T2 - Artrite Reumatoide Flashcards
Frequência de Artrite Reumatóide?
0,7%
3:1 (mulheres:homem)
Heridabilidade da Artrite Reumatóide?
30%
Fatores Ambientais na Artrite Reumatóide?
Virus (EBV, parvovirus B19) Tabaco Stress/Comida Álcool Fatores Hormonais (prolactina como imunomodulador)
Gene que aumenta risco de Artrite Reumatóide?
PTPN22
Manifestações articulares da Artrite Reumatóide?
Monoartrite (punho e joelho) Tenosinovite isolada Oligoartrite Poliartrite Simétrica (IFPs, MCFs, punho e MTFs) - Típico Idosos - Poliartrite Rizomélica
Detection of synovitis?
- Soft tissue swelling
- Tenderness
- Limited motion (frequently)
Extra-articular manifestations of Rheumatoid Arthritis?
- Fever
- Pericarditis
- Pleuritis
Laboratory investigations in Rheumatoid Arthritis?
- Elevated erythrocyte sedimentation rate and C-reactive protein
- Thrombocytosis; sometimes leucocytosis
- Rheumatoid factor in high titles
- Anti-cyclic citrullinated peptides
Conventional radiographic examinations in Rheumatoid Arthritis?
- Hands
- Wrists
- Feet
- Baseline assessment
Gold Standard?
Conventional radiography
Presence of erosions: key feature
Early conventional radiographic signs of Rheumatoid Arthritis?
- Soft tissue hipertrophy, mainly in MCPs and PIPs
- Periarticular osteoporosis in MCPs and PIPs
- Marginal erosions (1st. Carpus; second MCP; ulnar styloid; lateral fifth metatarsal head)
Advantage of High-resolution ultrasonography with power Doppler?
Higher sensitivity
Magnetic resonance imaging (MRI) in Rheumatoid Arthritis?
Higher sensitivity.
Bone marrow edema is also typical, which is a predictor of subsequent erosions.
Rheumatoid Arthritis classification criteria?
Joint involvement
Serology
Acute-phase reactants
Duration of symptons
Diagnóstico diferencial na Artrite Reumatóide?
Distinguir de Osteoartrite
Prediction of outcome in Rheumatoid Arthritis?
Prediciton of future physical disability
Prediciton of future structural damage
Prediciont of increased mortality
Hands involvement in Established rheumatoid arthritis?
Boutonnière deformity Z or 90-90 thumb Swan-neck deformity MCP deformities Volar subluxation of the wrist
Elbow and shoulder involvement in Established Rheumatoid Arthritis?
Elbow • Frequently involved • Early sign: loss of extension • After: loss of supination Shoulder • Not very frequently; • Synovitis leads to erosion and damage of both the humeral head and glenoid fossa.
Mais comum Subluxação da atlanto-axial?
Anterior (space between the odontoid process of C2 and the arch of the atlas
≥ 3 mm in cervical x-ray with the head in the flexed position)
Lower limbs involvement in Established rheumatoid arthritis?
Knee
• Frequently involved (80%)
• Early sign: reduction of knee extension
• After: Baker`s cyst in the popliteal region and Valgus knee.
Hip
• Infrequently involved
Feet involvement in Established Rheumatoid Arthritis?
• Triangle forefoot deformity – Hálux valgus + quintus varus • MTP joints subluxation – Clawing of the toes • Evolution: valgus flat foot • Calcaneal valgus
Other joints involvement in Established rheumatoid arthritis?
Temporal-mandibular joint • Painful limitation of mouth opening Cricoarytenoid joint • Hoarseness Ear ossicles • Hearing loss independent of medication-induced effects
Tenossinovites mais comuns?
- Flexor tenosynovitis
- Ulnar extensor carpi tenosynovitis
- Common fingers extensor tenosynovitis
Typical Bursitis in Established rheumatoid arthritis?
Olecranon bursitis
Sub-Achilles bursitis
Subcutaneous nodules in Established rheumatoid arthritis?
Extensor aspects of the proximal ulna
Other pressure locations
Not exclusive of rheumatoid arthritis
Extra-articular manifestations in Established rheumatoid arthritis?
Secondary osteoporosis Secondary Sjögren`s syndrome Infections (artrocentese em monoartrite com AR controlada) Hematological abnormalities Splenomegaly (Sind. Felty) Renal disease Gastrointestinal manifestations
Eye complications in Established rheumatoid arthritis?
- Episcleritis
- Dry eyes
- Escleromalacia
- Ocular perforation
- Iritis
Vasculitis in Established rheumatoid arthritis?
- Uncommon (1%), related to disease severity and activity
- Necrotising vasculitis
- Cutaneous ulceration
- Peripheral neuropathy
Pulmonary disease in Established rheumatoid arthritis?
- Pleuritis
- Intersticial pneumonitis
- Intersticial fibrosis
- Bronchiectasis
Rare Pulmonary disease in Established rheumatoid arthritis?
- Nodular lung disease
* Caplan Syndrome (macronodular AR + silicosis)
Cardiac and cardiovascular disease in Established rheumatoid arthritis?
Arteriosclerosis
Pericarditis
Mortality in Rheumatoid arthritis? Causes?
In severe forms, reduction of 5 years in life expectancy
Causes:
• Cardiovascular
• Infectious
Therapeutic targets in Rheumatoid arthritis?
Suppress inflammation Protect against joint destruction Preserve function Prevent comorbidities (cardiovascular and others) Improving the quality of life
Disease assessment in Rheumatoid arthritis?
• Tight control: every 3 months
• Global disease activity assessment by the patient on VAS
• Number of tender joints (pressure)
• Number of swollen joints (pressure)
Stanford Health Assessment Questionnaire (HAQ)
Remission criteria in Rheumatoid arthritis?
Tender joint count < 1
Swollen joint count < 1
Patient global assessment < 1
PCR < 1 mg/dl
Symptomatic treatment in Rheumatoid arthritis?
Rest Analgesics NSAIDs CCTs • Severe disease; NSAIDs contraindicated • Average dose: prednisolone 7,5 mg/day • EV methylprednisolone (500 mg to 1g/day, 3 consecutive days → flares)
Indications of glucocorticoids in early arthritis and established rheumatoid arthritis?
- Intra-articular in mono or oligo-articular flares
- In established rheumatoid arthritis for symptomatic control
- In a polyarticular flare for symptomatic control
Fármacos modificadores da doença reumática (imunosupressores)?
Justification
• Effective control of clinical and biological signs of disease
• Prevent /retard radiological progression
• Induce remission
Time of prescription
• The earliest possible: after diagnosis
Duration prescription
• Long as it remains effective and well-tolerated
DMARDs com Potencial prognóstico benigno ou dúvidas diagnósticas? E com prognóstico sério ou indeterminado? Ausência de resposta?
Hidroxicloroquina.
Metotrexato e Leflunamida.
Anti-TNF e Combination therapy.
Conclusion remarks on Rheumatoid arthritis?
Disabling condition:
• High morbidity
• Disability
Decrease in life expectancy in five years, compared to the general population
Window of opportunity
• Need for early diagnosis
• Need to establish early the patient outcomes
• Early institution of the most appropriate therapy
Need for tight control
