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Rheumatoid & Osteoarthritis Flashcards

1
Q

What is Rheumatoid Arthritis?

A

Chronic symmetric polyarticular autoimmune joint disease, which primarily affects the small joints of the hands and feet

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2
Q

What sex is most likely to be affected by RA?

A

F>M

3:1

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3
Q

What is the peak age of RA onset?

A

Peak age 4th/5th decade, but may occur at any age from 16 years and is seen in adults of all ages

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4
Q

What factors suggest a poorer prognosis of RA?

A

Younger onset

Male

More joints and organs affected

Presence of RF and anti-CCP

Erosions seen on xray

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5
Q

What causes RA?

A

Genetic susceptibility

  • HLA-DR4
  • HLA-DR1

+

Environmental trigger

  • Smoking
  • Chronic infection
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6
Q

What genes are associated with RA?

A

HLA-DR4

HLA-DR1

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7
Q

What criteria is used to diagnose RA?

A

2010 European League Against Rheumatism (EULAR) Criteria

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8
Q

How many EULAR points is diagnostic of RA?

A

6 or greater

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9
Q

What factors does the EULAR criteria take into consideration?

A

Joint involvement

Serology

  • RF, Anti-CCP

Acute phase reactants

  • CRP and ESR

Duration of symptoms

  • Less or over 6 weeks
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10
Q

How does RA present?

A

Joint pain

  • Worse in morning
  • Improves with exercise

Stiffness

  • Particularly in morning or after inactivity, for longer than OA (30-60mins)

Immobility

Swelling

Tenderness

Limitation of movement

Rheumatoid nodules

Synovitis of wrist, MTP, PIP

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11
Q

What hand deformities are associated with RA?

A

Boutonniere nodes

Swan-Neck

Ulnar Deviation

Z Deformity of thumb

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12
Q

Give systemic manifestations of RA

A

Amyloidosis and pulmonary fibrosis

Felty’s syndrome (RA, splenomegaly, neutropenia)

Sjrogen’s syndrome

Anaemia of chronic disease

Atherosclerosis and cardiovascular disease

Secondary vasculitis

Osteoporosis

Scleritis

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13
Q

Where are Boutonniere nodes present?

A

Proximal interphalangeal joints

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14
Q

What joints does RA start in?

A

Starts as small joints

  • Metacarpophalangeal
  • Wrist joint
  • Proximal inter-phalangeal (distal are almost never affected)
  • Metatarsophalangeal
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15
Q

As RA progresses, what joints can be affected?

A

As disease progresses, larger joints become affected

  • Shoulders
  • Elbows
  • Knees
  • Ankles
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16
Q

How many joints are usually affected in RA?

A

As RA is polyarticular, usually >3 joints are affected

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17
Q

What Imaging signs are seen in RA?

A

SNP

Soft tissue swelling

Narrowing/decreased joint space

Periarticular Osteopenia/osteoporosis

Decreased bone density

Bony erosions/loss of bone

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18
Q

What serology investigations are used in RA diagnosis?

A

Rheumatoid Factor, present in approx 70% of patients

Anti Cyclic Citrullinated Peptide Antibody (Anti-CCP), most specific and sensitive

Anti Citrullinated Protein Antibodies (ACPA)

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19
Q

Which antibody test is diagnostic of RA?

A

Anti Cyclic Citrullinated Peptide Antibody (Anti-CCP) as most specific and sensitive

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20
Q

What is raised in RA flares?

A

CRP and ESR

21
Q

What score assesses severity of RA?

A

Disease activity score (DAS28), assessment out of 28 points

22
Q

What DAS score represents clinical remission?

23
Q

What DAS represents eligibility for biologic therapy?

24
Q

What does a change in disease activity score less than 0.7 indicate?

