Year 2 - Week 5 - Stiff Hands Flashcards
Pain and stiff joints in hands, especially in the morning. What are the possible diagnoses?
Osteoarthritis
Rheumatoid arthritis
Peripheral spondyloarthropathy
Haemochromatosis
What symptoms can present with RA?
Symmetrical inflammation of the small joints of hands and feet
Pain - worse at rest or inactivity
Often morning stiffness - worse for first 30-60mins
Boggy swelling around the joints
Can get nocturnal pain, acute or subacute onset
Systemic features - malaise, fatigue, fever
Can be FHx
Ulnar deviation often associated with later progression of the disease
What symptom is usually associated with psoratic arthritis?
Hx of psoriasis
If you suspect a P has RA - what should you do?
Persistent synovitis of unknown cause - Refer to rheumatology for evaluation within 3 weeks
Refer urgently (3 days) - if small joints of hand/feet are affected, more than one joint is affected, or the P has waited more than 3 months since the onset of symptoms to seek medical advice.
Also do bloods.
What blood tests should you perform for RA?
FBC
Inflammatory markers - CRP & ESR
Rheumatoid factor
Poss anti-CCP
U&E
LFTs
Why is it good to check liver and kidney function in a possible diagnosis of RA?
To get baseline values of how they are performing before drugs for RA are started - which can affect the liver and kidney function.
What is the goal of secondary care for RA?
Achieve remission or, if not possible, to minimise disease activity
What is first line treatement for RA?
DMARDs - disease modifiying anti-rheumatic drugs
Name two conventional DMARD drugs
Methotrexate
Sulphasalazine
What treatment is given if Ps do not respond to DMARDs adequately?
Biological DMARDs (Biologics)
Once a patient is started on DMARDs and is considered stable - they can be transferred back to GP for routine care - what is this called?
Shared Care Agreement
What are the benefits of shared care agreements?
Reduce burden on secondary care
Help Ps be more active in their own care
What do shared care agreements outline?
What monitoring is required
What to do if abnormal results are received
What side effects to monitor for
When to stop/withhold treatment
What is it called when Ps experience symptoms even though they have been in remission?
Flare
What drugs are used to manage flares?
NSAIDs
Corticosteriods (oral or intra-articular)
Which vaccinations should RA Ps be offered?
Influenze
Pneuomcoccal
High risk - also Hep B
Can Ps with RA have live vaccinations?
No (except shingles - this may be ok)
What is the risk of CVD compared to general pop for Ps with RA?
1.5x higher
Which scoring system assessed CVD risk?
QRISK scoring system
For RA Ps - which RF put them at greater risk of developing CVD?
Had RA for 10+ years
Have extra-articular manifestations
Are RF or anti-CCP positive
Used corticosteriods or NSAIDs
What is the link between RA and skin cancer?
Ps with Ra - inc risk (x2 of gen pop) of developing SCC and 1.2x risk of BCC
Which skin cancer risk increases if Ps take anti-TNF meds?
Greater risk of SCC (not BCC)
What is the link between RA and mental health?
Approx 40% of Ps with RA get depression and 20% anxiety
Ps with these symptoms are more likely to have worse disease control
What should be discussed at annual review with RA patients?
- Flares
- Vaccinations
- CV Risk
- Mental Health
- Skin Cancer review
- Drug concordance
- Side Effects
- Monitoring
- Risk of osteoporosis
What is spondyloarthritis?
Another inflammatory arthritis - less common
What are the symptoms of spondyloarthritis?
Axial symptoms - inflammatory back pain
Peripheral symptoms - psoratic arthrtisi, reactive arthritis, enteropathic arthritis
What are the extra-articular manifestations of SA?
Uveitis
Psoriasis
Enthesitis
Dactylitis
Which gene is SA linked to?
HLA-B27
How many joints does psoratic arthritis affect?
Can be one (monoarthritis)
Can be a few (polyarthritis)
How many joints does psoratic arthritis affect?
Can be one (monoarthritis)
Can be a few (polyarthritis)
What percentage of Ps with psoratic arthtiris have Hx of skin psoriasis?
80%
What percentage of Ps with skin psoriasis will develop psoraiatic arthritis?
20-30%
What are psoriatic nail changes?
Pitting
Onchyolysis
What percentage of Ps with psoriatic arthritis will have nail changes?
90%
What does ethesitis affect?
The Achilles tendon & plantar fascia
What does ethesitis affect?
The Achilles tendon & plantar fascia
What can psoriatic arthritis cause in the eye?
Conjunctivitis
Uveitis
What should all Ps with skin psoriasis have each year?
Annual screen for psoriatic arthritis
What is used to screen for psoriatic arthritis?
PEST Screening Questionnaire (Psoriasis Epidemiology Screening Tool)
On the PEST tool - how many questions do you have to answer yes to in order that it is likely you have psoriatic arthritis?
3 or more
What does reactive arthritis usually present as?
Monoarthritis or a knee or ankle, or axial spondyloarthritis
What are both psoriatic arthritis and reactive arthritis associated with in terms of fingers or toes?
Dactylitis (sausage fingers/toes)
When does Reactive Arthritis usually occur?
Which infections usually pre-empt it?
1-6 weeks after infection
Usually GI infections (Campylobacter, Salmonella, Shigella) or urogenital (Chlamydia trachmatis, HIV).
