Rheumatoid Arthritis Pre-lecture Flashcards
Rheumatoid arthritis
chronic disease
symmetrical joint involvement
most common systemic inflammatory disease
Epidemiology
prevalence: 2.1 mil (1-2% of pop)
age: any age, onset usually 30-50 yrs, shortens lifespan by 3-18 yrs
sex: female > male
race: no discrimination
MHC
major histocompatibility complex
HLA: hyman lymphocyte antigen typing: HLA-DR4 and HLA-DR1
consider possibility of a genetic etiology/redisposition
Pathogenesis of RA
synovial space is infiltrated with inflammatory cells: macrophage, T cells, plasma cells –> development of pannus - inflamed proliferating synovia invades into healthy cartilage + bone –> erosions, destroys joint
the release of cytokines, mediators of the immune/inflammatory response, leads to cell proliferation + death
RA progression
inflammation might decline but disability increases
Clinical presentation - prodromal effects
non-specific sx found early in presence of RA; difficult to link these sx to RA
fatigue, weakness, loss of appetite, joint pain, low grade fever, stiffness + muscle ache –> joint swelling
Diagnostic criteria
joint involvement
serology
duration of sx
acute phase reactants
diagnosed with RA if score is 6 or more
Joint involvement
most common joints: hands, wrists, feet
may involve: elbows, shoulders, hip, knees, ankles
Joint involvement in hands
wrist, metacarpal, proximal interphalangeal
Extraarticular manifestations
rheumatoid nodules, vasculitis, pulmonary, ocular, cardiac, felty’s, other
Rheumatoid nodules
common: hands, elbows, forearms (pressure points)
more common in erosive disease (happes longer the pt has the disease or the less control the pt has over the disease)
20% of pts affected
asymptomatic = 0 intervention
Vasculitis
inflammation of small, superficial blood vessels
depends upon duration of disease
stasis ulcers
infarction –> necrosis
Pulmonary
pleural effusions
pulmonary fibrosis
nodules
rare: interstitial pneumonitis or arteritis
Ocular
keratoconjunctivitis sicca: itchy dry eyes + inflammation; sjogrens syndrome (KS + RA)
inflammation: sclera, espisclera, cornea
nodules
Cardiac
increased risk of CV mortality
pericarditis
conduction abnormalities
rare: myocarditis
Felty’s
have all 3: splenomegaly, neutropenia, RA
Other
lympadenopathy, renal disease, thrombocytosis, anemia
Laboratory indicators
help diagnose + assess disease progression
anemia, thrombocytosis, ESR, CRP, RF, anti-CCP/ACPA, ANA, joint aspirations, radiographic findings
Erythrocyte sedimentation rate (ESR)
non-specific (diagnostic indicator)
normal: 0-20 mm/hr
elevated in RA > 20
C-reactive protein (CRP)
normal 0-0.5 mg/dL
+ –> > 0.5 mg/dL
> 10 mg/dL can indicate bacterial infection
Rheumatoid factor
hallmark diagnostic criteria!
antibody specific for IgM
not all pts with RA diagnosis are RF+
60-70% are RF+
higher the titer –> poorer the prognosis
Anti-CCP/ACPA
auto-antibody presence test
high specificity, present earlier in disease, predictive value for erosive disease, marker of poor prognosis
Antinuclear antibodies (ANA)
elevated titers suggest autoimmune disease, more indicative of SLE (less specific for RA), reported as a titer
Joint aspiration
turbid, WBC 5,000-50,000/mm^3, glucose: normal to low compared to serum
Radiographic changes
joint space narrowing
erosions of bone
Poor prognosis - social factors
low socioeconomic status, lack of formal education, psychological stress, poor health assessment questionnaire scores
Poor prognosis - physical factors
extra-articular manifestations, elevated ESR and CRP, high titers of RF, elevated anti-CCP/ACPA, erosions on x-ray, duration of disease, swelling of >20 joints
Treatment goals
improve/increase QOL, reduce morbidity and mortality
alleviate s/sx of disease, preserve fx, prevent structural damage and deformity, control/avoid extra-articular manifestations
Early treatment of RA
goal of preventing long-term disability
early, more aggressive tx helps prevent long-term disability
can improve fx and decrease inflammation with earlier treatment
Nonpharmacologic treatment
education, emotional support, rest, weight reduction, physical/occupational therapy, heat, splints/prosthetics, surgery
should NOT be used as monotherapy
Pharmacologic treatment
NSAIDs, corticosteroids, DMARDs, biologic agents anti-TNF and non-TNF, monoclonal antibodies, targeted synthetic DMARDs