A

No response to current therapy

25
What does joint aspiration of RA show?
High WBC count Predominantly PMNs Appearance is typically yellow and cloudy Absence of crystals
26
How is RA managed?
NSAIDS, often co-prescribed with PPIs * Treatment of acute flares and symptom control IM corticosteroids * Methylprednisilone * Treatment of acute flares Disease Modifying Anti-Rheumatic Drugs (DMARD) Biologics
27
Describe the NICE guidelines for DMARDs and biologics
First line is monotherapy with methotrexate, leflunomide or sulfasalazine. Hydroxychloroquine can be considered in mild disease and is considered the “mildest” anti rheumatic drug. Second line is 2 of these used in combination. Third line is methotrexate plus a biological therapy, usually a TNF inhibitor. Fourth line is methotrexate plus rituximab
28
Give examples of DMARDs
Methotrexate Sulfasalazine Hydroxychloroquine Leflunomide
29
Give side effects of Hydroxychloroquine?
**Nightmares** **Reduced visual acuity (macular toxicity),** always have opthamology examination before initiation of drug Liver toxicity Skin pigmentation
30
Give side effects of Methotrexate
Mouth ulcers and mucositis Liver toxicity **Pulmonary fibrosis** Pneumonitis Agranulocytosis Teratogenic **LFT, U&E, FBC and xray must be done before commencing methotrexate**
31
What drugs should be avoided with methotrexate?
**Ttrimethoprim** or co-trimoxazole, increases risk of bone marrow suppression High-dose aspirin, increases the risk of methotrexate toxicity secondary to reduced excretion
32
How long after stopping methotrexate should women and men wait before trying to conceive?
6 months
33
What should be co prescribed with methotrexate?
Folic acid
34
Give side effects of Sulfasalazine
**Temporary male infertility (reduced sperm count)** Bone marrow suppression Pneumonitis Allergic reaction to aspirin
35
Give side effects of Leflunomide
Mouth ulcers and mucositis **HTN,** BP should be measured at baseline and at each review Rashes **Peripheral neuropathy** Liver toxicity Agranulocytosis Teratogenic
36
Give side effects of ciclosporin
**Everything is raised** Hypertrophy of the gums Hypertrichosis Hypertension Hyperkalaemia Hyperglycaemia
37
Give examples of biologics
Anti-TNF, such as infliximab and etanercept Anti-Cd20, such as rituximab JAK inhibitors IL-6 inhibitors
38
Give side effects of Rituximab
Vulnerability to severe infections and sepsis **Night sweats** **Thrombocytopenia** Peripheral neuropathy Liver and lung toxicity
39
Give side effects of Anti-TNF medications
Vulnerability to severe infections and sepsis **Reactivation of TB and hepatitis B,** always carry out a CXR prior to initiating anti-tnf
40
What is osteoarthritis?
Described as wear and tear of the joints, thought to be the result of an imbalance between the cartilage being worn down and the chondrocytes repairing it
41
How common is osteoarthritis?
Most common type of arthritis/joint problem Affects 50% of the \>60s
42
What are the two types of osteoarthritis?
Primary * Microtrauma over a long period Secondary * Single acute trauma
43
What joints are commonly affected in osteoarthritis?
Hips Knees Sacro-iliac joints Distal-interphalangeal joints in the hands (DIPs) The MCP joint at the base of the thumb Wrist Cervical spine
44
Give risk factors for osteoarthritis
Female Abnormal anatomy * Congenital developmental dysplasia of the hip Trauma Occupation * Farmers * Football players Persistent heavy physical activity * Elite running Obesity Age, as cartilage degrades over long periods of time Genetics/FH * Hereditability accounts for 43% at knee, 60% at hip and 65% at hand
45
How does osteoarthritis present?
Joint pain * Characteristically worse in the evening and after exercise Morning stiffness that lasts no longer than 30 minutes, night stiffness Restricted movement, due to capsular thickening Bony swelling around joint margins Synovitis occasionally Joint line tenderness Crepitus, due to rough articular surfaces Squaring of the thumb Heberden’s nodes, found at the distal interphalangeal joints, begin first Bouchard's nodes, found at proximal interphalangeal joints
46
What x-ray signs are seen in osteoarthritis?
**LOSS** Loss/reduced joint space Osteophytes/bony outgrowths Subchondral sclerosis, more sclerotic/white due to bone on bone Cystic formation, due to micro-trauma of a joint **However, osteoarthritis can be a clinical diagnosis**
47
What is the non-pharmacological management of osteoarthritis?
Thermotherapy * Heat/ice self-management Electrotherapy * Transcutaneous electric nerve stimulation Aids and devices * Walking stick Manual therapy/physiotherapy Lifestyle * Weight loss
48
What is the pharmacological and surgical management of osteoarthritis?
First line * Paracetamol (1st line) * Topical NSAIDS/capsacin cream Second line * Add oral NSAIDS * Coprescribe with PPI Third line * Consider opiates Intra-articular injections, provide temporary reduction in inflammation Joint replacent in severe cases
49
Give complications of joint replacement surgery
Infection DVT Pressure sores Loosening of implant Fat embolisation Haemorrhage Nerve damage, foot drop Decreased range of movement Revision, due to joint loosening of replacement

Musculoskeletal + Rheumatology (16 decks)

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