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Joints, bones and skin > Rheumatoid Arthritis and psoriatic arthritis > Flashcards

Rheumatoid Arthritis and psoriatic arthritis Flashcards

1
Q

What is rheumatoid arthritis?

A

Symmetrical synovitis of small synovial joints
Peripheral polyarthritis

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2
Q

What are acute phase reactants?

A

CRP, ESR - inflammatory markers

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3
Q

What is the threshold for diagnosis RA?

A

= or > 6 classification criteria met

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4
Q

What is the blood test for RA?

A

Anti-CCP (much more sensitive and specific than rheumatoid factor, but RF still recommended by NICE)

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5
Q

Aim of treatment

A

Low disease activity or remission and sustained

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6
Q

Management RA

A

DMARD, add another DMARD, biological agents

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7
Q

How do you manage an acute flar of rheumatoid arthritis?

A

Intramuscular steorids eg methylprednisolone

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8
Q

How do corticosteroids work?

A

have a primarily glucocorticoid effect and result in inhibition of proinflammatory cytokine production - rapid reduction in inflammation

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9
Q

When are corticosteroids used?

A

Short term relief to improve pain and discomfort - rapid reduction in inflammation

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10
Q

When are TNF inhibitors indicated in rheumatoid arthrtiis?

A

When 2 DMARDs including methptrexate have an inadequate response

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11
Q

What are etanercept and infliximab?

A

TNF inhibitors

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12
Q

What is the initial management of Rheumatoid arthritis?

A

DMARD monotherapy +/- short course bridging prednisolone

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13
Q

How do you monitor response to treatement in RA?

A

CRP + disease activity eg DAS28 (disease activity score calculator for RA)

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14
Q

Score for RA

A

DAS28 - 28 joints assess
Score from 1-10

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15
Q

Score for RA

A

DAS28 - 28 joints assess
Score from 1-10
ACR criteria
ACR 20, means that that patient has improved their tender and painful joint counts by 20 percent, as well as made a 20 percent improvement in three of the five above parameters

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16
Q

What DAS28 score considers

A

The number of tender joints of the 28 that are measured (tender28);
The number of swollen joints of the 28 that are measured (swollen28);
The Erythrocyte Sedimentation Rate (ESR), in mm/hour;
The patients’ general health (GH) or global disease activity measured on a Visual Analogue Scale (VAS) of 100 mm.

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17
Q

ACR criteria RA

A

Patient assessmnet
DOCTOR assessment
Infflammation - bloods
Pain scale
Functionality questionnaire

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18
Q

WHy is monitoring FBC and LFTs on methotrexate essential?

A

Risk of myelosuppression and liver cirrhosis

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19
Q

DMARDs for rheumatoid arthritis

A

Methotrexate
Sulfasalazine
Leflunomide
hydroxychloroquine

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20
Q

Which TNF inhibitors are monoclonal anitbodies

A

Infliximab - IV
adalimumab - SC

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21
Q

How does etanercept work?

A

recombinant human protein, acts as a decoy receptor for TNF-α,

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22
Q

Which TNF inhibitors can reactivate TB?

A

Etanercept (SC) - also demyelination
Infliximab

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23
Q

What is rituximab?

A

Anti-CD20 monoclonal antibody causing B cell depletion

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24
Q

What is psoriatic arthritis?

