Rheumatoid Arthritis (RA) Flashcards
Autoimmune Disease:
Which immunoglobulin is formed which attacks the cartilage?
What immunoglobulin is formed against the above, leading to synovitis?
It eventually leads to deposits in the synovial membrane and joint destruction.
Which sex is it more common?
IgG
IgM - Rheumatoid Factor (RF)
Female
Presentation:
Typical:
- Sym/Assym?
- What time of day is it worse?
Articular Manifestations:
Inflammatory features:
- What joints of the hand are affected? - 3
- What joint in the foot does is affect?
- What symptoms do they get?
- What 2 joints does it usually spare which can help differentiate it from OA?
IT HAS A RELAPSING AND REMITTING COURSE
Symmetrical
Morning time
MCP - metacarpal joint
PIP - proximal interphalangeal joint
Wrist
MTP - metatarsal joint
Swelling
Pain
Stiffness
The 1st MTP - so the big toe
The thumb
http://what-when-how.com/rheumatology/approach-to-articular-and-musculoskeletal-disorders-disorders-of-the-joints-and-adjacent-tissues-rheumatology-part-2
Presentation:
What would be an atypical presentation?
Palindromic RA is atypical. What is it?
They may also get De Quervain’s tenosynovitis. What is it?
Sudden onset
Widespread
Large joint monoarthropathy
Recurrent mono/polyarthritis of various joints
The course is often acute onset, with sudden and rapidly developing attacks or flares.
De Quervain’s tenosynovitis is a painful condition affecting the tendons on the thumb side of your wrist. If you have de Quervain’s tenosynovitis, it will probably hurt when you turn your wrist, grasp anything or make a fist.
Signs:
What are the 4 deformities?
Ulnar deviation
Wrist subluxation
Boutonniere and swan neck deformities
Signs:
Why does the ulnar deviation happen?
What is a subluxation?
What does the Boutonniere deformity affect?
Weakened radiocarpal ligaments cause radial rotation of the metacarpals and carpus on the radius, which results in ulnar deviation of the MP joint via the Z mechanism.
Partial dislocation
https://www.pinterest.co.uk/pin/489836896972399466/
The thumb - swan neck is with the fingers
Extra-articular manifestations:
Systemic symptoms - 3
Dermatological and mucosal:
- Sjogren’s syndrome - what is it? what are the 2 main symptoms?
- Raynaud’s syndrome/phenomenon - what is it?
- What may patients notice on their elbows?
- Pyoderma gangrenosum - what is it? where does it usually occur?
- Erythema nodosum - what is it? Where does it occur?
Fatigue
Fever
Weight loss
The body’s immune system attacks glands that secrete fluid, such as the tear and saliva glands.
Dry mouth and dry eyes
A medical condition in which spasm of arteries causes episodes of reduced blood flow.
Typically, the fingers, and less commonly the toes, are involved. Rarely, the nose, ears, or lips are affected.
Rheumatoid nodules
A rare condition that causes large, painful sores (ulcers) to develop on your skin, most often on your LEGS. The exact causes of pyoderma gangrenosum are unknown, but it appears to be a disorder of the immune system.
Erythema nodosum is a type of panniculitis, an inflammatory disorder affecting subcutaneous fat. It presents as tender red nodules on the ANTERIOR SHINS.
Extra-articular manifestations:
Where else can Rheumatoid nodules be found?
Why does anaemia happen in RA? What is it called?
Lungs Heart - cardiomyopathy CNS Lymphadenopathy Eyes
When you have an RA flare-up, the immune response causes inflammation in the joints and other tissues. Chronic inflammation can lower the production of red blood cells in your bone marrow. This can lead to the release of certain proteins that affect how the body uses iron.
Anaemia of chronic disease
Extra-articular manifestations:
Neurological:
- What will nerve entrapment in the wrist cause?
Rheumatoid lung disease:
- List what it can cause?
- What lung disease is heavily linked to RA?
Cardiac:
- Why does cardiac disease occur?
- What cardiac disease can occur?
Eyes:
- What does it cause?
- Kerato-conjunctivitis sicca also occurs. What is it?
Carpel tunnel syndrome
Pleural effusion
Pulmonary fibrosis
Bronchioltitis
Lung nodules
ILD
Inflammatory substances called cytokines fuel joint destruction in RA and blood vessel damage in CVD. Inflammation causes plaque build-up in the arteries, which slowly narrows blood vessels and blocks blood flow, and is the main cause of heart attack and stroke.
