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Musculoskeletal + Rheumatology > Rheumatoid & Osteoarthritis > Flashcards

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?

A

<2.4

23
Q

What DAS represents eligibility for biologic therapy?

A

>5.1

24
Q

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

A

No response to current therapy

25
Q

What does joint aspiration of RA show?

A

High WBC count

Predominantly PMNs

Appearance is typically yellow and cloudy

Absence of crystals

26
Q

How is RA managed?

A

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
Q

Describe the NICE guidelines for DMARDs and biologics

A

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
Q

Give examples of DMARDs

A

Methotrexate

Sulfasalazine

Hydroxychloroquine

Leflunomide

29
Q

Give side effects of Hydroxychloroquine?

A

Nightmares

Reduced visual acuity (macular toxicity), always have opthamology examination before initiation of drug

Liver toxicity

Skin pigmentation

30
Q

Give side effects of Methotrexate

A

Mouth ulcers and mucositis

Liver toxicity

Pulmonary fibrosis

Pneumonitis

Agranulocytosis

Teratogenic

LFT, U&E, FBC and xray must be done before commencing methotrexate

31
Q

What drugs should be avoided with methotrexate?

A

Ttrimethoprim or co-trimoxazole, increases risk of bone marrow suppression

High-dose aspirin, increases the risk of methotrexate toxicity secondary to reduced excretion

32
Q

How long after stopping methotrexate should women and men wait before trying to conceive?

A

6 months

33
Q

What should be co prescribed with methotrexate?

A

Folic acid

34
Q

Give side effects of Sulfasalazine

A

Temporary male infertility (reduced sperm count)

Bone marrow suppression

Pneumonitis

Allergic reaction to aspirin

35
Q

Give side effects of Leflunomide

A

Mouth ulcers and mucositis

HTN, BP should be measured at baseline and at each review

Rashes

Peripheral neuropathy

Liver toxicity

Agranulocytosis

Teratogenic

36
Q

Give side effects of ciclosporin

A

Everything is raised

Hypertrophy of the gums
Hypertrichosis
Hypertension
Hyperkalaemia
Hyperglycaemia

37
Q

Give examples of biologics

A

Anti-TNF, such as infliximab and etanercept

Anti-Cd20, such as rituximab

JAK inhibitors

IL-6 inhibitors

38
Q

Give side effects of Rituximab

A

Vulnerability to severe infections and sepsis

Night sweats

Thrombocytopenia

Peripheral neuropathy

Liver and lung toxicity

39
Q

Give side effects of Anti-TNF medications

A

Vulnerability to severe infections and sepsis

Reactivation of TB and hepatitis B, always carry out a CXR prior to initiating anti-tnf

40
Q

What is osteoarthritis?

A

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
Q

How common is osteoarthritis?

A

Most common type of arthritis/joint problem

Affects 50% of the >60s

42
Q

What are the two types of osteoarthritis?

A

Primary

  • Microtrauma over a long period

Secondary

  • Single acute trauma
43
Q

What joints are commonly affected in osteoarthritis?

A

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
Q

Give risk factors for osteoarthritis

A

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
Q

How does osteoarthritis present?

A

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
Q

What x-ray signs are seen in osteoarthritis?

A

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
Q

What is the non-pharmacological management of osteoarthritis?

A

Thermotherapy

  • Heat/ice self-management

Electrotherapy

  • Transcutaneous electric nerve stimulation

Aids and devices

  • Walking stick

Manual therapy/physiotherapy

Lifestyle

  • Weight loss
48
Q

What is the pharmacological and surgical management of osteoarthritis?

A

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
Q

Give complications of joint replacement surgery

A

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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