Final Rheum II Flashcards
(23 cards)
Describe the clinical features of RA
Polyarthropathy:
- multiple joints affected, usually in symmetrical distribution; typically the small joints of hands or feet (MCP most common; PIP; MTP)
- On palpation of the joints, there will be tenderness and synovial thickening, giving them a “boggy” feeling.
- Morning stiffness lasting more than 30 mins
- Joint swelling
- Cervical (but not lumbar) spine can be affected
- Knees, ankle, hips and shoulders
- Pain on palpitation
Muscle atrophy:
- may see ‘guttering’ between extensor tendons in hands due to wasting of the interossei muscles
Systemic symptoms
- myalgia
- fatigue
- low-grade fever
- weight loss
- low mood
TOM TIP: Rheumatoid arthritis very rarely affects the distal interphalangeal joints. Enlarged and painful distal interphalangeal joints are more likely to represent Heberden’s nodes due to osteoarthritis.
Name two other hand signs of RA (asides from swan-neck and Boutonniere deformities) [2]
Name a foot sign [1]
Ulnar deviation at MCPs:
- subluxation of the MCP joints with deviation of the fingers towards the ulnar bone due to dislocation of flexor tendons and disruption of extensor tendons.
Z-deformity at wrist:
- hyperextension of interphalangeal joint of thumb in association with carpal bone rotation and radial deviation as well as ulnar deviation at MCPs
- deformity to the thumb
Hammer toes:
- compensatory flexion of the toes due to weakening and subluxation of surrounding tendons.
Which factors indicate a worse prognosis in RA?
Poor prognostic features
* rheumatoid factor positive
* poor functional status at presentation
* HLA DR4
* X-ray: early erosions (e.g. after < 2 years)
* extra articular features e.g. nodules
* insidious onset
* anti-CCP antibodies
DAS28 is used to monitor RA; treat to target is the aim.
What DAS28 scores would indicate:
- disease remission [1]
- low severity [1]
- medium severity [1]
- high severity [1]
- disease remission: < 2.6
- low severity: 2.6 - 3.2
- medium severity 3.2 - 5.1
- high severity: > 5.1
Name this deformity seen in the hand associated with RA [1]
Describe the changes in hand position that occurs [2]
Describe the initial treatment plan for RA with MILD disease activity at initial presentation: not pregnant or planning pregnancy
1st Line: conventional DMARD:
- hydroxychloroquine - it is better tolerated and has a more favourable risk profile than other DMARDs
Consider: Corticosteroid
- Prednisolone
Consider: non-steroidal anti-inflammatory drug (NSAID)
- ibuprofen
NB: hydroxychloroquine: should only be considered for initial therapy if mild
BMJBP
Describe the MoA [1] and AEs [3] of MMF
MoA:
- Inhibits enzyme used for de novo purine synthesis - effects T & B cells
AEs:
- GI upset
- Infections
- Bone marrow suppression
What do you screen for prior to starting methotrexate; SSZ and LEF tx? [3]
- FBC; UEs; LFTs
- Viral serology screen
- Baseline CXR - for MTX as can cause PF
- Baseline BP for LEF
Describe the MoA and side effects of cyclophosphamide
MoA:
- Alkylating agent - cross links DNA strands, leading to cell death
Effects:
- Bone marrow suppression
- Bladder inflammation - hamorrhagic cystitis
- Infertility
- N&V
Describe some of the unwanted effects of blocking TNFa
TNFa is essential for granuloma formation, organisation and maintenance - risk of TB reactivation AND increased risk of infection
Autoimmune reactions:
- paradoxical psoriasis (new onset or worsening)
- drug induced lupus
- MS or optic neuritis
Allergic reactions
HF exacerbations
Blood abnormalities (anaemia; neutropenia)
Liver toxicity
Increased risk of malignancies
What should you screen for prior to anti-TNF tx? [4]
FBC ++
Serology for HIV, HBV & HCV
CXR and TB Elispot
Exclude infections, pregnancy, malignancy, NYHA Class III/IV and EF < 50%
Name an anti-TNF that can be used in pregnancy [1]
Certolizumab
Name an anti-TNF that might cause less chance of infection [1]
Etanercept
Name some side effects of JAK inhibitors [4]
Increased risk of serious infections - use in caution with > 65
Risk of MACE - caution with CVD
Malignancy - particularly increased risk of lymphoma and lunger cancer
Thrombotic events; GI side effects and anaemia
Describe the treatment pathway for RA
Describe the initial treatment plan for RA with MODERATE-SEVERE disease activity at initial presentation not pregnant or planning pregnancy
1st line cDMARD:
- methotrexate (primary option) with folic acid supplementation
- sulfasalazine (secondary option)
- hydroxychloroquine (secondary option)
- leflunomide (secondary option)
- bridged with corticosteroid - prednisolone for 2/3 months until methotrexate starts working
2nd line: Combination treatment with multiple cDMARDs
3rd line: bDMARDs
- etanercept (primary option)
- infliximab
- adalimumab
4th line: Rituximab
Double check with lecture
Which RA medication has a risk of reactivating TB? [1]
Etanercept and also
adalimumab, infliximab, golimumab and certolizumab
Describe the MoA of Leflunomide [1]
Name 5 side effects [5]
Leflunomide is an immunosuppressant medication that interferes with the production of pyrimidine.
Side effects:
* Mouth ulcers and mucositis
* Increased blood pressure
* Liver toxicity
* Bone marrow suppression and leukopenia (low white blood cells)
* Teratogenic (harmful to pregnancy) and needs to be avoided before conception in both women and men
* Peripheral neuropathy
TOM TIP: The unique side effects worth remembering are:
- Methotrexate [3]
- Leflunomide [2]
- Sulfasalazine [3]
TOM TIP: The unique side effects worth remembering are:
Methotrexate:
* Bone marrow suppression
* leukopenia
* highly teratogenic
Leflunomide:
- Hypertension
- peripheral neuropathy
Sulfasalazine:
- Orange urine
- male infertility (reduces sperm count)
TOM TIP: The unique side effects worth remembering are:
- Hydroxychloroquine [3]
- Anti-TNF medications [2]
- Rituximab [2]
Hydroxychloroquine:
- Retinal toxicity
- blue-grey skin pigmentation
- hair bleaching
Anti-TNF medications:
- Reactivation of tuberculosis
Rituximab:
- Night sweats
- thrombocytopenia
3-monthly monitoring for MTX, SSZ, and LEF includes..? [5]
3 monthly FBC; ALT; AST; ALP; Albumin; U&Es
A 30 year old woman presents for a routine antenatal scan at 24 weeks gestation. The fetus was found to have a slow heart rate of 90 beats per minutes. The mother had a history of SLE diagnosed 6 years ago and was found to have positive anti-Ro and anti-La in her blood stream.
Describe the complication the baby is likely to have developed? [1]
Congenital Heart Block (CHB) is a part of the Neonatal Lupus Syndrome due to transplacental passage of maternal anti Ro/SSA and anti La/SSB autoantibodies to the fetal cardiac tissue.
- It usually affects children born to women with SLE or Sjoren’s syndrome.
- In utero, CHB presents with fetal bradycardia between 18 to 28 weeks of gestation.
