Rheumatoid arthritis management Flashcards
Tretament prniciples
Treat to target - initiate DMARDs at diagnosis unless contraindication
Drugs initiate with diagnosis of rheumatoid arhteitis
Methotrexate
Short term glucocorticoids
NSAIDs
Alternatives to methotrexate if CI
Leflunomide
Sulfasalazine
When move from first stage of treatment to second RA
Fail to achieve improvement at 3 months and target at 6 months
Second line treatment rheumatoid
Change or add second conventional DMARD eg leflonomide, sulfasalzine, ethotrexate
JAK inhibitor
3rd line therapy rhueamtoid disease
Change the DMARD and replace with abatercept or IL-G inhibtiro, riflixumab or second TNF inhibitpr OR use JAK inhibtior
Screening before start DMARDs
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
What do with DMARDs in serious infection
Discontinue until reovered
Risks, cautions and side effects of biological DMARDs
Infection
Exacerbation of cardiac failure
Malignancy
Reactivation TB, hep B
Avoid live vaccines Demuelination, SLE like syndrome
What biologics use in high risk patient
Etanercept, abatercept
What caution with malignancy risk of DMARDs
Risk in SKIN cancer increases
Caution in patients w prev malignancy
JAK inhibitors vs bioloigcs advantage
Can take orally
How to achieve remission in rheumatoid arthritis
Aggressive, early targeted therapy
Aim for 50% patients sustained remission
Patient choice
Cause of rheumatoid
Large genetic influece
What does rheumatoid arthritis affect- different systems
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
Diagnostic criteria RA
> 2 swollen joints
Morning stiffness > 1 hr >6 weeks
Rf - 20%cases not positive
Investigations for RA
FBC, ESR, CRP, Rf, anti-CCP, ANA
Plain X ray
Pathophysiology of RA
Thickeining synovium
Destroys articular cartliage
Subchondral bone - cysts
Ligaments - attenuation and joint instability
Where does polyarthropathy often affect
Cervical spine
Hands
Feet
Ra ON xRAY
nARROWING JOINT SPACE
Marginal erosions
Periarticular osstopenia Irregular joint surface
Deformity/subluxation/dislocation
Soft tissue swelling
Secondary osteoarthritis
Surgery indications RA
Pain relief, improvement in function, tendon rupture, nerve compression
Correcting deformities, stabilising joints, decreasing stabilty
Options for RA surgery
Arthroscopy, synovectomy, tnedon transfer
Resection arthroplasty, arthrodesis, total joint relacement
ARHTROSOCPY ACE TUTORIAL
Assessing nerve compression
Nerve conduction studies - peripheral nerve function
Electromyogrpahy - electrical activity in a muscle
What is arthrodesis
Fusing the ankle joint eg K wires, also helps w pain relief
Symptomatic improvement
Indications for total elbow replacement joint
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
What can prevent the need for joint replacement
Steroid injections
Once every four months
What shouldnt you give 6 months before surgery
Steroid injections due to infection risl
