MSK - Rheumatoid arthritis Flashcards
contrast the outcomes of symptom- and disease-modifying RA treatments
key is early diagnosis and early intervention with disease-modifying anti-rheumatic drugs
(DMARDs)
DMARD: methotrexate is the gold standard and is first-line unless contraindicated
Biologic DMARD: indicated if inadequate response to DMARD
Symptomatic treatment (NSAID, corticosteroid): does not alter the course of RA
Describe a mechanical joint pain
- Chronic pain (months to years)
- Slowly worsening
- Worse with movement
- Improved by rest
- Not much swelling
- Little stiffness (10 – 15 minutes only)
Describe an inflammatory joint pain
- Acute or subacute pain
- May worsen quickly
- Better after movement
- Worse after rest
- Swelling often noticeable and may be prominent
- Stiffness may be prolonged (hours) and worse in the morning
Common Px of RA: • Morning stiffness >1 h, improves with use • Symmetric joint involvement • Initially involves small joints of hands and feet • Constitutional symptoms
Ix of a suspected RA (think of your 4 DDx)
- Rheumatoid factor
- Anti-citrullinated protein antibody (ACPA)
- Antinuclear antibody
- Parvovirus B19 antibody
To DDx: –Rheumatoid arthritis –Systemic lupus erythematosus –Psoriatic arthritis –Parvovirus associated arthritis
What are treatment goals in RA?
–Reduction of joint inflammation
–Prevention of joint damage
–Prevention of long-term RA-associated complications
–Avoid drug complications
–Maintenance of quality of life- decrease pain and stiffness
What (4) treatment strategies are there for RA?
–Pharmacological therapy •non-steroidal anti-inflammatory drugs •disease modifying anti-rheumatic drugs (DMARDs) •corticosteroids •analgesics
–Self-management - exercise, diet, joint protection, therapeutic compliance, education, personal empowerment
–Allied health intervention - physiotherapy, occupational therapy, orthotists etc
–Surgery
Describe NSAIDs use in RA
- mechanism
- Cx
- efficacy
–Mechanism - decrease prostaglandin production by cyclo-oxygenase inhibition. (2 iso-enzymes, COX-1 and 2)
–Complications - Peptic ulcers, mouth ulcers, enteropathy, rashes, hepatotoxicity, renal toxicity
–Efficacy - good short and long term efficacy in inflammatory arthritis
List (4) DMARDS (disease modifying anti-rheumatic drugs) & (4) biologic DMARDS
Disease modifying anti-rheumatic drugs (DMARDs) –Hydroxychloroquine –Sulphasalazine –METHOTREXATE –Leflunomide
Biologic DMARDs –TNF inhibitors – etanercept, adalimumab, infliximab, golimumab, certolizumab –B cell inhibitor – rituximab –Cell adhesion inhibitor – abatacept –Il-6 inhibitor - tocilizumab
Describe Corticosteroids use in RA (oral & intra-articular)
- Cx
- efficacy
Oral prednisolone
- efficacious
- but causes hypertension, weight gain, skin changes, hyperglycaemia, osteoporosis
Intra-articular steroids
- Efficacious in accessible joints
- few side effects if used intermittently
How do you measure disease ACTIVITY of RA to determine response to treatment?
–Patient and physician global assessment (often using a visual analogue scale)
–Swollen and tender joint count (on examination)
–Measures of inflammation (ESR or CRP)
How do you measure disease DAMAGE of RA to determine response to treatment?
- Bone and cartilage damage occurs more slowly than soft tissue swelling.
- MRI more sensitive than plain Xrays for detecting synovitis, cartilage damage, bone oedema and bone erosions.
- Xrays usually not required in early management
What is RA an independent risk factor for?
atherosclerosis and CV disease
RA is associated with increased overall mortality/morbidity from all causes: CV disease, neoplasm (especially lymphoma), infection.
What (6) types of joint deformities of digits can you get in RA?
Fingers:
- Boutonniere deformity
- Swan neck deformity
- Z deformity of the thumb
Toes:
- Claw toe
- Hammer toe
- Mallet toe
