Rheumatoid Arthritis & Seronegative Spondyloarthropathies Flashcards by Sarah Gillen

RA is an autoimmune disease that targets _____ tissues in _______ joints

Synovial; diarthrodial

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Systemic features of RA

Fatigue, fever, normochromic normocytic anemia

Elevated APPs (ESR, CRP)

Constitutional sxs: malaise, myalgia, depression

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1/3 of pts are susceptible to RA d/t genetic factors — typically _______ alleles

HLA-DRB 4

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T/F: pathologic changes in joints precede synovitis in RA pts by 5-10 years

True

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Initial pathogenesis of RA involves infiltration of leukocytes, cytokines, and macrophages that act as APCs to activate _____ cells.

Later _____ cells produce autoantibodies, and proinflammatory cytokines promote synovial proliferation, increase synovial fluid, and lead to _______ formation that invades cartilage and bone

B; pannus

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Imaging studies to order when RA is suspected

X-rays of hands and feet — detect symmetrical involvement of MCP/MTP joints; erosions

CT is more sensitive in detecting erosions!!

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Treatment for RA that presents acutely

Begin NSAID for pain control

Early use of DMARD

May need low dose steroid for a few weeks

Monitor progress and toxicity

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How does RA change during pregnancy?

Improves; then flares 4-6 weeks post partum

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Significant mortality caused by infection, renal disease, GI disease, heart disease, and malignancy is associated with RA moreso than the general population.

What are cardiac mortality associations with RA?

CAD, CHF due to endothelial damage from chronic inflammation

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In terms of the 2010 RA Classification Criteria, the target population of those who should be tested are patients who:

Have at least 1 joint with definite clinical ______ that is not better explained by another disease

Synovitis

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What are the 4 class criteria utilized in the 2010 RA Classification Criteria?

Joint involvement (number and size)

Serology (at least 1 positive test — RF, CCP)

Acute phase reactants (at least 1 test needed — CRP, ESR)

Duration of symptoms (>6 weeks gets a point)

[greater than 6/10 points = definite RA]

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What lab values are used to monitor treatment response in RA?

Acute phase reactants (ESR, CRP)

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What part of the spine is affected by RA?

C1-C2 — be careful with flexion and hyperextension; tell anesthesiologist before intubation d/t risk of subluxation!

[the remainder of the axial spine is SPARED!]

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T/F: RA pts have decreased risk of osteoporosis

False, they have increased risk

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______ deviation of the wrist in RA in addition to synovial proliferation may lead to compression of the ____ nerve and subsequent carpal tunnel syndrome

Radial; median

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Knee manifestations of RA

Bakers cyst — popliteal region

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Diagnosis of RA typically requires active signs of inflammation of at least _________ duration

6 weeks

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Complication of RA characterized by tender reddish purple papule; leads to necrotic, non-healing ulcer

Pyoderma gangrenosum

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Purpura, petechiae, splinter hemorrhages, and digital infarcts are characteristic of rheumatoid ______

Vasculitis

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T/F: Rheumatoid arthritis is an independent risk factor for CAD

True

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_____ syndrome = nodular lung densities after exposure to coal or silica dust

Caplan

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Sjogren’s syndrome is seen in 35% of pts with RA. What are 3 tests that may be used to support a dx of Sjogrens?

Ro/SS-a, La/SS-b Abs

Schirmers test (litmus paper under eyelids to test for tear production)

Slit-lamp exam

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Rheumatoid arthritis
Splenomegaly
Thrombocytopenia
Neutropenia
Fever
Anemia
RF and anti-CCP positive

Felty’s syndrome

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RA may be complicated by atlantoaxial subluxation (C1/C2) due to erosion of the _________ _______; other complications include peripheral neuropathy and ______ myelopathy

Odontoid process; cervical

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In which of the following might rheumatoid factor be positive? ``` A. Healthy elderly patient B. Hepatitis B/C pts C. CTD/SLE D. Polymyositis E. Sjogrens F. Systemic sclerosis G. Lymphoma or myeloma H. TB, mono, syphilis, and sarcoid I. All of the above ```

I. All of the above

Immunosuppresive drug class utilized in RA that can halt disease progression in synovium and halt/slow radiographic progression; treat to target — remission or low disease activity

DMARDs

One of the non-biologic DMARDs used in RA is methotrexate — this is the drug recommended as the first DMARD for RA/once a week. Pts on this drug should be given supplemental _______. It is also useful in psoriatic arthritis. It should not be given in pregnancy

Folic acid

Labs to monitor while pt is on MTX for RA

CBC LFTs Creatinine Monitor q4-8 weeks [toxicities include hepatic, myelosuppression, pulmonary]

Another non-biologic used in tx of RA is hydroxychloroquine (antimalarial) which is safe in pregnancy. This agent can also be used with MTX and sulfasalazine. What specialist should pts on hydroxychloroquine follow up with?

