Rheumatoid & Osteoarthritis Flashcards
What is Rheumatoid Arthritis?
Chronic symmetric polyarticular autoimmune joint disease, which primarily affects the small joints of the hands and feet
What sex is most likely to be affected by RA?
F>M
3:1
What is the peak age of RA onset?
Peak age 4th/5th decade, but may occur at any age from 16 years and is seen in adults of all ages
What factors suggest a poorer prognosis of RA?
Younger onset
Male
More joints and organs affected
Presence of RF and anti-CCP
Erosions seen on xray
What causes RA?
Genetic susceptibility
- HLA-DR4
- HLA-DR1
+
Environmental trigger
- Smoking
- Chronic infection
What genes are associated with RA?
HLA-DR4
HLA-DR1
What criteria is used to diagnose RA?
2010 European League Against Rheumatism (EULAR) Criteria
How many EULAR points is diagnostic of RA?
6 or greater
What factors does the EULAR criteria take into consideration?
Joint involvement
Serology
- RF, Anti-CCP
Acute phase reactants
- CRP and ESR
Duration of symptoms
- Less or over 6 weeks
How does RA present?
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
What hand deformities are associated with RA?
Boutonniere nodes
Swan-Neck
Ulnar Deviation
Z Deformity of thumb
Give systemic manifestations of RA
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
Where are Boutonniere nodes present?
Proximal interphalangeal joints
What joints does RA start in?
Starts as small joints
- Metacarpophalangeal
- Wrist joint
- Proximal inter-phalangeal (distal are almost never affected)
- Metatarsophalangeal
As RA progresses, what joints can be affected?
As disease progresses, larger joints become affected
- Shoulders
- Elbows
- Knees
- Ankles
How many joints are usually affected in RA?
As RA is polyarticular, usually >3 joints are affected
What Imaging signs are seen in RA?
SNP
Soft tissue swelling
Narrowing/decreased joint space
Periarticular Osteopenia/osteoporosis
Decreased bone density
Bony erosions/loss of bone
What serology investigations are used in RA diagnosis?
Rheumatoid Factor, present in approx 70% of patients
Anti Cyclic Citrullinated Peptide Antibody (Anti-CCP), most specific and sensitive
Anti Citrullinated Protein Antibodies (ACPA)
Which antibody test is diagnostic of RA?
Anti Cyclic Citrullinated Peptide Antibody (Anti-CCP) as most specific and sensitive
What is raised in RA flares?
CRP and ESR
What score assesses severity of RA?
Disease activity score (DAS28), assessment out of 28 points
What DAS score represents clinical remission?
<2.4
What DAS represents eligibility for biologic therapy?
>5.1
What does a change in disease activity score less than 0.7 indicate?
No response to current therapy
What does joint aspiration of RA show?
High WBC count
Predominantly PMNs
Appearance is typically yellow and cloudy
Absence of crystals
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
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
Give examples of DMARDs
Methotrexate
Sulfasalazine
Hydroxychloroquine
Leflunomide
Give side effects of Hydroxychloroquine?
Nightmares
Reduced visual acuity (macular toxicity), always have opthamology examination before initiation of drug
Liver toxicity
Skin pigmentation
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
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
How long after stopping methotrexate should women and men wait before trying to conceive?
6 months
What should be co prescribed with methotrexate?
Folic acid
Give side effects of Sulfasalazine
Temporary male infertility (reduced sperm count)
Bone marrow suppression
Pneumonitis
Allergic reaction to aspirin
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
Give side effects of ciclosporin
Everything is raised
Hypertrophy of the gums
Hypertrichosis
Hypertension
Hyperkalaemia
Hyperglycaemia
Give examples of biologics
Anti-TNF, such as infliximab and etanercept
Anti-Cd20, such as rituximab
JAK inhibitors
IL-6 inhibitors
Give side effects of Rituximab
Vulnerability to severe infections and sepsis
Night sweats
Thrombocytopenia
Peripheral neuropathy
Liver and lung toxicity
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
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
How common is osteoarthritis?
Most common type of arthritis/joint problem
Affects 50% of the >60s
What are the two types of osteoarthritis?
Primary
- Microtrauma over a long period
Secondary
- Single acute trauma
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
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
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
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
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
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
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