What are the classical symptoms of reactive arthritis? What are they called?
Arthritis
Urethritis
Conjunctivitis
(Cant see, cant pee, cant climb a tree) - called Reiter’s syndrome
However not all Ps have all three.
How does enteropathic spondyloarthritis present?
Assymetrical oligoarthritis - affecting lower limbs - emerging after onset of IBD
Whcih diseases is enteropathic spondyloarthritis more common in?
Crohns (more than UC)
Which gene is linked to enteropathic spondyloarthritis?
HLA-B27
What are the symptoms of osteoarthritis?
Affects small joints of the hands = pain
Stiffness but normally less pronounced than RA and lasts <1 hour in the morning
Pain / stiffness is exacerbated by activity
What is the progression of OA?
Normally gradual onset and progressive deterioration - but can get transient inflammatory flares as well.
What is the gold standard for diagnosis of osteoarthritis?
X-Ray
What are the criteria for a diagnosis of OA without X-rays?
> 45 years
Activity-related joint pain
No joint stiffness or it lasts <30 mins
What are the typical sites affected by OA?
Neck
Lower back
Thumb base
Hip
Fingers
Knee
Toe base
What is an important differential to consider in place of an OA diagnosis?
Inflammatory arthritis
What is the main treatment for OA?
Exercise and physio
There are no disease modifying drug therapies for OA . Which drugs can be used to minimise pain?
NSAIDs - oral and topical
Capsaicin (topical)
Paracetamol
Opiods
Prednisolone (oral)
Which is more effective in reducing pain in OA - paracetamol or NSAIDs?
NSAIDs
What drug is the first line treatment for OA?
Topical NSAIDs
What drug is used when topical NSAIDs are ineffective?
Oral NSAIDs
What are the potential side effects of oral NSAIDs?
GI, renal, liver and CV toxicity
Asthmatic Ps - may reduce FEV
Can inc risk of miscarriage and delay labour
What should be prescribed alongside oral NSAIDs?
PPI
What is capsaicin made from?
How does it work?
What is it used for?
What are its side effects?
Chilli peppers
Though to disrupt pain signals reaching the brain
Knee and hand osteoarthritis
SE - can cause skin irritation but no systemic side effects
When should opioids be used in OA?
Generally not recommended.
NICE - weak opiods should be used for short-term relief when other treatments are ineffective.
Strong opiods should not be used.
How long do intra-articular corticosteriod injections last for?
When are they recommended?
2-10 weeks of benefit
Recommended when other treatments are infective - to facilitate therapeutic exercise
Name two alternative treatments for OA
Glucosamine
Chondroitin
Do glucosamine and chondroitin work?
Little evidence that they are more beneficial than placebo
How is arthritis affected during pregnancy?
Often symptoms improve during pregnancy, but then many experience a flare after birth
Which RA medications are contraindicated during pregnancy?
DMARDs = can be tetrogenic - discuss before getting pregnant
Biologics - best to stop during pregnancy
Which arthritis can occur in children?
Juvenile idiopathic arthritis
Is paracetamol recommended for OA?
No - little evidence for its efficacy
Which joints are predominantly affected by OA?
Hips
Knees
Small joints of the hands
Which lifestyle factor can increase the chances of developing OA?
Obesity
What type of gait do Ps with OA of the hip or knee sometimes have?
Antalgic gait - try to avoid putting pressure on the sensitive area
What nodes of the hands are sometimes seen with OA?
Heberden’s nodes - on DIPJ
What is the normal range of movement in the hip for the following?
- Flexion
- Abduction
- Adduction
- Internal rotation
- External rotation
- Extension
Flexion - 110-120 degrees
Abduction - 30-50 degrees
Adduction - 20-30 degrees
Internal rotation - 30-40 degrees
External rotation - 40-60 degrees
Extension - 10-15 degrees
How long should stiffess in OA last?
Approx 30mins - much longer then start thinking of differentials
Which conservative measures should be told to Ps with OA?
Weight loss and exercise
Which is the first drug to try for pain relief from OA of the hip?
Paracetamol - although efficiacy is doubted
What is the first drug to try for pain relief from OA of knee?
NSAIDs
What are the risks of opioids and codeine?
Can make P drowsy and inc chances of a fall
If a P is on aspirin and has OA - should you prescribe NSAIDs?
No - NSAIDs make aspirin less effective and inc risk of GI bleeding
When should GP refer for joint replacement?
When P’s pain cannot be controlled, or their ability to function is persistently affected.
If a P does not want surgery, what other treatments can be suggsted?
Intra-articular injections of corticosteriod
What is the correct length of a walking stick?
From the flexor crease of the wrist to the ground - P must be in shoes and standing straight.
What age is the peak incidence of RA?
70
What is the ratio of incidence of RA between M and F?
F x2 more likely to get RA than M.
Answer the following questions for both RA and OA.
Age of Onset?
Joints Affected?
Association with Movement?
Stiffness?
Age of Onset -> OA = 50s+, RA = any age but peak 70
Joints Affected -> OA = Knees, hips and hands, RA = small joints of hands, feet, wrists and ankles
Association with movement -> OA = pain worsens with activity, RA = no association with movement
Stiffness -> OA = lasts less than 30 mins, RA = lasts > 30 mins
