Rheumatoid arthritis management

Question 2

Tretament prniciples

Answer 2

Treat to target - initiate DMARDs at diagnosis unless contraindication

Question 3

Drugs initiate with diagnosis of rheumatoid arhteitis

Answer 3

Methotrexate
Short term glucocorticoids
NSAIDs

Question 4

Alternatives to methotrexate if CI

Answer 4

Leflunomide
Sulfasalazine

Question 5

When move from first stage of treatment to second RA

Answer 5

Fail to achieve improvement at 3 months and target at 6 months

Question 6

Second line treatment rheumatoid

Answer 6

Change or add second conventional DMARD eg leflonomide, sulfasalzine, ethotrexate
JAK inhibitor

Question 7

3rd line therapy rhueamtoid disease

Answer 7

Change the DMARD and replace with abatercept or IL-G inhibtiro, riflixumab or second TNF inhibitpr OR use JAK inhibtior

Question 8

Screening before start DMARDs

Answer 8

Fretility, pregnancy, delivery
Baseline assess - weight, height, BP
Bloods - BC U+Es, LFTs, albumin
Screen for TB, HIV and hepatitis
Comorbidities - resp, occult infection
Flu and pneumococcal vaccines
DMARD counselling and education

Question 9

What do with DMARDs in serious infection

Answer 9

Discontinue until reovered

Question 10

Risks, cautions and side effects of biological DMARDs

Answer 10

Infection
Exacerbation of cardiac failure
Malignancy
Reactivation TB, hep B
Avoid live vaccines Demuelination, SLE like syndrome

Question 11

What biologics use in high risk patient

Answer 11

Etanercept, abatercept

Question 12

What caution with malignancy risk of DMARDs

Answer 12

Risk in SKIN cancer increases
Caution in patients w prev malignancy

Question 13

JAK inhibitors vs bioloigcs advantage

Answer 13

Can take orally

Question 14

How to achieve remission in rheumatoid arthritis

Answer 14

Aggressive, early targeted therapy
Aim for 50% patients sustained remission
Patient choice

Question 15

Cause of rheumatoid

Answer 15

Large genetic influece

Question 16

What does rheumatoid arthritis affect- different systems

Answer 16

Synovial joints, tendons, ligaments
Skin - extensor rheumatoid nodles
Eyes - episecleritis, dry eyes Cardio pulmonary - pericarditis, rheumatoid nodules in lungs
Splenomegaly
Blood - anaemia of chronic disease
Renal - amyloidosis
CNS nad PNS - cervical spine (axial instability ligmaent laxity) , carpal tunnel

Question 18

Diagnostic criteria RA

Answer 18

> 2 swollen joints
Morning stiffness > 1 hr >6 weeks
Rf - 20%cases not positive

Question 19

Investigations for RA

Answer 19

FBC, ESR, CRP, Rf, anti-CCP, ANA
Plain X ray

Question 20

Pathophysiology of RA

Answer 20

Thickeining synovium
Destroys articular cartliage
Subchondral bone - cysts
Ligaments - attenuation and joint instability

Question 21

Where does polyarthropathy often affect

Answer 21

Cervical spine
Hands
Feet

Question 22

Ra ON xRAY

Answer 22

nARROWING JOINT SPACE
Marginal erosions
Periarticular osstopenia Irregular joint surface
Deformity/subluxation/dislocation
Soft tissue swelling
Secondary osteoarthritis

Question 23

Surgery indications RA

Answer 23

Pain relief, improvement in function, tendon rupture, nerve compression
Correcting deformities, stabilising joints, decreasing stabilty

Question 24

Options for RA surgery

Answer 24

Arthroscopy, synovectomy, tnedon transfer
Resection arthroplasty, arthrodesis, total joint relacement

Question 25

ARHTROSOCPY ACE TUTORIAL

Question 26

Assessing nerve compression

Answer 26

Nerve conduction studies - peripheral nerve function
Electromyogrpahy - electrical activity in a muscle

Question 27

What is arthrodesis

Answer 27

Fusing the ankle joint eg K wires, also helps w pain relief
Symptomatic improvement

Question 28

Indications for total elbow replacement joint

Answer 28

Painful snovitis/swelling
Reduction in ROM - lack full extesnion #
Ulnar nerve neuropathy - cubital tunnel syndrome - compression by inflamed synovium
Laxity of soft tissue -> instability
Destruction of articular surfaces - joint erosion, cyst formation, bone loss

Question 29

What can prevent the need for joint replacement

Answer 29

Steroid injections
Once every four months

Question 30

What shouldnt you give 6 months before surgery

Answer 30

Steroid injections due to infection risl