Week 2 - B - Rheumatoid arthritis - joints affected, symptoms, ACR/EULAR, DAS28, scans, treatment Flashcards
Rheumatism or rheumatic disorder is an umbrella term for conditions causing chronic, often intermittent pain affecting the joints and/or connective tissue Describe rheumatoid arthritis in a sentence?
Rheumatoid arthritis is a chronic systemic inflammatory disease characteristic by a symmetrical inflammatory arthritis infecting mainly the peripheral joints
Which sex is rheumatoid arthritis more common in? When is it the opposite?
Rheumatoid arthritis is 3 times more common in females
However, it is more common in males when it comes to affecting extra-articular structures
What is the approximate prevalence of rheumatoid arthritis? What type of joints are affected by RA and how?
Affects approximately 1% of the population It can affect any synovial joints - typically affects the small joints -
RA targets the synovium lining the joint capsules and tendon sheaths
Which joints in the neck are affected by RA and why?
Commonly affects the antlatno-occipital joint (C1 and occipital bone) and atlanto-axial joint (C1 and C2)
Less commonly it affects the facet joints It can affect these spinal joints because they are synovial joints (between normal vertebral bodies they are secondary cartilaginous joints)
Which haplotype is RA mediated by? What is thought to be a major risk factor for RA due to increase one of the autoantibodies associated with the disease?
HLA-DR4 and sometimes HLA-DR1
A major risk factor linked to RA is smoking as it is associated with a large increased in anti-CCP antibodies (anti cyclic citrillunated peptide antibodies)
How much synovial fluid usually exists in synovial joints? What does inflammation of synovium in rheumatoid arthriits cause?
Normally there is about 1-2 mls of synovial fluid existing in a joint
Inflammation of the synovium causes more synovial fluid to be excreted.
When the synovium is inflamed it brings in inflammatory cells into the fluid causing damage
What type of bone change is caused by rheumatoid and osteoarthritis * Hypotrophic or hypertrophic
Hypoptrophic bone changes are typically seen on xray in rheumatoid
Rather than hypertrophic picture seen in OA
* Gout and rheumatoid show an erosive athritis
Rheumatoid arthritis (RA) causes an inflammatory response in joints that leads to synovial tissue proliferation (vascular hypetrophy of the synovium). What is this known as?
This is known as Pannus - this is where there is vascular hypertrophy of the synovium due to inflammation of the joint
What is activated in rheumatoid arthritis that causes bone erosion?
There is increased osteoclast activity due to rheumatoid factor
How does synovitis present and how can it affect the muscles?
Synovitis presents as swelling and inflammation
It can lead to muscle wasting
What is the syndrome known as that describes increased swelling of the extensor tendons in the hand which leads to atraumatic rupture of these tendons most commonly associated with rheumatoid arthritis? In which order do the tendons rupture in this syndrome?
This is known as Vaughan Jackson Syndrome
The presentation is with reduced extension of the fingers 1-5.
Typically, the fifth digit is the first to lose extension, and then sequentially the fourth, the third, and then finally the second digit
What is early rheumatoid defined as? When is the therapeutic window for most beneficial effects in the treatment of early RA?
Early rheumatoid is defined as less than 2 years since symptoms onset
Therapeutic window for most beneficial effects in treatment of early RA is within the first 3 months
Diagnosis of rheumatoid arthritis is based on the clinical presentation, radiograph findings and serological analysis What s the classification system for diagnosis RA? What are the four categories measured?
Classification system is the ACR and EULAR
Rheumatoid arthritis classification criteria
Four categories measured
* Joint involvement
* Serology
* Acute phase reactants
* Duration of symptoms
According to the ACR and EULAR Classification * What is look for in joint involvement? * What is tested for in serology? * What acute phase reactants are measured? * What duration is significant?
* Joint involvement - swelling or tenderness of joints +/- imaging evidence
* Serology - rheumatoid factor and/or anti-cyclic citrillunated peptide (anti-CCP)
* Acute phase reactants - ESR and/or CRP raised
* Duration - >/= 6 weeks
What is the score needed in the ACR/EULAR classification for a diagnosis of RA?
A score of greater than or equal to 6 out of a possible 10 is diagnostic of rheumatoid arthritis
What are three clinical features of rheumatoid arthritis? (how long is the prolonged stiffness)
* Morning stiffness greater than 30 minutes (relieved by exercise)
* Symmetrical, swollen, painful joints
* Involvement of the small joints of the hands and feet
What test can be done to test for synovitis? (involves the metacarpophalngeal (MCP) and metatarsophalngeal (MTP) joints)
Compression test (aka Gaenslen’s squeeze test) can be done to test for synovitis
Gaenslen’s test (GT) positivity is characterized by tenderness upon lateral compression (squeezing) of the metacarpophalangeal (MCP) or metatarsophalangeal (MTP) joints
Is monoarthritis a common feature of rheumatoid arthritis? What is carpal tunnel syndrome? What causes the compression?
Monoarthritis is not a common feature of rheumtoid arthritis
Carpal tunnel syndrome is where there is compression of the median nerve under the flexor retinaculum (fibrous tissue forming the carpal tunnel) of the hand
Compression is due to the swelling of a tendon or tissue in the carpal tunnel
What is the type of rheumatoid where it is intermittent and the joint is the same before and after the episode? What percentage of this type of rheumatism go on to have RA?