Atherosclerosis
Pericardial effusion
Mitral regurg
Pericardial effusion
Episcleritis and scleritis
Keratoconjunctivitis sicca is dryness of the conjunctiva (the membrane that lines the eyelids and covers the white of the eye) and cornea (the clear layer in front of the iris and pupil). Too few tears may be produced, or tears may evaporate too quickly.
Investigations:
Diagnoses are made clinically but investigations are used to support that diagnosis!!!
Bloods:
- Why is FBC done?
- What inflammatory factors are looked at?
- Autoantibody Rheumatoid Factor is used to help diagnosis which is 70% sensitive. What other autoantibody can be used which is more specific and prognostic?
What is the difference between specificity and sensitivity?
Anaemia of chronic disease
ESR/CRP - raised
Anti-CCP
In medical diagnosis, test sensitivity is the ability of a test to correctly identify those with the disease (true positive rate), whereas test specificity is the ability of the test to correctly identify those without the disease (true negative rate).
A highly sensitive test means that there are few false-negative results, and thus fewer cases of the disease are missed. The specificity of a test is its ability to designate an individual who does not have a disease as negative. A highly specific test means that there are few false-positive results.
Investigations:
X-rays:
- What is imaged? - 2
- Mneumonic LESS - what does it mean?
- What can be done if there is diagnostic uncertainty or septic arthritis?
What score is used to make a final diagnosis?
What is involved in this score?
Hands and Feet
L – loss of joint space (sym)
E – erosions (high risk of progression)
S – soft tissue swelling
S – soft bones (juxta-articular osteopenia)
Juxtaarticular: Near a joint. For example, a juxta-articular fracture is a break near a joint.
Joint aspirate
DAS-28 score
Joint involvement
Serology - RF, anti-CCP
Acute phase reactants - ESR/CRP
Duration of symptoms - <6 wks/>6 wks
Management:
Who should they be referred to?
What can be used to monitor progress to Rx?
What analgesia is used? - 2
NSAIDs and glucocorticoids are used as antiinflammatories.
What routes can be used to give glucocorticoids?
What can be used for acute flare ups?
What drugs need to be started within 3 months of persistent symptoms to improve long term outcomes?
A rheumatologist
DAS-28 score and anti-CCP
Paracetamol
Weak opioids
IM
Intra-articular
PO during flare ups
IM methylprednisolone
DMARDS
Management:
What do DMARDs stand for?
What 4 drugs are classed as conventional DMARDs?
What biological agents can also be used?
What can surgery can be done?
Disease-Modifying Antirheumatic Drugs
Methotrexate
Sulfasalazine
Leflunomide
Hydroxychloroquine
Anti-TNFs - infilxamab, rittuximab
Joint replacement
Methotrexate:
Indications - name some?
Route?
How often is it given?
What needs to be prescribed alongside methotrexate?
Side effects:
- What are 2 pulmonary side effects?
- How does it cause immunosuppression?
- What are some systemic side effects?
- Why may they get a sore mouth? - 3
- What happens to their hair?
- What about on their skin?
Some other side effects are headaches, dizziness, deranged LFTs and cirrhosis.
RA Psoriasis Crohn's Chemotherapy Abortion/ectopic pregnancy ======
IM - weekly - need to give folate
Pneumonitis
Pulmonary fibrosis
Due to pancytopenia
N&V
Diarrhoea
Ulcerative stomatitis
Glossitis
Gingivitis
Hair loss
Rash
Methotrexate:
Contraindications:
- Pregnancy is a CI. How long before trying to conceive should you stop the medication?
- Why can you not take ibuprofen along with this?
Management:
- How often are blood tests done?
- What other vitamin should be taken along with it?
Pregnancy - stop 3 months before starting to try and conceive.
Ibuprofen may increase the blood levels and side effects of methotrexate. You may be more likely to experience this interaction if you have kidney disease or are receiving a high dose of methotrexate.
Weekly until dose stabilised and then 3 monthly
Folate
Joint injection:
What is injected?
How long does it last?
Indications in RA?
Contraindications:
- What type of infection is contraindicated?
You should also not give an injection to those with:
- A fractured joint
- A prosthetic joint
- Immunosuppressed
- Have uncontrolled diabetes
- Coagulopathy
What is the maximum number of injections you can have per yr?
What are some side effects or adverse effects of receiving a joint injection?
What may they get a dimple at the site of injection?
RA - relapses or as bridge until DMARDs
Corticosteroids
Lidocaine
Infliximab
2 wks
Septic arthritis (or a history of it)
4 MAX
Post-injection pain
Infection
Trauma, including nerves and tendons
Subcutaneous fat atrophy
