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Flashcards in Rheumatoid arthritis Deck (19)
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1
Q

How does RA typically present?

A

Symmetrical swollen, painful snd stiff small joints in the hands and feet.
It is worse in the morning.
Can fluctuate and larger joints may become involved.

2
Q

What are the less common presentations of RA?

A
  • Sudden onset, widespread arthritis
  • Recurring mono/polyarthritis of various joints (palindromic RA)
  • Persistent monoarthritis (often hip, shoulder or knee)
  • Systemic illness with extra-articular symptoms e.g. fatigue, fever, weight loss, pericarditis, pleurisy but initially few joint problems (more common in men)
  • Polymyaligic onset - vague limb girdle aches
  • Recurrent soft-tissue symptoms e.g. frozen shoulder, carpal-tunnel syndrome, de Quervain’s tenosynovitis
3
Q

What is the epidemiology of RA?

A

Prevalence roughly 1% - increased in smokers
M 1:2 F
Peak onset in 50s 60s
Increased severity linked with HLA DR4/1

4
Q

What are the early signs in RA?

A

These are due mostly to inflammation without joint damage

  • swollen MCP, PIP, wrist or MTP joints. Symmetrical.
  • Tenosynovitis and bursitis
5
Q

What are the late signs of RA?

A

Joint damage and deformity

  • ulnar deviation of fingers
  • dorsal subluxation of wrist
  • Boutonierre and swan-neck deformities of fingers
  • Z deformity of the thumb
  • hand extensor tendons may rupture
  • foot changes are similar
  • large joints can be involved
  • atlanto-axial subluxation may compromise the spinal cord (rare)
6
Q

What are the extra-articular signs of RA?

A
  • nodules on elbows and in lungs
  • lymphadenopathy
  • vasculitis
  • fibrosing alveolitis
  • obliterative bronchiolitis
  • pleural and pericardial effusion
  • Reynaud’s syndrome
  • carpal tunnel syndrome
  • peripheral neuropathy
  • splenomegally (5%)
  • episcleritis
  • sceritis
  • scleromalacia
  • keratoconjunctivitis sicca
  • osteoporosis
  • amyloidosis
7
Q

What investigations should be undertaken in a case of suspected RA?

A
  • Rheumatoid factor (present in about 70%), a high titre is associated with severe disease, erosions and extra-articular disease
  • Anticyclic citrullinated peptide anti bodies antiCCP are 98% specific
  • Often anaemia of chronic disease
  • Increased platelets, ESR and CRP due to inflammation
  • X-ray
  • ultrasound +MRI
8
Q

What would you see on x-ray?

A

Show soft tissue swelling, juxta-articular osteopenia and decreased joint space. Later may see bony erosions, subluxation and complete carpal destruction

9
Q

What is at the advantage of US and MRI?

A

Can identify synovitis more accurately and have greater sensitivity in detecting bone erosions than X-ray

10
Q

Who should be tested for RA?

A

Those with 1 or more joints with definite swelling which is not better explained by another disease…

11
Q

What are the diagnostic criteria for RA?

A

Total A-D score, 6 or more out of 10 are diagnostic
A) Joint involvement: swelling or tenderness with imaging evidence
B) Serology: RF and antiCCP
C) Acute phase reactants: CRP and ESR
D) Duration of symptoms: Less or more than 6 weeks

12
Q

What are DMARDs and how are they used in RA?

A

Disease-Modifying Antirheumatic Drugs

They are the first line treatment. Ideally started within 3 months of persistent symptoms.
Can take 6-12 weeks for symptomatic benefit
Best results are often achieved with a combination:
Methotrexate + Sulfasalazine + Hydroxychloroquine (others include leflunomide and IM gold)

13
Q

What is a major side-effect of DMARDs?

A

Immunosuppression

Can be potentially fatal, resulting in pancytopenia, increased risk of infection and neutropenic sepsis

14
Q

What are the side-effects of the DMARDs?

A

1) Methotrexate - penumonitis, oral ulcers, hepatotoxicity
2) Sulfasalazine - rash, reduced sperm count, oral ulcers
3) Leflunomide - teratogenicity, oral ulcer, increased BP, hepatotoxicity
4) Hydroxychloroquine - irreversible retinopathy

15
Q

What are the other biological agents used and their nice guidance?

A

1) TNF-alpha inhibitors
- Infliximab, etanercept, adalimulab, certolizumabpegol, golimumab.
- All approved by NICE, usually in combination with methotrexate, as 1st line agents for active RA after FAILURE to respond to 2 DMARDs.
- Clinical response can be striking

2) B-cell depletion
- e.g. rituximab
- Used in conjunction with Methotrexate in severe active RA
- Indicated when DMARDs and TNF-alpha blockers have failed

3) IL-1 and IL-6 inhibition
- e.g. Toclizumab (IL-6)
- Used in conjunction with methotrexate for patients where both TNF-alpha and rituximab have failed
- Less clinical improvement that other agents

4) Disruption of T-cell function
- e.g. Abatacept
- Used infrequently for patients who haven’t responded to DMARDs, TNF-alpha blockers and rituximab

16
Q

What are the side-effects of the biological agents used in RA?

A
  • Serious infection
  • reactivation of TB and hep B
  • worsening heart failure
  • hypersensitivity
  • injection site reactions
  • blood disorders
  • Neutralising antibodies may decrease efficacy with infliximab and adalimumab
  • ANA and reversible SLE-type illness may evolve
17
Q

What is the typical management plan for RA?

A

1) Refer to rheumatologist

2) Disease activity measured using the DAS28. Aim is to reduce score to

18
Q

How should steroid be used in RA?

A

They should be used conservatively and mainly for ‘flares’
e.g. I.M. depot of methylprednisolone 80-120mg
Intra-articular steroids have a rapid but short term effect
Oral steroids e.g. prednisolone 7.5mg/day, may control difficult symptoms but long term use is not advised.

19
Q

What are the best predictors of disease impact on quality of life?

A

Depressive symptoms and pain.
These are better than disease markers or radiological damage.
Psychological intervention is often necessary as impact on life, relationships and work can be debilitating.