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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
Q

Gene ass with psoriatic arthritis

A

HLA B27

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26
Q

Investigations

A

Bloods - all negative except serum IgA (2/3)

27
Q

Psoriatic arthritis on X ray

A

Soft tissue swell early diseae
Erosion of DIP + periarticular new bone formation
Osteolysis
Pencil in cuo

28
Q

Signs and symptoms psoriatic arthritis

A

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
Q

Patterns of arthritis

A

DR SAM
DIP joint disease
Rheumatoid pattern
Spondyloarthritis
Asymmetrical oligoarthritis - large joints
Mutilans arthritis - severe-

30
Q

What distinguished between rheumatoid pattern psoriatic arthritis and RA

A

Psoriatic -
lacks rheumatoid nodules
RF negative
Psoriasis

31
Q

Risk factors psoriatic arthritis

A

Middle age, white, FH, psoriasis

32
Q

Non pharmacological management psoriatic arthritis

A

Exercise
Physiotherapy - strengthen
Synovectomy and joint replacement

33
Q

Pharmacological treatment psoriatic arthritis

A

NSAIDs
DMARDs - 1st line
Intra-articular steroids - adjunctive
Anti-TNF alpha
Ustelinumab

34
Q

When are antiTNF alphas used in psoriatic arthritis

A

Inadequate response to NSAIDs and one DMARD eg methotrexate

35
Q

What is Ustekinumab

A

Monoclonal antibody against IL12-23

36
Q

What can you give for psoriatic arthritis in severe disease

A

Methotrexate and antiTNF alpha
Methotrexate and Ustekinumab

37
Q

Anti-TNF alpha examples

A

adalimumab, etanercept, golimumab, infliximab

38
Q

Complication of RA

A

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
Q

Where does RA affect?

A

Symmetrical synovitis of small joints hand and feet

40
Q

Symptoms of RA

A

Pain, swelling, heat and stiffness in affected joints
Swelling - around joint, ‘boggy’
Stiff - early morning over an hour

41
Q

Extra-articular features RA

A

Rheumatoid nodules - hard, firm swellings over extensor surfaces
Vasculitis
Malaise, fatigue, fever, sweats, weight loss

42
Q

Investigations RA

A

Rheumatoid factor
antiCCP antibodies
Xrays hand and feet
FBC, U+Es, LFTs
CRP/ESR
US/MRI joints

43
Q

Which HLA is ass with RA?

A

DR1 and DR4

44
Q

Risk factors RA

A

Female
Gentics - HLADR1/4
Smoking
Infection - trigger
Autoantibodies - RF , antiCCP

45
Q

Conservative management of RA

A

Regular exerc

46
Q

Medical management of RA

A

NSIADs
Corticosteroid
Biological agents

47
Q

Which deformities are present in RA

A

Boutinneiere
Swan neck
Ulnar deviation
Z thumb

48
Q

Articular features of RA

A

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
Q

Xray of RA joints what see

A

Soft tissue swell
Periarticular osteopenia
Loss joint space
Bony eroisons
Deformity

50
Q

Non specific investigations RA

A

Bloods: FBC (normocytic anaemia _ reactive thrombocytosis in RA)
CRP/ESR
U+Es, LFTs urate, ANA - SLE
Urinalysis
CXR
Synocial fluid analysis

51
Q

Felty syndrome what is

A

Triad of RF positive RA, neutropenia and splenomegaly

52
Q

What are the categories for ACR/EULAR joint criteria?

A

Joint involvemtn (0-5)
Serology (0-3)
Duration symptoms (0-1)
Actute phase reactants - CRP/ESR (0-1)

53
Q

What score is diagnositc for RA in ACR/EULAR joint criteria?

A

> 6

54
Q

ACR criteria

A

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
Q

When do yuo suspect an RA flare

A

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
Q

Mangement of RA flare

A

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
Q

Risk factors for septic arthritis

A

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
Q

Symptoms/signs of septic arthritis

A

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
Q

Investgiations septic arthritis

A

Bloods - WC increased, high ESR/CRP, blood culutre
IMaging - Xray, US, CT/MRI
Joint aspiration and synovial fluid analysis

60
Q

Causative agents of septic arthritis

A

Grma positive cocci - S.aureus, coagulase negative staph
Gram negative cocci - Neissiera gonorrhea
Gram negative bacili eg E.coli - diabetics, elderly, IVDUs

61
Q

Why important to askk sexual history of young person with septic arthritis?

A

Gonorrhea is causative agent commonly

62
Q

Mangement of septic arthritis

A

Emprirical IV antibiotics eg flucloxacillin while wait
Orthopaedic reciew = arthrocentesis, lavage, debridement of joint
Joint immobilisation with splinting

63
Q

wHAT CAN SHOW on CT/MRI in septic arthritis

A

Periarticular abscesses, joint effusions, osteomyelitis

64
Q

What is tested in synovial fluid analysis after joint aspiration in septic arthritis?

A

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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