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MSK block > Rheumatoid Arthritis (R2) > Flashcards

Rheumatoid Arthritis (R2) Flashcards

1
Q

What is Rheumatoid arthritis?

Is it more common in males or females and what age group is most affected?

A

Autoimmune condition that causes chronic inflammation of the synovial lining of joints

  • Women:men = 4:1
  • Age peaks 30-55 y.o (middle age)
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2
Q

List 2 risk factors for RA

A
  1. Women
  2. Family history.
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3
Q

List 2 genes associated with RA

A
  1. HLA DR4
  2. HLA DR1
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4
Q

List 2 antibodies associated with RA

A
  1. Rheumatoid Factor, most often IgM
  2. Cyclic citrullinated peptide antibodies (anti-CCP)
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5
Q

State the following about RA

  • Distribution of affected joints?
  • Onset gradual/acute?
  • Intra-articular/extra-articular manifestations?
A

distribution: symmetrical polyarthritis
onset: gradual
manifestations: extra-articular

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6
Q

How does RA present?

A
  1. Symmetrical distal polyarthropathy
  2. Pain, swelling and stiffness of small joints
  3. Early morning stiffness > 45 min
  4. Associated systemic symptoms
  5. Pain improves with activity, worse at rest
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7
Q

List 4 systemic symptoms of RA

A
  1. Fatigue
  2. Weight loss
  3. Flu like illness
  4. Muscles aches and weakness
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8
Q

List in order the 4 most common joints affected by RA

A

PIP > MCP > wrists > elbows

> shoulders > hips > knees > ankles > MTP

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9
Q

How may RA affect the cervical spine?

A

Atlantoaxial Subluxation

The odontoid peg (on C2) shifts within the atlas (C1) due to local synovitis and damage to ligaments and bursa

Emergency as subluxation can cause spinal cord compression

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10
Q

List 4 classic hand signs seen in RA

A
  1. Z shaped deformity to the thumb
  2. Swan neck deformity
  3. Boutonnieres deformity
  4. Ulnar deviation of the fingers at the knuckle
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11
Q

What is a swan neck deformity?

A

Hyperextended PIP with flexed DIP

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12
Q

What is a boutonnieres deformity?

Pathophysiology?

A

Hyperextended DIP with flexed PIP

Occurs due to a tear in the central slip of the extensor components of the fingers

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13
Q

What is scored in the 2010 ACR/EULAR diagnostic criteria for RA?

A
  1. Joints involved (more and smaller joints score higher)
  2. Serology (RF and anti-CCP)
  3. Inflammatory markers (ESR and CRP)
  4. Duration of symptoms (more or less than 6 weeks)

≥6 = definite RA

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14
Q

What is assessed in the DAS28 score for RA?

How is it used clinically?

A

Disease Activity Score - assessment of 28 joints, points given for:

  • Swollen joints
  • Tender joints
  • ESR/CRP result
  • Global assessment of health

Useful in monitoring disease activity and response to treatment.

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15
Q

What do the following values of DAS 28 indicate:

  • < 2.6
  • 2.6 – 3.2
  • 3.2 – 5.1
  • >5.1
A

< 2.6: Disease remission

  1. 6 – 3.2: Low disease activity
  2. 2 – 5.1: Moderate disease activity, may merit a change in treatment for some people

> 5.1: Severe disease activity, will merit a change in treatment for most people

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16
Q

What is the HAQ?

How is it used clinically?

A

Health Assessment Questionnaire - measures functional ability

NICE recommend using this at diagnosis to check the response to treatment

17
Q

Investigations to diagnose RA following history and exam

A
  1. Rheumatoid factor and anti-CCP antibodies
  2. CRP and ESR
  3. X-ray of hands and feet
  4. USS of the joints to confirm synovitis
18
Q

List 4 X-ray features indicative of RA

A
  1. Periarticular osteopenia
  2. Soft-tissue swelling
  3. Joint destruction and deformity ie. ankylosis (fusion)
  4. Boney erosions
19
Q

What may be seen on USS of RA in early disease?

A
  • Synovial swelling
  • Hypervascularity
  • Erosions
20
Q

List 4 Extra-articular manifestations of RA

(CAR PIPE)

A
  1. Cervical myelopathy, CTS
  2. Anaemia of chronic disease
  3. Rheumatoid nodules
  4. Pulmonary fibrosis (Caplan’s syndrome)
  5. ILD
  6. Pleural effusions
  7. Episcleritis and scleritis
21
Q

List 4 examples of DMARDs

A
  1. Methotrexate
  2. Leflunomide
  3. Sulfasalzine
  4. Hydroxychloroquine
22
Q

List 4 examples of Biological Therapies for RA

A

Anti-TNFs: adalimumab, infliximab and etanercept

Anti-CD20: rituximab

23
Q

What is the biggest risk of biologics?

A

Lead to immunosuppression

Patients are prone to serious infections and/or reactivation of dormant infections ie. TB and hep B

24
Q

Firstline therapy for RA?

A

Monotherapy with synthetic (s)DMARDs

ie. Methotrexate, leflunomide, sulfasalazine

25
Q

Second line therapy for RA?

A

Dual therapy with methotrexate, leflunomide or sulfasalazine

26
Q

Third line therapy for RA?

A

Methotrexate plus a biological therapy, usually a TNF inhibitor (ie. infliximab)

27
Q

Fourth line therapy for RA?

A

Methotrexate plus rituximab

28
Q

Methotrexate

  1. MoA
  2. Form(s) of administration
  3. Notable s/e
A
  1. Interferes with folate metabolism
  2. Injection or tablet once a week
  3. Pulmonary fibrosis, teratogenic
29
Q

Sulfasalzine

  1. MoA
  2. Notable s/e
A
  1. Mechanism not clear, may be related to folate metabolism
  2. Male infertility (↓ sperm count) and Bone marrow suppression
30
Q

What must be given along with Methotrexate?

A

Folic Acid 5 mg ONCE weekly >24 hours after Methotrexate

31
Q

Leflunomide

  1. MoA
  2. Notable s/e
A
  1. Interferes with production of pyrimidine (component of RNA and DNA)
  2. Hypertension and peripheral neuropathy
32
Q

Hydroxychloroquine

  1. MoA
  2. Notable s/e
A
  1. Interferes with TLRs and antigen presentation, increases pH in the lysosomes of immune cells
  2. Nightmares and reduced visual acuity
33
Q

Anti-TNF drugs

  1. MoA
  2. Notable s/e
A
  1. TNF is a cytokine involved in (+) inflammation, blocking reduces inflammation
  2. Reactivation of TB or Hep B
34
Q

Rituximab

  1. MoA
  2. Notable s/e
A
  1. Monoclonal antibody that targets the CD20 protein on surface of B cells. Causes destruction of B cells
  2. Night sweats and thrombocytopenia
35
Q

List 2 DMARDs which are safe in pregnancy?

A

Sulfasalzine and Hydroxychloroquine

36
Q

List 2 other treatments used for RA

A
  1. Steroids
  2. Analgesics (ie. NSAIDs/COX-2)
37
Q

What is co-prescribed alongside NSAIDs/COX-2 inhibitors

Why?

A

PPIs due to risk of GI bleeding

38
Q

According to NICE, when is referral advised in general practice for RA?

A

Any adult with persistent synovitis, even with (-) RF, anti-CCP and inflammatory markers

Urgent referral if it involves small joints of the hands or feet, multiple joints or present for more than 3 months.

39
Q

How do we monitor success of RA treatment

A

CRP and DAS28

MSK block (30 decks)

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