Rheumatoid arthritis (O) Flashcards
What is RA?
AI condition causing chronic inflammation on synovial lining on joints, tendon sheaths and bursa
What type of arthritis is RA?
Inflammatory
What is synovitis?
Inflammation of synovial linings
What is usual distribution of RA?
Symmetrical
Affects multiple joints
Who is likely to get RA?
- Women
- Middle age
- Fam Hx
Genetic associations:
- HLA DR4
- HLA- DR1
Presentation of RA?
Symmetrical Distal polyarthropathy Key symptoms: - Pain -Swelling -Stiffness
Assoc symptoms:
- Fatigue
- Wt loss
- Muscle aches/weakness
- Flu-like
Pain from OA different to pain from RA how?
Pain from OA: Better after rest, worse after activity
Pain from RA: Better after activity, worse after rest
What is palindromic arthritis?
Short episodes of 1-2 days
Self-limiting inflammatory arthritis
Atlanto-axial subluxation?
Caused by local synovitis and ligament/bursa damage
-In the cervical spine, Axis (C2) and odontoid peg, shift within atlas (C1)
Can cause spinal cord compression= emergency
Signs on hands of RA?
On synovium palpation it feels boggy around joints
- Z-shaped thumb deformity
- Swan-neck deformity
- Boutonnieres deformity
- Ulnar deviation of fingers at MCP joints
What is swan neck deformity?
Hyperextended PIP + flexed DIP
What is Boutonnieres deformity?
Hyperextended DIP + Flexed PIP
Extra-articular manifestations of RA?
- Pulmonary fibrosis + pulmonary nodules = Caplan’s
- Bronchiolitis Obliterans (Inflammation = Small airway destruction)
- Felty’s syndrome (RA, neutropenia and splenomegaly)
- Secondary Sjogren’s syndrome
- Anaemia
- CVD
- Rheumatoid nodules
- Lymphadenopathy
- Carpal tunnel syndrome
- Amyloidosis
- Eye manifestations
Eye manifestations of RA?
- Scleritis
- Episcleritis
- Keratitis
- Keratoconjunctivitis sicca
- Cataracts (steroid caused)
- Retinopathy (secondary to chloroquine)
Investigation for RA?
Clinical Diagnosis +
- Check RF
- If RF -ve, check anti-CCP antibodies
- Inflammatory markers (CRP & ESR)
- X-ray of hands & feet
US scan of joints confirms synovitis
X-ray changes seen in RA?
- Joint destruction/deformity
- Soft tissue swelling
- Periarticular osteopenia
- Boney errosions
Diagnosis of RA is based on?
- Joints involved (more and smaller score higher)
- Serology (RF and anti-CCP)
- Inflammatory markers (ESR & CRP)
- Duration of symptoms (6 weeks?)
What does DAS Score monitor?
Disease activity:
Assessment for 28 joints and points for swelling, tenderness and ESR/CRP result
Prognosis of RA is worse if?
You are:
- Male
- Young onset
- More affected joints
- Erosions on x-ray
- RF & anti-CCP antibodies
Management of first presentation?
Short course of steroids (NSAIDs can be used but bleeding risk therefore + PPI)
NICE guidelines for DMARDs?
1st line: Monotherapy with methotrexate, leflunomide or sulfasalazine
Hydroxychloroquine can be considered in mild disease
2nd line: 2 of these used in combo
3rd line: Methotrexate + biological therapy usually TNF inhibitor
4th line: Methotrexate + rituximab
Methotrexate indications?
Once a week via tablet or injection
Alongside
Folic acid 5mg taken on one weekly on a day methotrexate isn’t taken in a week
Side effects of methotrexate?
- Mouth ulcer/mucositis
- Liver toxicity
- Pulmonary Fibrosis
- Teratogenic
- Bone marrow suppression & leukopenia
What is lefluonomide?
Immunosuppressant
What does leflunomide do?
Interferes with pyrimidine production (component of DNA or RNA)
Side effects of leflunomide?
- Mouth ulcers/mucositis
- Increased BP
- Liver toxicity
- Peripheral neuropathy
- Bone marrow suppression
- Teratogenic
What is sulfalsazine?
Immunosuppressive & anti-inflammatory
Side effects of sulfasalazine?
- Temporary male infertility
- Bone marrow suppression
What is hydroxychloroquine traditionally used as?
Antimalarial drug
Side effects of hydroxychloroquine?
- Nightmares
- Reduced visual acuity
- Skin pigmentation
- Liver toxicity
What do anti-TNF drugs do?
Block TNF reduced inflammation
Examples of anti-TNF drugs?
Adalimumab Golimumab Infliximab Certolizumab pegol -Etanercept
Side effects of anti-TNF drugs?
- Vulnerability to sepsis and infections
- Reactivation of Hep B/TB
What is ritixumab?
Monoclonal AB targetting CD20 protein on B cells surface
Side effects of rituximab?
- Vulnerability to severe infections/sepsis
- Night sweats
- Thrombocytopenia
- peripheral neuropathy
- Liver and lung toxicity
Unique side effect of methotrexate?
Pulmonary fibrosis
Unique side effect of leflunomide?
HT
Peripheral neuropathy
Unique side effect of Sulfasalazine?
Male infertility
Unique side effect of hydroxychloroquine?
Nightmares
Reduced visual acuity
Unique side effects of Anti-TNF meds?
Reactivation of Hep B/TB
Unique side effects of rituximab?
Night sweats
Thrombocytopenia
