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MSK > Clinical Aspects of RA and Approach to Therapeutics > Flashcards

Clinical Aspects of RA and Approach to Therapeutics Flashcards

1
Q

What is rheumatoid arthritis?

A
  • A chronic autoimmune systemic illness characterised by a symmetrical peripheral arthritis and other systemic features
  • It is one of the commonest chronic illnesses and may be associated with joint damage, disability and premature mortality
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2
Q

What are the 7 RA classification criteria?

A
  1. Morning stiffness
  2. Arthritis of 3 or more joint areas
  3. Arthritis of hand joints
  4. Symmetric arthritis
  5. Rheumatoid nodules
  6. Serum rheumatoid factor
  7. Radiographic changes
    SAVED UNDER RA CLASSIFICATION 1 and 2
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3
Q

What is the epidemiology of RA?

A
  • 1% pop.
  • F:M 3:1
  • Peak onset 40s-50s but can occur at any age >16
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4
Q

Describe the genetic aetiology of RA

A
  • Overall incidence of RA ~1% rises to 2-4% in siblings and 12-15% in monozygotic twins
  • Genetic contribution to RA estimated to be ~50-60%
  • Closest association with specific amino acid sequences at positions 70-74 of DRb1 (shared epitope)
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5
Q

What are the 2 environmental aetiological factors for RA?

A
  • Cigarette smoking

* Chronic infection e.g. periodontal disease

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6
Q

Describe the pathogenesis of RA

A

Synovitis

SAVED UNDER SYNOVITIS

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7
Q

What immunological investigations are used to diagnose RA?

A
  • Rheumatoid factor (IgG, IgM)

* Anti Cyclic Citrullinated Antibodies (anti CCP, ACPA)

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8
Q

What imaging investigations can be used to diagnose RA?

A
  • X-ray

* MRI

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9
Q

What are the symptoms of arthritis?

A
  • Pain
  • Stiffness
  • Immobility
  • Poor function
  • Systemic Symptoms
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10
Q

What are the clinical signs of arthritis?

A
  • Swelling
  • Tenderness
  • Limitation of Movement
  • (Redness)
  • (Heat)
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11
Q

What are some non-specific systemic features of RA?

A
  • Fatigue/lassitude
  • Weight loss
  • Anaemia
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12
Q

What are some specific systemic features of RA?

A
  • Eyes
  • Lungs
  • Nerves
  • Skin
  • Kidneys
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13
Q

What are some long-term systemic features of RA?

A
  • CVS

* Malignancy

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14
Q

What are some long-term systemic features of RA?

A
  • CVS

* Malignancy

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15
Q

What score is used to assess RA?

A
  • Disease Activity Score
  • DAS<2.4 represents clinical remission
  • DAS>5.1 represents eligibility for biologic therapy
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16
Q

What is the outcome of RA?

A

HISTORIC
•50% of patients dead or disabled within 20 years of diagnosis (1987)
•50% out of workplace within 2 years of diagnosis
•Life expectancy shortened by approx 7 years
2009
•75% of cases diagnosed during working life
•Approx 33% will have stopped working within 2 years
•Approx 50% will be unable to work due to disability within 10 years of diagnosis
•A person with RA will have, on average 40 days sick leave/year (compared with 6.5)

17
Q

What the treatments inflammatory arthritis?

A
  • Medicines
  • Injections
  • Therapies
  • Surgery
18
Q

What are the 4 therapeutic categories used to treat RA?

A

1) Non steroidal anti inflammatory drugs (NSAID)
2) Disease Modifying anti Rheumatic drugs (DMARD)
3) Biologics
4) Corticosteroids (oral, i-m, i-a)

19
Q

What are Disease Modifying Anti Rheumatic Drugs (DMARD)?

A
  • A group of structurally unrelated, typically small molecule drugs which have been demonstrated to have SLOW ONSET EFFECT on disease activity and retard disease progression
  • Traditionally, these have been associated with identifiable toxicity profiles and risk of occasional serious adverse event
20
Q

What are the DMARDs in use?

