Seropositive Inflammatory Arthropathies (mainly RA) Flashcards
What are symptoms suggestive of inflammatory arthropathies?
joint pain & swelling morning stiffness improvement of symptoms with exercise synovitis with examination raised inflammatory markers extra-articular symptoms
What are general options for treatment of inflammatory arthropathies?
analgesia
anti-inflammatory medications: steroids & NSAIDs
steroid injections
DMARDs
What are seropositive inflammatory arthropathies?
Rheumatoid Arthritis SLE Scleroderma Vasculitis Sjogren's
What is the most common seropositive inflammatory arthropathy?
Rheumatoid artritis
Pathogenesis of RA
Auto-immune inflammatory systemic polyarthropathy
There is an immune response against synovium - inflammatory pannus forms which attacks & denudes articular cartilage
joint destruction, tendon ruptures, soft tissue damage
joint instability, subluxation
F:M ratio of RA
3:1
prevalence of RA
1% of population, increasing prevalence with age
Age RA usually diagnosed at
35-50
Genetic & Environmental factors of RA
genetic factors: 50% of the risk
smoking & RA association
Signs & Symptoms Of RA
symmetrical synovitis (doughy swelling)
mainly small joints of hands & feet
DIP spared!!!
morning stiffness
extra-articular manifestation of RA
rheumatoid nodules - 25$ extensor surfaces/mechanical irritation sites
lung: pleural effusion, interstitial fibrosis, pulmonary nodules
CV: morbidity & mortality increased
ocular involvement
ocular involvement of RA
keratoconjunctivitis sicca
episcleritis
uveitis
nodular scleritis - sleromalacia
What is a joint that RA may affect and could be life-threatening?
C1-2
investigations of RA
X-Ray: peri-articular osteopenia, periarticular erosions later in disease (at onset it may not show anything)
US: synovial inflammation
Serology: Rheumatoid Factor, Anti-CCP (more specific)
Serology of RA
Rheumatoid Factor
Anti-CCP (more specific)
15-20% of RA patients are seronegative
Diagnosis of RA is based on
clinical presentation
radiographic findings
serological analyiss
ACR & EULAR RA criteria scoring system
Disease activity is measured by
DAS28: tender joint count, swollen joint count, CRP/ESR, visual analogue score
DAS28 score limits
DAS28 < 2.6 - remission
DAS28 2.7-3.2 - low disease activity
DAS28 3.3-5.1 - moderate disease activity
DAS28 > 5.1 - high disease activity (eligible for biologic)
Symptom relief in RA
simple analgesia
NSAIDs
steroids: IM/intra-articular/oral
Treatment pattern for RA
1 DMARD: methotrexate (1st line)
2 DMARDs: methotrexate & sulfalazine
Biologic therapy (if it doesn’t respond to DMARDs & has high DAS28 score)
What is the critical window for DMARD therapy to be started?
It should be started within the first 3 months of symtpom onset
DMARDs
methotrexate
sulphalazine
hydroxychloroquine
leflunomide
Side effects of DMARDs
immunosuppressive - need to monitor bloods
What does taking the drugs look like for someone on methotrexate?
pregnancy test before starting
contraception has to be taken
regular blood tests
methotrexate 1/ week - 15 mg start
folic acid 1/week (3 days after drug)
What happens if you’re low on folate?
nausea, alopecia
What to do if the patient wants to be pregnant
stop methotrexate for 3 months before conception - still take contraceptive pill
RA gets better during pregnancy
after pregnancy it gets worse - give sulphalazine
(not methotrexate due to breastfeeding)
Options for biologic therapy
anti-TNF
toxlizumab
rituximab
abatacept
Risk of biologics
infection
latent TB reactivation (need to screen - if positive, you give them latent TB therapy and then start biologics)
Other therapies for RA
physiotherapy, OT, podiatrist, orthotists, surgery for resistant disease
Surgery for RA
synovectomy joint replacement joint excision tendon transfers arthrodesis (fusion) cervical spine stabilization
