Rheumatoid Arthritis Flashcards

1
Q

rheumatoid arthritis initially

A

diseaseof synovium with gradual inflammatory joint destrucion

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2
Q

2 patterns of joint involvement in RA

A
  • Sero-positive RA
    • rheumatoid factor present
  • Sero-negative RA
    • rheumatoid factor NOT present
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3
Q

RA prevalence

A
  • most common serious joint disease
  • 1% prevalence
  • 6:1 female pre-menopause
  • 3:1 female post-menopause
  • peaks in 3rd-5th decades (20-50yrs) not elderly
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4
Q

osteoarthritis Vs rheumatoid artritis

A

osteoarthritis – cartilaginous covering loss

rheumatoid – symmetrical poly arthritis

  • all synovial joints in body affected – toes, ankles, knees, fingers, wrists, elbows, shoulders, atlanto-occipital, TMJ
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5
Q

joints that can be affected by RA

A

all synovial joints in body

  • symmetrical poly arthritis

toes, ankles, knees, fingers, wrists, elbows, shoulders, atlanto-occipital, TMJ

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6
Q

symptoms of RA

A
  • Fatigue, morning stiffness, joint stiffness/pain/swelling, numbness, tingling, decreased range in motion
  • slow onset
    • initally hands and feet
    • proximal spread
    • potentially ALL synovial structures
  • SYMMETRICAL polyarthritis
  • Occ. onset with SYSTEMIC symptoms
    • fever, weight loss, anaemia
      • systemic illness targeted more at synovial joints than other body systems
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7
Q

early signs of RA

A
  • symmetrical synovitis of MCP joints (meta carpel phalangeal)
  • symmetrical synovitis of PIP joints (proximal carpel phalangeal)
  • symmetrical synovitis of wrist joints

changes cause swelling, stiffness, pain  destruction of joint

(DCP in osteo)

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8
Q

late signs of RA

A
  • ulnar deviation of fingers at MCP joints (pull to ulnar)
    • loss ability of joint to maintain directional integrity
      • tendon action has little/no effect
        • destruction of bone ends means normal range of motion lost so pull of tendon causes different effects
  • hyperextension of PIP joints
    • “swan-neck” deformity
  • “Z” deformity of thumb
    • hyperflexion of MCP
    • hyperextension of IP joint
  • subluxation of the wrist - still attached to tendons but pulled out
  • loss of abduction and external rotation of shoulders
  • flexion of elbows and knees
  • deformity of the feet & ankles
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9
Q

replacement of joints in RA Vs OA

A

rheumatoid arthritis needs functional replacement of joints

whereas

osteoarthritis need replacement of joints due to pain

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10
Q

radiographical signs of RA

A

loss of definition and stability of joints until completely disturbed

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11
Q

RA hands features

A
  • hard to grip and use hands effectively
  • fingers pull far laterally – further than normal circumstance
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12
Q

extra-articular features of RA

7

A
  • Due to systemic vasculitis
    • Inflammation of Blood Vessels
  • present in 75% of patients/
  • Psoriasis in some patients
    • Give much more aggressive form of RA and in younger patients
      • ‘psoriatic arthritis’
  • Eye involvement
    • scleritis & episcleritis,
    • dry eyes, Sjögrens syndrome (dryness)
  • Subcutaneous nodules
    • pressure points
  • Amyloidosis
  • Pulmonary inflammation
  • Neurological
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13
Q

2 investigations for RA

A
  • Radiographs
    • erosions, loss of joint space, deformity
    • joint destruction & secondary osteoarthritis
  • Blood
    • normochomic, normocytic anaemia – failure of RBC stimulation
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14
Q

treatment of RA

A
  • holistic management”
    • aim to improve quality of life
  • combinations of
    • physiotherapy
    • occupational therapy
    • drug therapy
    • surgery
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15
Q

physiotherapy for RA

A
  • Aim to keep the patient active for as long as possible!
    • active and passive exercises
      • to maintain muscle activity
      • to improve joint stability
      • to maintain joint position

delay onset of debilitating disease

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16
Q

occupational therapy for RA

A

continue independent living

  • maximising the residual function
  • providing aids to independent living
  • assessment & alteration of home

live safe and healthy life – stair lift, wet room etc

17
Q

drug therapy for RA in majority of cases

4 types

A
  • analgesics
    • paracetamol, cocodamol
  • NSAIDs
    • Often combined with anti-PUD agents (peptic ulcer disease)
  • Disease Modifying Drugs
    • hydroxychloroquine, methotrexate,
    • Less commonly now: sulphasalzine, penacillamine, gold (new pts rarely started on)
  • Steroids - intra-articular
18
Q

drug therapy for RA in moderate to severe cases (previous drugs ineffective)