A
  • METHOTREXATE
  • Sulfasalazine
  • Hydroxychloroquine
  • Leflunomide
21
Q

What are the DMARDs are no longer in use?

A
  • Gold salts (i-m, oral)
  • Penicillamine - toxic
  • Others
22
Q

What is the approach to management of RA?

A
  • Early and aggressive intervention is the key to obtaining optimal outcomes in the management of RA
  • Effective suppression of inflammation will improve symptoms and prevent joint damage and disability
  • How early and how aggressive
  • Move from sequential monotherapy to combination (step up, step down and parallel)
23
Q

What is so special about methotrexate?

A
  • Effective, well tolerated (severe toxicity is rare) and cheap
  • Cornerstone of combination treatment (with DMARD and biologic)
  • People stay on it
24
Q

How are biologics used in arthritis?

A
  • Biologic DMARDs have been developed from improved understanding of immunology to target key aspects of inflammatory cascade
  • Typically these are large complex proteins which need to be given parenterally
  • Compared to traditional DMARD, they work rapidly and are generally well tolerated although with important toxicities e.g. infection and come at high cost
25
Q

Which biologics are used to treat RA?

A
  • TNFa inhibitors (x5)
  • IL-1 inhibitors (Anakinra)
  • Anti B Cell therapies (CD20, Rituximab)
  • Anti T Cell therapies (Abatacept)
  • IL-6 inhibitors (Tocilizumab, Sarilumab)
  • Oral kinase inhibitors (JAK inhibitors) (Baricitinib, Tofacitinib)
26
Q

How do DMARDs compare with biologic DMARDs?

A
  • They are much less complicated molecules

* Biologics much be given parenterally

27
Q

What are the issues with biologics?

A
  • Efficacy - enhanced response when used with methotrexate
  • Toxicity - Minor (e.g. injection site reaction), infection, ?malignancy
  • Cost - £9500 vs. £50
28
Q

How can corticosteroids be administered?

A
  • By mouth
  • IA (intra-articular) or IM injection
  • IV infusion
29
Q

What are the issues with using corticosteroids?

A
  • Short term benefits vs. long term toxicity

* Rarely appropriate as single drug therapy

30
Q

What blood test results may indicate RA?

A
  • Raised CRP and ESR
  • Positive RF
  • Positive anti CCP (cyclic citrullinated peptide) antibody
31
Q

How might you initiate RA treatment?

A

•Corticosteroids and a DMARD

can be moved up to dual DMARD therapy

32
Q

How do you keep monitoring RA?

A
  • DAS28
  • Monthly appointment
  • Monitoring blood tests
33
Q

Describe the MDT for early RA

A
  • Rheumatology Specialist Nurse
  • Rheumatology Occupational Therapist
  • Rheumatology Physiotherapist
  • Pharmacist
  • Clinical Psychologist
  • Podiatrist
  • Orthotics
34
Q

How might you assess a patient for treatment escalation to biologic therapy?

A
  • BCG scar/chest x-ray
  • Chronic infection screening - hep B and C, quantiferon test (for TB)
  • Varicella-zoster serology - biologic therapy would increase immunosuppression
35
Q

What are the risks of corticosteroid use?

A
  • CVS
  • T2DM
  • Osteoporosis
36
Q

What are the complications of RA?

A 
•Orthopaedic intervention
-Chronic synovitis
-Mechanical deformities
-Secondary osteoarthritis
-Poor function
-Pain 
•Extra-articular involvement
-Rheumatoid nodules
-Interstitial lung disease
-Vasculitis
•Cardiovascular risk
•Socio-economic
37
Q

How can functional impairment caused by RA be combated?

A
  • Special adaptive cutlery
  • Special footwear
  • Walking aids
  • Use of wheelchair for outdoors
  • Supportive family
  • Care package

MSK (28 decks)

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