Rheumatoid Arthritis + OA + Hip Pain Flashcards
What is RA and what joints are common
Autoimmune systemic illness Chronic symmetric polyarticular arthritis + other features Hands and feet common - PIP + MCP of hand - Wrist and ankle - MTP - Cervical spine
REMEBER - DIP never affected so more likely Hebreden node
When doe RA typically present
F>M
4th / 5th decade but from 16
Other autoimmune - DM / pernicious anaemia / alopecia
HLA DR4 / DR1
What are the typical symptoms of any rheumatoid arthritis
What are the typical signs in the hands
Symmetrical Pain Stiffness >30 minutes Often worse in morning and symmetrical Onset can be gradual or rapid Usually small joints of hands and feet Swelling Tenderness Reduced ROM Heat Redness Recurrent soft tissue infections Rheumatoid nodules
Systemic - fever, weight loss, flu like illness
Hand signs
- Boggy soft swelling
- Z shape thumb deformity
- Swan neck deformity (hyperextended PIP)
- Ulnar deviation of fingers at the knuckle (MCP)
- Radial deviation of wrist
What are the features needed for classification?
4/7 >6 weeks Morning stiffness >1 hour Arthritis >3 joints (can all be in hand) At least one in hand (wrist, MCP, PIP) Symmetric arthritis Rheumatoid nodules Serum rheumatoid factor Erosions / bony decalcifications on X-RAy not just OA changes
What else can rheumatoid present with but rare
Extra-articular features but few joint problems
Much rarer
What happens to the eyes in RA
Keratoconjunctivitis sicca = most common Scleritis / episcleritis 2nd Sjogren's Cataract due to steroids Corneal ulceration/ keratitis
What are CVS features
Pericarditis
Pericardial effusion
Increased lipid metabolism
IHD
What are features in the lung
Fibrosing alveolitis Pleural effusion Pulmonary fibrosis Methotrexate pneumonitis Bronchiolitis obliterins
What is Felty’s syndrome
RA
HSM
Neutropenia / low WCC - predisposed to severe infection as enlarged spleen destroys
What other diseases can present with RA
Anaemia chronic disease Vasculitis Amyloidosis Raynaud's Osteoporosis Carpal tunnel Kidney issues Depression Increased risk of infection Atlanta-axial subluxation - post surgery get AP and lateral C-spine X-ray as risk of cord compression if occurs - MRI if it does
How do you Dx RA
Largely clinical Dx
Bloods
Immunological tests
X-Ray
USS can be used to confirm synovitis if unclear
MRI
If aspirate joint in flare would look like SA but more well
What are the immunological variables in RA
RF +Ve
If RF -ve then check anti-CCP = more sensitive but expensive
ANA +ve
What do bloods show
Increased ESR / CRP
Anaemia of chronic disease
Increased platelets
What are early x-ray changes
Loss of joint space
Juxta-articular osteopenia
Soft tissue swelling
Joint deformity
What are late x-ray changes
Unequivocal bony decalcification Loss of joint space Subluxation Soft tissue swelling Peri-articular osteopenia and erosions
What do disease activity scores suggest DAS28
<2.4 = remission >5.1 = need for biologics
What is important when treating
Early Rx needed before irreversible destruction occurs
How do you Rx
Simple analgesia - paracetamol / codeine (reduce need for NSAID)
NSAID + PPI
DMARD’s = 1st line and recommended to be started ASAP
Biologics
Manage CVS RF as accelerates atherosclerosis
How do you Rx flare up
Oral or intra-articular steroids
How do you monitor response and how does this change management
CRP
Disease activity - DAS28
If disease activity increasing then need to alter DMARD
If just painful then alter pain relief
What are non-pharmacogical options
Regular exercise
OT
Physio
Aids
What is common DMARD
Methotrexate = 1st line
Use short course of bridging prednisolone
What are other DMARD’s
Sulfasalazine
Lefuonmide
Hydroxychloroquine - mildest
If pregnant use hydrochloroquine or sulfasalazine
When are biologics given
Inadequate response to 2+ DMARD
Biologic examples
Infliximab / Etanercept = Anti-TNF
Ritixumab = B cell depletion (Anti-CD20)
What other conditions have positive RF
Sjogren SLE Scleroderma Felty IE
What suggests poor prognosis
Male Younger onset RF +ve Anti-CCP Poor functional status More joints and organs affected HLA DR4 Early erosions Extra-articular features e.g. nodules Insidious onset
What are SE of DMARD
Immunosuppression Methotrexate pneumonitis Oral ulcers Hepatotoxicity / cirrhosis Teratogenicity
What do you get if on DMARD
CXR before methotrexate
Regular FBC + LFT monitoring
What causes RA
Autoimmune
Genetics
Environment
What is autoimmune part
RF ACPA Anti-CCP ANA+ve Can get sero-ve RA
What genetics are involved
Lots of genes different to immune
HLA genes - DR1/DR4
Environment role
Infections - EBV / CMV / E.coli / mycoplasma
Smoking