Ophthalmologist d/t risk of macular damage to retina, blurred vision, halos, photophobic

What RA drug?: Pyrimidine antagonist Rapid excretion with cholestyramine Don’t use when pregnant GI/hepatic toxicity/teratogenic

Leflunomide

Sulfasalazine is also effective in RA and can be used with MTX. It is safe in pregnancy. What lab should be monitored on this drug?

WBC

Toxicities of all biologics used in RA

Increased risk of infection Reactivation of latent TB Neoplasia Multiple sclerosis Autoimmune disease

Pro-inflammatory cytokine in RA pathogenesis that stimulates synovial cell proliferation and collagenase

TNF-alpha

Anti-TNF agents used in RA

Etanercept Inflixumab Adalimumab Rituximab

Overall management of RA

# Define extent of joint and extra-articular involvement Full dose NSAID Early use of DMARD (MTX w/i 3-6 month window) Add a biologic Low dose steroids for flares/bridge Adequate pain management Monitor progress/toxicity

Enteropathic arthritis and spondylitis develops in 20% of pts with either _____ or ______; this condition responds to treatment with ______

Crohns; UC; infliximab

Clinical manifestations of spondyloarthropathies

Predilection for spine, SI joints New bone formation at sites of inflammation Joint ankylosis; fusion, rigidity, kyphosis Asymmetric peripheral arthritis Enthesitis Ocular inflammation

_______ = inflammation of insertion points of tendons and ligaments onto bones; component of spondyloarthropathies Seronegative spondyloarthropathies may be related to immune susceptibility via allele _____

Enthesitis HLA-B27

______ = swelling of finger or toe; commonly seen in reactive arthritis/psoratic arthritis

Dactylitis

Keratoderma is a skin manifestation of _______ arthritis

Reactive

2 types of chronic polyarthritis with symmetric SI involvement and smooth, marginal syndesmophyte

Ankylosing spondylitis Enteropathic arthrities

2 types of chronic polyarthritis with asymmetric SI involvement and course, non-marginal syndesmophyte

Psoriatic arthritis Reactive arthritis

M:F ratio of RA, ankylosing spondylitis, enteropathic arthritis, psoriatic arthritis, and reactive arthritis

Rheumatoid — 1:3 (F) AS — 3:1 (M) EA — 1:1 (=) PA — 1:1 (=) Reactive — 10:1 (M) [M:F]

Eye manifestations of RA, ankylosing spondylitis, and reactive arthritis

Rheumatoid — scleritis AS — iritis Reactive — iritis and conjunctivitis

Hallmark of spondyloarthropathy in children

Enthesitis — examples include plantar fasciitis, achilles tendonitis, costochondritis

Not all pts with spondyloarthropathies are positive for HLA-B27. Which of the spondyloarthropathies is 90% positive for HLA-B27?

Ankylosing spondylitis [reactive arthritis is positive 80% of the time, enteropathic spondylitis is 75%, psoriatic arthritis is 50%]

What is the importance of asking if physical activity improves a young male pts’ SI joint pain?

If exercise makes it better, it is NOT DJD, and more likely to be AS

Tests/imaging to order in a pt you suspect may have ankylosing spondylitis

HLA-B27 CRP, ESR CBC X-rays of pelvis — attention SI joints (shows erosions of SI joints, pseudo-widening, sclerosis, fusion, ankylosis, etc) X-rays of lumbar vertebrae (shows squaring — loss of anterior convexity, and shiny corners = sclerosis at edge of vertebral bodies) CT of lumbar/pelvis if X-rays non-diagnostic