Palindromic rheumatoid arthritis - recurring mono-polyarthritis of various joints 50% of palindromic RA go on to have rheumatoid arthritis
What are the systemic effects of rheumatoid arthrtis?
Systemic effects (constitutional symptoms) - weight loss, night sweats, cachexia (weakness and wasting of the body due to chronic illness)
In RA, there can often be a common swelling on the ulnar aspect of the hand. Which tendon is swollen here? It is usually this tendon that is the first to rupture in Vaughan Jackson syndrome
It is usually the extensor carpi ulnaris tendon which is inflamed causing a swelling - this is known as extensor tenosynovitis (inflammationn of the synovium around the extensor tendon) - it often presents as a painful swelling on the ulnar dorsal aspect of the hand
What are the two auto-antibodies raised in rheumatoid arthritis? How sensitive are the two antibodies when testing for RA? Which antibody is more specific?
Rheumatoid factor and anti-CCP antibodies are raised in rheumatoid arthritis
Both antibodies are approx 70% sensitive for the condition
* (proportion of people who correctly identified as positive over those who actually have the disease)
Anti-CCP is more specific for RA (90-99% specific)
* (proportion of people who correctly identified as negative over those who do not have the disease)
If the antibodies are negative (RA and anti-CCP), is rheumatoid arthritis ruled out? What risk factor is associated with an increase in anti-ccp?
If antibodies are negative in RA, the disease is not ruled out
Smoking is associated with an increase in anti-ccp
What are the three imaging techniques mainly used in diagnosis / disease monitoring for RA?
Plain Xray of hands and feet
Ultrasound scanning MRI scans
What are the advantages of xray scans in rheumatoid arthritis? What are the disadvantages?
Xrays are cheap and reproducible
Soft tissue swelling also appears on the CXR
Disadvantage - absence of findings ine arly disease
What scan is useful for detecting synovitis in early disease and how? What is useful for detecting erosions also in early disease?
Ultrasound scan and MRI are useful as when there is synovitis, there is increase blood flow that is picked up
Ultrasound and MRI are also both more sueful at detecting bone erosions than conventional Xrays
What is the difference in what is seen on CXR in OA vs RA?
Osteoarthritis xray
- L – loss of joint space
- O – osteophytes
- S – subchondral sclerosis
- S – subchondral cysts
Rheumatoid arthritis xray
- L – loss of joint space
- E – erosions
- S – soft tissue swelling
- S – soft bones (osteopenia - bone thinning (less white))
The ACR/EULAR is used to confirm RA. What assessment is used to assess the activity of the disease? How many joints are taken into consideration in this scoring system?
Disease is activity is measured using the DAS-28 score
This is a composite of 4 domains and takes into account 28 different joints
What are the four domains of the DAS 28 scoring system that are considered?
* Tender joint joint
* Swollen joint count
* CRP/ESR
* Visual analogue score - patients own assessment of their disease progression
Gives a maximum score out of 10
The DAS 28 scoring system has four stages of disease activity What are the four stages and what score is needed for each stage?
Remission = 2.6
Low disease activity 2.6 < DAS 28 = 3.2
Moderative disease activity, 3.2 < DAS 28 = -5.1
High disease activity >5.1
When giving treatment for rheumatoid arthritis, what is the initial therapy?
NSAIDs + Steroids + DMARD should be started early as this improves long term outcomes
NSAID - non-steroidal anti-inflammatory drug
DMARD - disease modifying anti-rheumatic drug
How do each of the initial drugs work in managing the patient with RA? * How are the steroids given? * When should DMARDs ideally be started?
NSAIDs- good for symptom relief, no effect on disease progression
Steroids - rapidly reduce symptoms and inflammation - can be given intra-articular if few joints involved or oral
DMARDs - 1st line and should be ideally started within 3 months of persistent symptoms
What are the first, second, third and fourth line DMARDs that are typically given?
* First line - methotrexate
* Second line - sulfasalazine
* Third line - hydroxychloroquine
* Fourth line - leflunomide
Typically would trial for 3 months before changing or adding another medication
Which DMARD is typically prescribed for palindromic rheumatoid arthritis?
Typically hydroxychloroquine is prescribed for palindromic RA
What score is required for a patient to be eligible for biological therapy to treat the rheumatoid arthritis? What are the other requirements?
DAS 28 score of >5.1 - therefore high disease activity is required for biological therapy
The patient must have a high disease activity DAS 28 score despite adequate trial of at least 2 DMARDs
What are the most commonly used biological drugs for RA? Give 2 examples What is given in combination with the biological agent?
The most commonly used biologics are anti-TNF alpha drugs, all of which are given by injection.
* eg inflixamab, etanercept, adalimumab
Methotrexate is usually given in combination with the biological agent
What steroid is usually used in rheumatoid arthriits? What are some of the side effects that can be caused by steroids?
If intra-articular injections - methylprednisolone
If oral steroids - prednisolone
Side effectts
* Increased risk of osteoporosis - leading to wedge fractures
* Delay in wound healing
* Striae (stretch marks)
* Bruising
* Cushing’s
* DIabetes
What is the primary aim of treatment in rheumatoid arthritis? Which DMARD is not an immunosuppresant and therefore may be able to be used during pregnancy?
The primary target in RA should be a state of clinical remission
Sulfasalazine may be able to be used in pregnancy
