Rheumatoid Arthritis (R2) Flashcards
What is Rheumatoid arthritis?
Is it more common in males or females and what age group is most affected?
Autoimmune condition that causes chronic inflammation of the synovial lining of joints
- Women:men = 4:1
- Age peaks 30-55 y.o (middle age)
List 2 risk factors for RA
- Women
- Family history.
List 2 genes associated with RA
- HLA DR4
- HLA DR1
List 2 antibodies associated with RA
- Rheumatoid Factor, most often IgM
- Cyclic citrullinated peptide antibodies (anti-CCP)
State the following about RA
- Distribution of affected joints?
- Onset gradual/acute?
- Intra-articular/extra-articular manifestations?
distribution: symmetrical polyarthritis
onset: gradual
manifestations: extra-articular
How does RA present?
- Symmetrical distal polyarthropathy
- Pain, swelling and stiffness of small joints
- Early morning stiffness > 45 min
- Associated systemic symptoms
- Pain improves with activity, worse at rest
List 4 systemic symptoms of RA
- Fatigue
- Weight loss
- Flu like illness
- Muscles aches and weakness
List in order the 4 most common joints affected by RA
PIP > MCP > wrists > elbows
> shoulders > hips > knees > ankles > MTP
How may RA affect the cervical spine?
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
List 4 classic hand signs seen in RA
- Z shaped deformity to the thumb
- Swan neck deformity
- Boutonnieres deformity
- Ulnar deviation of the fingers at the knuckle
What is a swan neck deformity?
Hyperextended PIP with flexed DIP
What is a boutonnieres deformity?
Pathophysiology?
Hyperextended DIP with flexed PIP
Occurs due to a tear in the central slip of the extensor components of the fingers
What is scored in the 2010 ACR/EULAR diagnostic criteria for RA?
- Joints involved (more and smaller joints score higher)
- Serology (RF and anti-CCP)
- Inflammatory markers (ESR and CRP)
- Duration of symptoms (more or less than 6 weeks)
≥6 = definite RA
What is assessed in the DAS28 score for RA?
How is it used clinically?
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.
What do the following values of DAS 28 indicate:
- < 2.6
- 2.6 – 3.2
- 3.2 – 5.1
- >5.1
< 2.6: Disease remission
- 6 – 3.2: Low disease activity
- 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
What is the HAQ?
How is it used clinically?
Health Assessment Questionnaire - measures functional ability
NICE recommend using this at diagnosis to check the response to treatment
Investigations to diagnose RA following history and exam
- Rheumatoid factor and anti-CCP antibodies
- CRP and ESR
- X-ray of hands and feet
- USS of the joints to confirm synovitis
List 4 X-ray features indicative of RA
- Periarticular osteopenia
- Soft-tissue swelling
- Joint destruction and deformity ie. ankylosis (fusion)
- Boney erosions
What may be seen on USS of RA in early disease?
- Synovial swelling
- Hypervascularity
- Erosions
List 4 Extra-articular manifestations of RA
(CAR PIPE)
- Cervical myelopathy, CTS
- Anaemia of chronic disease
- Rheumatoid nodules
- Pulmonary fibrosis (Caplan’s syndrome)
- ILD
- Pleural effusions
- Episcleritis and scleritis
List 4 examples of DMARDs
- Methotrexate
- Leflunomide
- Sulfasalzine
- Hydroxychloroquine
List 4 examples of Biological Therapies for RA
Anti-TNFs: adalimumab, infliximab and etanercept
Anti-CD20: rituximab
What is the biggest risk of biologics?
Lead to immunosuppression
Patients are prone to serious infections and/or reactivation of dormant infections ie. TB and hep B
Firstline therapy for RA?
Monotherapy with synthetic (s)DMARDs
ie. Methotrexate, leflunomide, sulfasalazine
Second line therapy for RA?
Dual therapy with methotrexate, leflunomide or sulfasalazine
Third line therapy for RA?
Methotrexate plus a biological therapy, usually a TNF inhibitor (ie. infliximab)
Fourth line therapy for RA?
Methotrexate plus rituximab
Methotrexate
- MoA
- Form(s) of administration
- Notable s/e
- Interferes with folate metabolism
- Injection or tablet once a week
- Pulmonary fibrosis, teratogenic
Sulfasalzine
- MoA
- Notable s/e
- Mechanism not clear, may be related to folate metabolism
- Male infertility (↓ sperm count) and Bone marrow suppression
What must be given along with Methotrexate?
Folic Acid 5 mg ONCE weekly >24 hours after Methotrexate
Leflunomide
- MoA
- Notable s/e
- Interferes with production of pyrimidine (component of RNA and DNA)
- Hypertension and peripheral neuropathy
Hydroxychloroquine
- MoA
- Notable s/e
- Interferes with TLRs and antigen presentation, increases pH in the lysosomes of immune cells
- Nightmares and reduced visual acuity
Anti-TNF drugs
- MoA
- Notable s/e
- TNF is a cytokine involved in (+) inflammation, blocking reduces inflammation
- Reactivation of TB or Hep B
Rituximab
- MoA
- Notable s/e
- Monoclonal antibody that targets the CD20 protein on surface of B cells. Causes destruction of B cells
- Night sweats and thrombocytopenia
List 2 DMARDs which are safe in pregnancy?
Sulfasalzine and Hydroxychloroquine
List 2 other treatments used for RA
- Steroids
- Analgesics (ie. NSAIDs/COX-2)
What is co-prescribed alongside NSAIDs/COX-2 inhibitors
Why?
PPIs due to risk of GI bleeding
According to NICE, when is referral advised in general practice for RA?
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.
How do we monitor success of RA treatment
CRP and DAS28