A

Autoimmune inflammatory arthritis ass with psoriasis

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25
Gene ass with psoriatic arthritis
HLA B27
26
Investigations
Bloods - all negative except serum IgA (2/3)
27
Psoriatic arthritis on X ray
Soft tissue swell early diseae Erosion of DIP + periarticular new bone formation Osteolysis Pencil in cuo
28
Signs and symptoms psoriatic arthritis
Joint pain and stiff - prolonged morning > 30mins, improves with use Dactylitis/sausage fingers Enthesitis insertions bone eg achilles tendon pain and stiff Psoriatic rash Nail changes Uveitis
29
Patterns of arthritis
DR SAM DIP joint disease Rheumatoid pattern Spondyloarthritis Asymmetrical oligoarthritis - large joints Mutilans arthritis - severe-
30
What distinguished between rheumatoid pattern psoriatic arthritis and RA
Psoriatic - lacks rheumatoid nodules RF negative Psoriasis
31
Risk factors psoriatic arthritis
Middle age, white, FH, psoriasis
32
Non pharmacological management psoriatic arthritis
Exercise Physiotherapy - strengthen Synovectomy and joint replacement
33
Pharmacological treatment psoriatic arthritis
NSAIDs DMARDs - 1st line Intra-articular steroids - adjunctive Anti-TNF alpha Ustelinumab
34
When are antiTNF alphas used in psoriatic arthritis
Inadequate response to NSAIDs and one DMARD eg methotrexate
35
What is Ustekinumab
Monoclonal antibody against IL12-23
36
What can you give for psoriatic arthritis in severe disease
Methotrexate and antiTNF alpha Methotrexate and Ustekinumab
37
Anti-TNF alpha examples
adalimumab, etanercept, golimumab, infliximab
38
Complication of RA
Amyloidosis Anaemia Dy eye syndrome, keratitis Feltys syndrome Fatugie ILD, pleural effusion, fibrosing alveolitis Neuropathy Orthopaeidc problems - carpal tunnel syndrome, tendon rupture, cervical myelopathy Vasculitis Weight loss CVS disease Depression Lymphomas
39
Where does RA affect?
Symmetrical synovitis of small joints hand and feet
40
Symptoms of RA
Pain, swelling, heat and stiffness in affected joints Swelling - around joint, 'boggy' Stiff - early morning over an hour
41
Extra-articular features RA
Rheumatoid nodules - hard, firm swellings over extensor surfaces Vasculitis Malaise, fatigue, fever, sweats, weight loss
42
Investigations RA
Rheumatoid factor antiCCP antibodies Xrays hand and feet FBC, U+Es, LFTs CRP/ESR US/MRI joints
43
Which HLA is ass with RA?
DR1 and DR4
44
Risk factors RA
Female Gentics - HLADR1/4 Smoking Infection - trigger Autoantibodies - RF , antiCCP
45
Conservative management of RA
Regular exerc
46
Medical management of RA
NSIADs Corticosteroid Biological agents
47
Which deformities are present in RA
Boutinneiere Swan neck Ulnar deviation Z thumb
48
Articular features of RA
Stiffness >1hr in morning Symmetrical Swollen Small joints Sec - female Speed - weeks to months onset Specific hand signs: swollen MCP, PIP, MTPs -> deformities DIP sparing
49
Xray of RA joints what see
Soft tissue swell Periarticular osteopenia Loss joint space Bony eroisons Deformity
50
Non specific investigations RA
Bloods: FBC (normocytic anaemia _ reactive thrombocytosis in RA) CRP/ESR U+Es, LFTs urate, ANA - SLE Urinalysis CXR Synocial fluid analysis
51
Felty syndrome what is
Triad of RF positive RA, neutropenia and splenomegaly
52
What are the categories for ACR/EULAR joint criteria?
Joint involvemtn (0-5) Serology (0-3) Duration symptoms (0-1) Actute phase reactants - CRP/ESR (0-1)
53
What score is diagnositc for RA in ACR/EULAR joint criteria?
>6
54
ACR criteria
Morning stiffness over 1 hour Arthritis >3 joints Hand joints, wrist, MCP, PIPs Symmetrical srthritis Rheumatoid nodules +RF Radiographic changes >4 = RA 1-4 must be present for 6 weeks
55
When do yuo suspect an RA flare
Symptoms of stiffness, pain, joint swelling, or general fatigue. Signs of joint synovitis, joint tenderness, or loss of joint function. Inflammatory markers — for example, an increase in C-reactive protein from previous levels.
56
Mangement of RA flare
Intra-articular glucocorticoid injection eg methylprednisolone acetate for localised flare IM glucocorticoid Oral glucocorticoid - reducing course over 2-4 weeks NSAId at lowest dose for shortest time
57
Risk factors for septic arthritis
Prosthetic joint Prior joint damage/disease - RA, gout, connective tissue disorders DM joint surgery Penetrating injury Low socioeceonomic status Extremities of age IVDU Immunodeficiency - HIV Immunosupression - steroids
58
Symptoms/signs of septic arthritis
Acutely painful, worse when move Swollen Decreased mobility Tender, erythematous and warrm Effusion Systemic features of infection Unable to weight bear Loosening of implant - chronic in joint replacement ONe joint affected
59
Investgiations septic arthritis
Bloods - WC increased, high ESR/CRP, blood culutre IMaging - Xray, US, CT/MRI Joint aspiration and synovial fluid analysis
60
Causative agents of septic arthritis
Grma positive cocci - S.aureus, coagulase negative staph Gram negative cocci - Neissiera gonorrhea Gram negative bacili eg E.coli - diabetics, elderly, IVDUs
61
Why important to askk sexual history of young person with septic arthritis?
Gonorrhea is causative agent commonly
62
Mangement of septic arthritis
Emprirical IV antibiotics eg flucloxacillin while wait Orthopaedic reciew = arthrocentesis, lavage, debridement of joint Joint immobilisation with splinting
63
wHAT CAN SHOW on CT/MRI in septic arthritis
Periarticular abscesses, joint effusions, osteomyelitis
64
What is tested in synovial fluid analysis after joint aspiration in septic arthritis?
Gram stain WCC Culture - organsisms and antibiotic sensitivities Polarised light microscopy - rule out gout/pseudogout

Joints, bones and skin (31 decks)

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