Most common inflammatory disorder of axial skeleton

Ankylosing spondylitis

Clinical manifestations of ankylosing spondylitis

Low back pain >3 mos Morning stiffness, improved with exercise, worse with rest Fatigue, weight loss, fever Symmetrical SI joint pain (sacroiliitis); loss of mobility/flexibility; arthritis of hips Tendonitis, plantar fasciitis

Extra-articular manifestations of ankylosing spondylitis

Anterior uveitis (iritis) Photophobia, eye pain, blurred vision Aortic insufficiency, aortic aneurysm Pulmonary fibrosis — restrictive IBD Psoriasis [NOTE: iritis is NOT found in RA, but may be seen with SLE or herpes simplex]

2 special tests that may be performed on PE to identify ankylosing spondylitis

Schober Test — restricted forward flexion; measures 5 cm below and 10 cm above LS junction while pt bends forward. Less than 4 cm = decreased mobility FABERE test — decreased chest expansion if less than 5 cm

ESR, CRP, HLA, CBC, RF, ACCP, and ANA results in ankylosing spondylitis

ESR and CRP increased HLA-B27 positive in 90% CBC shows Anemia of chronic disease Negative RF, ACCP, ANA

_______ = bony growth originating inside a ligament, commonly seen in the ligaments of the spine, specifically the ligaments in the intervertebral joints leading to fusion of vertebrae

Syndesmophytes

The differential diagnosis for ankylosing spondylitis includes _________, which causes calcification along the lateral aspect of 4 contiguous vertebral bodies but does NOT affect the SI joints

DISH (diffuse idiopathic skeletal hyperosteosis)

The differential diagnosis for ankylosing spondylitis includes _________, which affects young and middle aged females; manifestations include NORMAL SI joints; x-ray shows sclerosis on iliac side of SI joint

Osteitis condensans ilii

Late complications of ankylosing spondylitis include _________ lung disease, _______ fractures, and __________ syndrome evidenced by bowel/bladder dysfunction and pelvis+low back pain

Restrictive; compression; cauda equina

Treatment for ankylosing spondylitis

Exercise, PT, swimming, stretching (preserve mobility/prevent kyphosis) NSAID — pain control, may slow damage progression TNF-a inhibitors — decrease inflammation of axial spine and improve mobility (helps in 50% of pts) Non-biologic DMARDs — MTX/sulfasalazine for peripheral arthritis but NOT axial dz

Autoimmune disease; asymmetric mono-arthritis or oligo-arthritis (large joints) in lower extremities; may be associated with GI/GU infection — salmonella, shigella, yersinia, campylobacter, chlamydia trachomatis

Reactive arthritis

Features of reiter’s syndrome/reactive arthritis

Urethritis Arhtritis Conjunctivitis (uveitis) May also see mucocutaneous lesions (oral ulcers)

Manifestations of reactive arthritis may include _____ _____ which are vesicles/ulcers on the glans penis, as well as _____ _____ which are painless eruptions on the palms and soles

Circunate balanitis Keratoderma blennorrhagicum

Reactive arthritis treatment

Usually self-limited (6 months) NSAID, steroids (intraarticular) If chronic progression, use DMARD (sulfasalazine, MTX, leflunomide) Urethritis — if chlamydia, tx with azithromycin or doxycycline

Pencil in cup deformity on x-ray

Psoriatic arthritis

Treatment for psoriatic arthritis

NSAID - pain control Non-biologic DMARD — for peripheral arthritis Biologics (TNF inhib) - prevent progression of joint damage/psoriasis Typically combine MTX with TNF-inhibitor, inflixumab, etanercept

In enteropathic arthritis/IBD-associated arthritis, the peripheral arthritis typically parallels the activity of IBD, affects _____ joints of the lower extremity, and _____ joints of the upper extremity. All extra-articular manifestations occur more commonly in _______ 50-75% of pts are HLA-B27 positive

Large; small Crohns disease

Extraarticular manifestations of enteropathic arthritis/IBD-associated arthritis (skin, eyes, GI, GU, CV, bones)

Skin — pyoderma gangrenosum, erythema nodosum Eyes — uveitis GI — CD/UC GU — nephrolithiasis CV — thromboembolism Bones — fracture, low bone density, vit D deficiency

Treatment for enteropathic arthritis/IBD-associated arthritis

NSAID Steroids — short relief MTX/sulfasalazine TNF-a inhib are effective for IBD arth