2 types

A

Immune modulators used commonly in moderate cases as benefit to pt quality of life and decrease rate debilitating progression

  • Azathioprine
  • Mycophenolate
  • Biologics
    • TNF inhibitors - infliximab, adalimumab, entanercept
    • Rituximab (CD20) & tocilizumab (IL6r)

Steroids – oral prednisolone

19
Q

sugery for RA

A
  • excision of inflamed tissue
    • inflamed synovial causing destruction within the joint
  • joint replacement
    • most synovial joints: fingers, wrist, hip, knees, ankles
  • joint fusion
  • osteotomy

Remember - patients often have a poor medical condition for surgery

20
Q

prognosis for RA

A

pts with joint destruction usually progress

  • 10% spontaneously remit
  • remainder have fluctuating course
  • RF and late onset have worse prognosis
    • 10% severely disabled
  • remainder have mild/moderate disability

REMEMBER complications

  • infection, PUD, extra-articular, DRUGS
21
Q

dental aspects of RA

5 categories

A
  • disability from the disease
    • reduced dexterity for OH measures (elbow, shoulder, fingers, wrist)
    • access to care
  • Sjögren’s syndrome
    • association of CT disease the dry eyes/mouth  high caries
  • Joint replacements
    • multiple - large & small joints
  • drug effects
    • bleeding - NSAIDs & sulphasalazine
    • infection risk - steroids, azathioprine
    • oral lichenoid reactions
      gold, sulphasalazine, hydroxychloroquine
    • oral ulceration - methotrexate
    • oral pigmentation – hydroxychloroquine
  • Chronic anaemia - GA problems – hospital setting
22
Q

atlanto-occipital instability

A

Damage to ligaments in neck – skull base to upper cervical vertebrae

  • Atlas – C1
  • Axis – C2 – dens protrude through C1 with ligament
    • Allows pivoting and turning of head

Ligaments at front and back of neck – support skull

  • Can become weakened in rheumatoid arthritis
    • Slipping of structures in upper neck
      • Sudden trauma – more likely ligaments rupture – bone impinge spinal cord = significant spinal damage
23
Q

3 sero negative sponglyoarthitides

A
  • ankylosing spondylitis
    • spinal joint arthritis – neck and vertebral bodies of spine
      • primary focus on axial skeleton unlike rheumatoid (peripheral tissues more)
  • reiter’s disease
  • arthritis of IBD
24
Q

family of ankylosing spondyloarthropathies

seronegative

A
  • reactive arthritis
  • psoriatic artritis
  • IBD associated arthritis
  • undifferentiated spongylo-arthropathy
  • juvenile spondylo-arthropathy
25
Q

ankylosing spondytlitis

A

spinal joint arthritis – neck and vertebral bodies of spine

  • primary focus on axial skeleton unlike rheumatoid (peripheral tissues more)

loss of facet joints and cartilaginous discs

in AS – fusion of joints and anterior vertebrae – stiff, no movement relative to each other – pt hard to turn, twist and bend

26
Q

features of AS (ankylosing spondylitis and SpA)

sero negative

A
  • association with HLA-B27 (genetic trait)
    • infection likely as a precipitant
      • 95% have
        • 10% caucasians have HLA-B27
        • 0.5% of these get ank. spond
  • often symmetrical peripheral arthritis – spinal is typical
  • ocular & mucocutaneous manifestations
  • 8:1 Male predominance
    • Unusual in autoimmune disease
  • Onset about 20yrs - rare after 45yrs (sim to RA)
  • 20% have large joint disease as well – knee or hip issues
27
Q

features of RA (sero positive)

A
  • 6:1 female pre-menopause
  • 3:1 female post-menopause (similar to SpA)
    • peaks in 3rd-5th decades (20-50yrs)
28
Q

ankyloysing spondylitis effects

A
  • Disabling progressive lack of axial movement
    • Cannot bend head forward to look at something, rigidly focussed ahead – need to move whole body
  • symmetrical other joint involvement – e.g. Hips

Results in:

  • low back pain
  • limited back and neck movement
    • turning spine restricted
  • limited chest expansion
    • breathing compromised – heightened by kyphosis
  • cervical spine tipped forward (Kyphosis) – tip forward
    • due to bone fusion not collapse (osteoarthritis))
  • movements restricted
29
Q

treatment of ankylosing spondylitis

A
  • Generally, the same as Rheumatoid Arthritis:
    • Analgesia & NSAIDs
    • Physiotherapy
    • Occupational therapy
    • DMDs
    • Immune modulators
  • Surgery where appropriate for joint replacement – function not pain
30
Q

dental aspects of AS

A
  • GA hazards – access issues
    • Limited mouth opening
    • Limited neck flexion
  • TMJ involvement possible, but rare except in Psoriatic Arthritis