Rheumatology! Flashcards
Inflamation charaacteristics
Pain, swelling, redness, heat
tenderness, stiffness, crepitation, functional impairment
joint numbers
mono oligo 2-4 pauci <5 extended pauci 5-6 Poly 6+
enthesis
where muscle joins bone
what drives inflammation
acute phase reactants
CRF, fibrinogen
ESR non-protein APR that effects plasma viscosity as fibrinogen is consumed.
More inflammation the less viscous the plasma becomes and cells fall out of suspension faster
ESR is elevated with inflammation
Initial immune indicators
before symptoms start to show up
RF +
Anti-CCP +
increased CRP
RF factors are
usually IgM autoantibodies
Rheumatoid factors
produced by RA synovium
fix complement - (consumed in RA joint)
complement fragments recruit/activate PMSs
complement coated antibody/antigen reaction
what does damage to the joint
TNF and MAC
pro inflammatory cytokines
TNF-a
IL 1
RA epidemiology
women 3:1
25-45
improves during pregnancy
ACR classification criteria for RA
morning stiffness > 1 hour > 6 weeks swelling 3+ jts > 6 weeks swelling hand jts > 6 weeks symmetric joint swelling > 6 weeks rheumatoid nodules Rheumatoid factor erosions/osteopenia on hand x-ray Need 4
Joints RA goes after
Wrist, MCT, PIP, Knee, ankle, MTP
what is pannus
t-cells/lymphocytes, dense inflammatory cells invading the joint space -> big swollen jts
Hand changes RA
ulnar deviation
hand deformaties
synovitis
joint space narrowing and erosions
Best imaging for RA
US and MRI
had deformaties
boutonniere
swan neck
What is felty syndrome
RA, splenomegaly and neutropenia
Extra articular manifestations of RA
R Nodules - RF + neuromyopathy
Sjogren’s syndrome inflammatory Eye Dx
feltys osteoporosis
vasculitis lymphadenopathy
rehumatoid lung hyperviscosity
cardiac disease cryoglobulinemia
dermatologic amyloidosis
Myelopathy in RA
transverse ligament of atlas becomes frayed
C1 translates on C2 - esp with leaning forward
muscle weakness in arms/legs
severe neck pain radiating to occiput
dysesthesias of fingers/feet
marble sensation in limbs/trunk
jumping legs
disturbed bladder fxn
Inflammatory eye diseases in RA
scleritis
scleromalacia
sjogrens syndrome
small vessel vasculitis
sjogrens syndrome treatment
anti inflammatories and immunosuppressive drugs
Sjogrens associations
SS-a(Ro) and SS-b (La)
Lab findings in RA
RF + Anti CCP antibody + ANA + Elevated ESR/CRP anemia, thrombocytosis, hyperglobulinemia leukopenia/granulocytopenia glucose in body fluids - very low
Best diagnostic test
RF < 50 U/mL + anti-CCP
High RF titer (>50) significance
good tool for diagnosis
good predictor for erosiveness
Low RF titer (<50) significance
RF of little diagnostic value
need to add Anti-CCP to get diagnostic and prognostic value
Goals of RA therapy
alleviate pain
slow rate of Jt damage
can’t do: control disease activity, maintain fxn, max quality of life, reduce premature mortality, safe/efficacious
Non pharm RA treatment
Education, phy/occup therapy, rest, articular rest
exercise, heat/cold, assistive devices, splints, weight loss
Limits of NSAIDS
do not halt disease progression
toxicity associated
efficacy/toxicity - frequent switching
limits of corticosteroids
chronic use has many side effects
“miracle drug in mexico clinic
Limits of DMARDS
high discontinuation rate
need for monitoring
delayed onset of action
Limits of biologic agents
opportunistic infections
Methotrexate Pros
DMARD - 1x week
long term clinical experience
favorable rate of continuing therapy
proven efficacy in moderate-sever RA
Methotrexate Cons
lab monitoring every 4-8 weeks
CBC, liver fxn tests, creatnine
Toxicities: alopecia, hepatic, cat X
myelosuppression, pulmonary
Leflunomide - Pros
well absorbed po
early onset of action
stabilized benefit for long term use
targets AI lymphocytes to reduce adverse effects
rapid excretion w/ cholestryramine (gall bladder)
Leflunomide - Cons
lack of clinical experience
tox: hepatic, gastrointestinal, teratogenic
Biologic - toxicities
increase risk of infection reactiviating latent TB noplasia MS autoimmune disease
Types of biologics
Anakinra - IL-1 receptor antagonist 1/2- 4-6 hours
Infliximab - anti tnf-a AB 1/2 - 8-10 days
Etanercept - soluble TNF receptor 1/2 3-5 days
Adalimumab - Anti tnf-a AB 1/2 10-20 days
ACR remission criteria
AM stiffness < 15 mins
no fatigue, jt pain, jt tenderness/ROM pain
no soft tissue swelling in jts or tendon sheaths
ESR < 30 males < 20 femals
need > 5 for > 2 months
Clinical pearls RA
confirm, define extent of joint and extra articluar involve consider co-morbid disease full dose NSAID early DMARD use add biologic - when others fail low dose steroids to bridge pain mangement frequent monitoring
