Week 2 - Rheumatoid Arthritis Flashcards
what is the most prevalent seropositive arthropathy?
rheumatoid arthritis (RA)
what is RA?
autoimmune inflammatory symmetrical polyarthropathy which commonly affects the small joints of the hands and feet
where does RA affect?
usually small joints of the hands and feet but can affect larger joints (knees etc) as disease progresses
who is more commonly affected by RA?
women
most commonly peaks between 35-50
what increased risk of RA?
genetic factors account for 50% of risk
first degree relatives have 2-3X higher risk
describe the pathogenesis of RA?
immune response is initiated against synovium
inflammatory pannus forms which then attacks and denudes articular cartilage leading to joint destruction
tendon ruptures and soft tissue damage can occur leading to joint instability and subluxation
what can trigger RA?
smoking
infection
trauma
stress
how is RA diagnosed?
clinical presentation
radiography
serological analysis
what are the clinical features of RA?
symmetrical synovitis (doughy swelling) pain morning stiffness (>30 mins - 1 hr) sparing of DIP joints in hand
what are the early features of RA?
small joint synovitis
wrists, MCPs and PIPs affected
late features of RA?
deformities of the joint if aggressive or untreated
how can RA affect the spine?
atlanto-axial subluxation can be seen in longstanding disease which can result in cervical cord compression
how can RA affect the skin?
can cause rheumatoid nodules in 25% of RA patients
usually on extensor surfaces or sites of frequent mechanical irritation
how can RA affect the lungs?
pleural effusions
interstitial fibrosis
pulmonary nodules
how can RA affect the heart?
increases cardiovascular morbidity and mortality
how can RA affect the eyes?
keratoconjunctivitis sicca (dry eyes?)
episcleritis
uveitis
nodular scleritis
how is RA investigated?
autoantibodies - rheumatoid factor - anti CCP (more specific) raised CRP, ESR and plasma viscosity X ray/US
what is seen in X ray in RA?
often normal in early stages but can show
- peri-articular osteopenia (bone thinning)
- soft tissue swelling
later stages show periarticular erosions
what is the goal in RA treatment?
early and aggressive treatment
aim to commence DMARD therapy within 3 months of symptoms onset
what treatments are used for short term symptoms relief?
simple analgesia
NSAIDs
steroids - intramuscular/intra-articular/oral
name 4 DMARDs, which one is first line?
Methotrexate (first line)
hydroxychloroquinone
leflunomide
sulfasalazine
what are the risks with DMARDs? how is this managed?
they are immunosuppressive so can increase infection risk and suppress bone marrow
regular blood monitoring needed
what is used if DMARDs don’t work and what do they do?
biological agents
target different parts of the immune response
what is the most common biological agent used?
anti TNF
- e.g adalimumab, etanercept etc
what are the risks with biological agents?
they suppress immune response so increased infection risk
anti TNF also increases TB reactivation risk
how do patients qualify for biological agent therapy?
DAS28 > 5.1
2 DMARDs tried
what are the 4 domains of the DAS28 score?
tender joint count
swollen joint count
CRP/ESR
visual analogue score
what are the cut off points for DAS28 score?
<2.6 = remission
2.7 - 3.2 = low disease activity
3.3 - 5.1 = moderate disease activity
>5.1 = high disease activity
name some surgeries used in RA
synovectomy joint replacement joint excision tendon transfers arthrodesis (fusion) cervical spine stabilisation
