Rheumatoid Arthritis Flashcards
What is RA?
Inflammatory Arthritis
Autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa
What is the typical distribution of RA?
Tends to be symmetrical
Affects multiple joints
Symmetrical polyarthritis
Who gets RA?
Three times more common in women
Most often develops in middle age
FH increases risk
Genetic associations with RA
HLA DR4 (a gene often present in RF positive patients)
HLA DR1 (a gene occasionally present in RA patients)
What is Rheumatoid Factor?
Autoantibody presenting in around 70% of RA patients
Targets the Fc portion of the IgG antibody
What are Cyclic citrullinated peptide antibodies (anti-CCP antibodies)
Autoantibodies
More sensitive and specific to rheumatoid arthritis than rheumatoid factor
Often pre-date the development of RA - indication patient will go on to develop RA
How does RA present?
Symmetrical distal polyarthropathy
Typically the wrist, ankle, MCP and PIP (very rarely DIP) joints in the hands
Joint:
Pain
Swelling
Stiffness
Onset of RA
Can be very rapid (i.e. overnight) or over months to years
Associated systemic symptoms of RA (4)
Fatigue
Weight loss
Flu like illness
Muscles aches and weakness
Pain in RA - rest/activity
Improves with activity
Worse after rest
What is atlantoaxial subluxation?
Axis (C2) and the odontoid peg shift within the atlas (C1)
Caused by local synovitis and damage to the ligaments and bursa around the odontoid peg
Can cause spinal cord compression
Hand signs in RA (5)
Boggy joints
Z shaped deformity to the thumb
Swan neck deformity (hyperextended PIP with flexed DIP)
Boutonnieres deformity (hyperextended DIP with flexed PIP)
Ulnar deviation of the fingers at the knuckle (MCP joints)
Extra-articular Manifestations (11)
Pulmonary fibrosis with pulmonary nodules (Caplan’s syndrome)
Bronchiolitis obliterans (inflammation causing small airway destruction)
Felty’s syndrome (RA, neutropenia and splenomegaly)
Secondary Sjogren’s Syndrome (AKA sicca syndrome)
Anaemia of chronic disease
Cardiovascular disease
Episcleritis and scleritis
Rheumatoid nodules
Lymphadenopathy
Carpel tunnel syndrome
Amyloidosis
Investigations in RA
Check rheumatoid factor
If RF negative, check anti-CCP antibodies
Inflammatory markers such as CRP and ESR
X-ray of hands and feet
Xray changes in RA (4)
Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions
Diagnosis
Based on:
Joints that are involved (more and smaller joints score higher)
Serology (rheumatoid factor and anti-CCP)
Inflammatory markers (ESR and CRP)
Duration of symptoms (more or less than 6 weeks)
What is DAS28?
Disease Activity Score
Assessment of 28 joints
Swollen joints
Tender joints
ESR/CRP result
What is HAQ?
Health Assessment Questionnaire
Measures functional ability
NICE recommend using this at diagnosis to check the response to treatment
What worsens the prognosis of RA? (5)
Younger onset
Male
More joints and organs affected
Presence of RF and anti-CCP
Erosions seen on xray
Treatment during flare ups
Monitoring treatment
NSAIDs/COX-2 inhibitors - minimal effective dose
(PPI)
CRP and DAS28 is used to monitor the success of treatment
First line treatment
Disease Modifying Anti-Rheumatic Drugs (DMARDs)
Methotrexate
Leflunomide
Sulfasalazine
(Hydroxychloroquine used in mild disease)
Second third and fourth line treatment
2nd - 2 1st line used in combination
3rd - methotrexate plus a biological therapy, usually a TNF inhibitor
4th - methotrexate plus rituximab
Treatment in pregnancy
Sulfasalazine and hydroxychloroquine
Biologics used in RA
Anti-TNF (adalimumab, infliximab, etanercept, golimumab and certolizumab pegol)
Anti-CD20 (rituximab)
Anti-IL6 (sarilumab)
Anti-IL6 receptor (tocilizumab)
JAK inhibitors (tofacitinib and baricitinib)
How does methotrexate work?
Interferes with the metabolism of folate
Suppresses certain components of the immune system
Folic acid 5mg also prescribed
SE of Methotrexate (5)
Mouth ulcers and mucositis
Liver toxicity
Pulmonary fibrosis
Bone marrow suppression and leukopenia (low white blood cells)
It is teratogenic (mothers and fathers)
How does Leflunomide work?
immunosuppressant
Interfering with the production of pyrimidine (important component of RNA and DNA)a
SE of Leflunomide (7)
Mouth ulcers and mucositis
Increased blood pressure
Rashes
Peripheral neuropathy
Liver toxicity
Bone marrow suppression and leukopenia (low white blood cells)
It is teratogenic
How does sulfasalazine work?
Immunosuppressive
Anti-inflammatory
Appears to be safe in pregnancy
SE of sulfasalazine
Temporary male infertility (reduced sperm count)
Bone marrow suppression
SE of Hydroxychloroquine
Nightmares
Reduced visual acuity (macular toxicity)
Liver toxicity
Rash
What is TNF?
Cytokine involved in stimulating inflammation
SE of Anti-TNF drugs
Vulnerability to severe infections and sepsis
Reactivation of TB and hepatitis B
Action of rituximab
Targets the CD20 protein on the surface of B cells
Causes destruction of B cells
SE of rituximab (5)
Vulnerability to severe infections and sepsis
Night sweats
Thrombocytopenia (low platelets)
Peripheral neuropathy
Liver and lung toxicity
Unique SE of drugs used in RA
Methotrexate: pulmonary fibrosis
Leflunomide: Hypertension and peripheral neuropathy
Sulfasalazine: Male infertility (reduces sperm count)
Hydroxychloroquine: Nightmares and reduced visual acuity
Anti-TNF medications: Reactivation of TB or hepatitis B
Rituximab: Night sweats and thrombocytopenia
