Rheumatoid arthritis (RA) Flashcards
Background
Its a chronic systemic inflammatory autoimmune disease and causes persistent symmetrical joint synovitis.
Can affect all synovial joints, typically small joints of hands and feet.
Signs and symptoms
Pain
Prolonged stiffness - worse at rest or after inactivity
Swelling
Tenderness
Heat at the affected joint
Others:
Malaise
Fatigue
Weight loss
Fever
As disease progresses:
Joint deformity
Affect other organs (heart, eyes, lungs etc)
RA (Table in pack)
Age: Any time in life
Speed of onset: Rapid over weeks to months
Joint symptoms: Painful, swollen, stiff
Pattern of affected joints: Both sides small and large joints
Duration of morning stiffness: >1 hr
Whole body symptoms?: Fatigue, feeling of illness
Diagnosis
NO real diagnostic tool. Early diagnosis and treatment helps reduce impact of RA.
All patients suspected inflammatory joint disease to be referred to a specialist ASAP.
Urgent refer if:
- small joints of hand or feet affected
- More than 1 joint affected
- Delay of 3 months or + between symptoms start and medical advise.
Investigations to diagnose:
- Blood test for RA factor
- Can measure anti-CCP Antibodies if negative for RA factor
- X ray hands and feet if RA sus and persistent synovitis
Investigation after diagnosis:
- Measure Anti-CCP antibodies
- X ray hands and feet to see if erosion
- Measure functional ability
IF anti-CCP present or there’s erosions:
- Advise on radiological progression risk
- And need to monitor condition - rush to specialist if flare/worsen
DAS28 - measures disease activity on 28 joints.
Treatment
PHARMACOLOGICAL:
1st line - cDMARD (oral methotrexate, leflunomide, or sulfasalazine)
ALT - hydroxychloroquine sulfate for Mild RA or palindromic rheumatism. Escalate dose as tolerated.
cDMARDs are slow - 2-3 months to work. Can use short term CORTICOSTEROIDS. provides rapid symptomatic control while waiting. They also decrease inflammation.
If treatment target not achieved (remission or low disease activity) on cDMARD= OFFER COMBO OF 2 cDMARDs
Still fail then Tumour necrosis factor (TNF) alpha inhibitor (adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab), other biological DMARD (abatacept, sarilumab, or tocilizumab), or targeted synthetic DMARD (baricitinib, filgotinib, tofacitinib, or upadacitinib) is recommended.
Severe active RA = Rituximab + Methotrexate if everything else failed including 1 TNF alpha inhibitor.
PAIN RELIEF
Short term NSAID/COX2 inhibitor. Give PPI prevent GI effects.
If already on low dose aspirin try something else b4 NSAID. NSAID on lowest effective dose for shortest time.
NON-PHARMACOLOGICAL:
- Mediterranean diet (bread, fruit, fish, vegetables, replace butter and cheese with veg and plant oils. Helps with CVS people with RA more at risk of CVD.
- Physiotherapy
- Occupational therapy
- Hand exercise
- Podiatry
- Psychological intervention
DRUGs INFO
ALL cDMARD need regular blood test.
ALL biologic DMARD needs to be screened for Hx of TB, multiple sclerosis, recurrent infection, Leg ulcers, cancer. Done via chest X ray, FBC, LFT. Treat active or latent TB b4 treatment of bDMARD.
Methotrexate = taken OW oral. If GI or mucosal effects give folic acid on different day OW 5mg.
FBC, Renal function (creatinine/GFR), LFTs (ALT and/or AST and albumin) monitor:=
- Every 2 weeks until stable for 6 weeks THEN monthly for 3 months *
- THEN every 3 months
- Monitor more IF higher toxicity risk
- Dose increase monitor every 2 weeks until stable for 6 weeks
* methotrexate + leflunomide = monthly for 12 months then reduce intervals
- Exclude P b4 treatment- contraception during and 6 months after treatment. STOP BF.
Sulfasalazine = monitoring same as methotrexate BUT can stop after 1 year.
Leflunomide = monitoring same as methotrexate BUT monitor BP and WEIGHT too.
- AVOID in hepatic impairment and moderate/severe renal impairment
- AVOID in P and BF
- Contraception for 2 years after treatment in women and 3 months after in men. (need plasma conc. monitoring and washout procedure can reduce waiting time for conception). CONC. need to be <20mcg/L B4 conception occurs.
- WASHOUT PROCEDURE: give colestyramine or activated charcoal. Helps drug elimination.
Hydroxychloroquine= Monitor renal function ANNUALLY - people >70 and pre-existing renal impairment, HTN and/or diabetes.
- Eye assessment = ANNUALLY - if taking drug >5 years. Can still do eye test even if not >5 years IF:=
- on tamoxifen therapy, impaired renal function eGFR <60 mL/min/1.73 m2) OR
– on High dose >5mg/kg/day
Biologic DMARD = Monitor:
- FBC, U&E (INC. creatinine), LFTs (ALT and/or AST and albumin) - AT 3-4 months THEN every 6 months.
- Lipid profile - 1-2 months after treatment.
- Infection signs - B4 each dose
- Hep B, C, HIV, autoantibodies, TB, Urinalysis (if indicated), Skin check.
Target synthetic DMARD: NO lab test for apremilast.
- TOFACITINIB / BARICITINIB:
– FBC, Creatinine/GFR, LFT (ALT and/or AST and albumin): - every2 weeks until dose stable for 6 weeks THEN every 3 months, More frequent if high risk of toxicity, if dose increased every 2 weeks till stable for 6 weeks then normal.
– Lipid profile - 8 weeks after for TOFA, 12 weeks after for BARI. THEN periodically.
– TB (if indicated)
Follow up/Referral for surgery
Refer for surgery IF:
For opinion BC No response to non surgical:
- persistent pain from joint damage
- Worsening joint function
- Progressive deformity
- persistent localised synovitis
For opinion B4 damage/deformity worsens:
- Imminent/actual tendon damage
- Nerve compression
- Stress fracture
OFFER URGENT SURGERY + Medical treatment to people with RA who suspected/proven septic arthritis.
Palindromic rheumatism
An inflammatory arthritis that causes attacks of joint pain and swelling similar to RA. Between attacks the joints return to normal.
