Rheumatoid Arthritis and psoriatic arthritis Flashcards
What is rheumatoid arthritis?
Symmetrical synovitis of small synovial joints
Peripheral polyarthritis
What are acute phase reactants?
CRP, ESR - inflammatory markers
What is the threshold for diagnosis RA?
= or > 6 classification criteria met
What is the blood test for RA?
Anti-CCP (much more sensitive and specific than rheumatoid factor, but RF still recommended by NICE)
Aim of treatment
Low disease activity or remission and sustained
Management RA
DMARD, add another DMARD, biological agents
How do you manage an acute flar of rheumatoid arthritis?
Intramuscular steorids eg methylprednisolone
How do corticosteroids work?
have a primarily glucocorticoid effect and result in inhibition of proinflammatory cytokine production - rapid reduction in inflammation
When are corticosteroids used?
Short term relief to improve pain and discomfort - rapid reduction in inflammation
When are TNF inhibitors indicated in rheumatoid arthrtiis?
When 2 DMARDs including methptrexate have an inadequate response
What are etanercept and infliximab?
TNF inhibitors
What is the initial management of Rheumatoid arthritis?
DMARD monotherapy +/- short course bridging prednisolone
How do you monitor response to treatement in RA?
CRP + disease activity eg DAS28 (disease activity score calculator for RA)
Score for RA
DAS28 - 28 joints assess
Score from 1-10
Score for RA
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
What DAS28 score considers
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.
ACR criteria RA
Patient assessmnet
DOCTOR assessment
Infflammation - bloods
Pain scale
Functionality questionnaire
WHy is monitoring FBC and LFTs on methotrexate essential?
Risk of myelosuppression and liver cirrhosis
DMARDs for rheumatoid arthritis
Methotrexate
Sulfasalazine
Leflunomide
hydroxychloroquine
Which TNF inhibitors are monoclonal anitbodies
Infliximab - IV
adalimumab - SC
How does etanercept work?
recombinant human protein, acts as a decoy receptor for TNF-α,
Which TNF inhibitors can reactivate TB?
Etanercept (SC) - also demyelination
Infliximab
What is rituximab?
Anti-CD20 monoclonal antibody causing B cell depletion
What is psoriatic arthritis?
Autoimmune inflammatory arthritis ass with psoriasis
Gene ass with psoriatic arthritis
HLA B27
Investigations
Bloods - all negative except serum IgA (2/3)
Psoriatic arthritis on X ray
Soft tissue swell early diseae
Erosion of DIP + periarticular new bone formation
Osteolysis
Pencil in cuo
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
Patterns of arthritis
DR SAM
DIP joint disease
Rheumatoid pattern
Spondyloarthritis
Asymmetrical oligoarthritis - large joints
Mutilans arthritis - severe-
What distinguished between rheumatoid pattern psoriatic arthritis and RA
Psoriatic -
lacks rheumatoid nodules
RF negative
Psoriasis
Risk factors psoriatic arthritis
Middle age, white, FH, psoriasis
Non pharmacological management psoriatic arthritis
Exercise
Physiotherapy - strengthen
Synovectomy and joint replacement
Pharmacological treatment psoriatic arthritis
NSAIDs
DMARDs - 1st line
Intra-articular steroids - adjunctive
Anti-TNF alpha
Ustelinumab
When are antiTNF alphas used in psoriatic arthritis
Inadequate response to NSAIDs and one DMARD eg methotrexate
What is Ustekinumab
Monoclonal antibody against IL12-23
What can you give for psoriatic arthritis in severe disease
Methotrexate and antiTNF alpha
Methotrexate and Ustekinumab
Anti-TNF alpha examples
adalimumab, etanercept, golimumab, infliximab
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
Where does RA affect?
Symmetrical synovitis of small joints hand and feet
Symptoms of RA
Pain, swelling, heat and stiffness in affected joints
Swelling - around joint, ‘boggy’
Stiff - early morning over an hour
Extra-articular features RA
Rheumatoid nodules - hard, firm swellings over extensor surfaces
Vasculitis
Malaise, fatigue, fever, sweats, weight loss
Investigations RA
Rheumatoid factor
antiCCP antibodies
Xrays hand and feet
FBC, U+Es, LFTs
CRP/ESR
US/MRI joints
Which HLA is ass with RA?
DR1 and DR4
Risk factors RA
Female
Gentics - HLADR1/4
Smoking
Infection - trigger
Autoantibodies - RF , antiCCP
Conservative management of RA
Regular exerc
Medical management of RA
NSIADs
Corticosteroid
Biological agents
Which deformities are present in RA
Boutinneiere
Swan neck
Ulnar deviation
Z thumb
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
Xray of RA joints what see
Soft tissue swell
Periarticular osteopenia
Loss joint space
Bony eroisons
Deformity
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
Felty syndrome what is
Triad of RF positive RA, neutropenia and splenomegaly
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)
What score is diagnositc for RA in ACR/EULAR joint criteria?
> 6
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
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.
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
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
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
Investgiations septic arthritis
Bloods - WC increased, high ESR/CRP, blood culutre
IMaging - Xray, US, CT/MRI
Joint aspiration and synovial fluid analysis
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
Why important to askk sexual history of young person with septic arthritis?
Gonorrhea is causative agent commonly
Mangement of septic arthritis
Emprirical IV antibiotics eg flucloxacillin while wait
Orthopaedic reciew = arthrocentesis, lavage, debridement of joint
Joint immobilisation with splinting
wHAT CAN SHOW on CT/MRI in septic arthritis
Periarticular abscesses, joint effusions, osteomyelitis
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
