Rheumatoid Arthritis Flashcards
rheumatoid arthritis initially
diseaseof synovium with gradual inflammatory joint destrucion
2 patterns of joint involvement in RA
- Sero-positive RA
- rheumatoid factor present
- Sero-negative RA
- rheumatoid factor NOT present
RA prevalence
- 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
osteoarthritis Vs rheumatoid artritis
osteoarthritis – cartilaginous covering loss
rheumatoid – symmetrical poly arthritis
- all synovial joints in body affected – toes, ankles, knees, fingers, wrists, elbows, shoulders, atlanto-occipital, TMJ
joints that can be affected by RA
all synovial joints in body
- symmetrical poly arthritis
toes, ankles, knees, fingers, wrists, elbows, shoulders, atlanto-occipital, TMJ
symptoms of RA
- 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
- fever, weight loss, anaemia
early signs of RA
- 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)
late signs of RA
- 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
- tendon action has little/no effect
- loss ability of joint to maintain directional integrity
- 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
replacement of joints in RA Vs OA
rheumatoid arthritis needs functional replacement of joints
whereas
osteoarthritis need replacement of joints due to pain
radiographical signs of RA
loss of definition and stability of joints until completely disturbed
RA hands features
- hard to grip and use hands effectively
- fingers pull far laterally – further than normal circumstance
extra-articular features of RA
7
- 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’
- Give much more aggressive form of RA and in younger patients
- Eye involvement
- scleritis & episcleritis,
- dry eyes, Sjögrens syndrome (dryness)
- Subcutaneous nodules
- pressure points
- Amyloidosis
- Pulmonary inflammation
- Neurological
2 investigations for RA
- Radiographs
- erosions, loss of joint space, deformity
- joint destruction & secondary osteoarthritis
- Blood
- normochomic, normocytic anaemia – failure of RBC stimulation
treatment of RA
- holistic management”
- aim to improve quality of life
- combinations of
- physiotherapy
- occupational therapy
- drug therapy
- surgery
physiotherapy for RA
- 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
- active and passive exercises
delay onset of debilitating disease
occupational therapy for RA
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
drug therapy for RA in majority of cases
4 types
- 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
drug therapy for RA in moderate to severe cases (previous drugs ineffective)
2 types
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
sugery for RA
- 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
prognosis for RA
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
dental aspects of RA
5 categories
- 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
atlanto-occipital instability
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
- Slipping of structures in upper neck
3 sero negative sponglyoarthitides
- ankylosing spondylitis
- spinal joint arthritis – neck and vertebral bodies of spine
- primary focus on axial skeleton unlike rheumatoid (peripheral tissues more)
- spinal joint arthritis – neck and vertebral bodies of spine
- reiter’s disease
- arthritis of IBD
family of ankylosing spondyloarthropathies
seronegative
- reactive arthritis
- psoriatic artritis
- IBD associated arthritis
- undifferentiated spongylo-arthropathy
- juvenile spondylo-arthropathy
ankylosing spondytlitis
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
features of AS (ankylosing spondylitis and SpA)
sero negative
- 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
- 95% have
- infection likely as a precipitant
- 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
features of RA (sero positive)
- 6:1 female pre-menopause
- 3:1 female post-menopause (similar to SpA)
- peaks in 3rd-5th decades (20-50yrs)
ankyloysing spondylitis effects
- 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
treatment of ankylosing spondylitis
- Generally, the same as Rheumatoid Arthritis:
- Analgesia & NSAIDs
- Physiotherapy
- Occupational therapy
- DMDs
- Immune modulators
- Surgery where appropriate for joint replacement – function not pain
dental aspects of AS
- GA hazards – access issues
- Limited mouth opening
- Limited neck flexion
- TMJ involvement possible, but rare except in Psoriatic Arthritis
