At least 3 joints
- Symmetrical
- hands- PIPJ, MCPJ
- worse in morning - gets better after activity
Why the DIPJ not typically affected in RA?
What genes are involved in RA?
- HLA DR4
- HLA DR1
What are the RF for RA?
- F
- Smoker
- Middle age - but can occur in any age
What are RA pt at risk of developing?
cardiovascular disease
What is the Px of RA?
- Rheumatoid Factor RF (which is an IgM) targets Fc portion of IgG
- Activation of systemic immune system against pt own IgG
3.
What are the Sx for RA?
- Symmetrical, swollen, painful, stiff small joints of hands and feet
- worse in morning
Less common
- Sudden onset widespread arthritis
- Recurring mono/polyarthritis
- persistent monoarthitis
What are the signs of RA?
- Early
- swollen MCP, PIP, wirst, MTP joints
- tenosynovitis
- bursitis
- Late
- Ulnar deviation & sublaxation of wrist and fingers
- Boutonniere deformity
- Swan neck deformity
- Z-deformity of thumb
What are the extra-articular signs of of RA?
- Systemic
- fever, weight loss, fatigue
- Eyes
- Episcleritis, scleritis
- Lungs
- Interstitial fibrosis, pleural disease, bronchiolitis obliterans
- Heart
- pericarditis, IHD, pericardial effusion
- MSK
- rheumatoid nodules, Carpal Tunnel Syndrome
- Felty’s syndrome
*
What is Palindromic Rheumatism?
- short episodes of inflammatory arthritis
- last for 1-2days - resolves after
- if RF and anti-cpp + > will prgress to full RA
Where is Heberden’s nodes typically seen in?
OA
What is Boutenniere’s deformity?
- hyperextended DIP
- flexed PIP
What is swan neck deformity?
- hyperextended PIP
- flexed DIP
What is Felty’s syndrome?
*rememebr SANTA
- Splenomegaly
- Anaemia
- Neutropenia
- Thrombocytopenia
- Arthritis
What ix would you order for RA?
*RA is clinically diagnose
Bloods
- RF
- anti-CCP (very specific 98%)
- infalmmatory markers
Imaging
- bilatera xray of hands, feet
What are the hallmark signs of RA on xray?
*remember LESS
- Loss joint space
- Erosions
- Soft tissue swelling
- Soft bone (osteopenia)
What are patiets scored on for RA?
What is the cut off point?
- Joints involved (more and smaller score higher)
- Serology (RF & anti-CPP)
- Infalmmatory markers (ESR, CRP)
- Duration of Sx (more or less than 6 weeks)
What type of questionnaire is used to check response to tx?
Health Assessment Questionnaire (HAQ)
What are the criterias to refer pt for specialist review?
- Any adult with persistent synovitis - even with neg RF and aCCP
- Urgent if
- small joints of hands and feet involved
- multiple joints
- sx persist for 3months
How would you Mx RA?
- Sx relieve
- steroids
- NSAIDs
- Disease Modifying AntiRheumatic Drug (DMARD)
- Biological Therapies
- Surgery
What is the NICE guidelines for DMARD?
- First line
- Hydoxychloroquin - most mild
- Methotrexate
- Leflunomide
- Sulfasalazine
- Second line
- use 2 from above
- Third line
- Methotrexate + TNF inh.
What are the examples of biological therapies?
- Anti TNF
- adalimumab
- infliximab
- entanercept
- Anti CD20
- rituximab
What is the MOA of Methotrexate?
- Inh. dihydrofolate reductase > decrease folate production
What is the dose for Methotrexate and what supplement is co-prescribed with it?
- 2.5mg once weekly
- Folic acid 5mg once weekly
What are the Side efects for methotrexate?
- Pulmonary Fibrosis
- Teratogenic
- Myelosuppressive
What is the MOA of Sulfasalazine?
- Unclear. Act as immunosuppresion
- Safe in pregnancy
What are the side effects of Sulfasalazine?
- Myelosuppresion
- Temporary male infertility
What is the MOA of leflunomide?
- inh. mitochondrial enzyme DODH
- Prevent pyrimidine production
What are the side effects of leflunomide?
- Peripheral neuropathy
- teratogenic
- liver toxicity
- myelosuppresion
What is the MOA of hydroxychloroquin?
- Blocks Toll-like receptors
- disrupt antigen presenting
- increase pH in lysosome of immune cells
Safe in pregnancy
What are the s.e. of Hydroxychloroquin?
- Night mares
- macular toxicity
- liver toxicity
- skin pigmentation
What is the MOA of anti TNF?
- monoclonal antibodies targeting TNF
- prevent inflammation from occuring
What are the s.e. of anti TNF
- reactivation of latent TB, Hep B
- vulnerable to severe infection and sepsis
What are the s.e. of Rituximab?
- night sweats
- thrombocytopenia
What is the histological appearance of subcutaneous nodules in RA?
- Fibrinoid necrosis surrounded by palisading epitheloid cells
What will be the annual primacy care review for RA?
- Assess for flares
- Ensure pt knows how to access specialist help
- Drug monitoring
- Assess disease activity
- Use QRISK and FRAX and other tools to assess comorbidities
- Smoking cessation, exercise, healthy diet
- Offer vaccinations (pneumococcal and influenza)
What are the adverse effects of Sulfasalazine?
- oligospermia (will be back to normal if drug is stoppd`)
- Stevens-Johnson syndrome
- pneumonitis / lung fibrosis
- myelosuppression, Heinz body anaemia, megaloblastic anaemia
- may colour tears → stained contact lenses
What are the contraception and pregnancy advice for pt on methotrexate?
- women should avoid pregnancy for at least 6 months after treatment has stopped
- the BNF also advises that men using methotrexate need to use effective contraception for at least 6 months after treatment
What medications would you use when RA pt have flares?
- corticosteroid PO or IM
