ic16 rheumatoid arthritis management Flashcards
risk factors for RA
peak incidence 40-50 yo, more common in women
- family history
- genetics: HLA-DRB1 gene in MHC region = major genetic susceptibility
- smoking
what is the clinical presentation of rheumatoid arthritis?
1) pain
2) swelling
3) erythematous + warm
4) early morning stiffness >30min
5) SYMMETRICAL poly-arthritis usually with the small joints (MCP and PIP of hand; IP of thumb; wrist; MTP of toes)
also large joints (elbows, shoulders, hips, knees, ankles)
*MCP = metacarpal
*IP = intermediate phalanges
*PIP = proximal inter-phalanges
*MTP = meta-tarso-phalangeal
systemic symptoms of RA
1) generalised aching or stiffness
2) fatigue
3) fever
4) weight loss
5) depression
more present in disease onset >60 yo
what are the extra-articular complications of RA
eye: scleritis (inflammation of sclera), sjogren syndrome (dry eyes/mouth)
heart:** CAD**, AF, HF, myocarditis…
haematology: anemia, Felty’s syndrome (triad of RA, splenomegaly, granulocytopenia), lymphoproliferative disease (excessive production of lymphocytes)
lungs: pleural effusion (accumulation of fluid in the pleural space), interstitial lung disease
renal: glomerulonephritis, amyloidosis (amyloid build-up)
skin: rheumatoid nodules, neutrophilic dermatoses, skin ulcers
vascular: **rheumatoid vasculitis **(blood vessel inflammation), PVD
presentation of chronic RA
1) deformities
- swan neck, boutonniere
- z shaped thumb
- MCP subluxation (finger); MTP subluxation (toes)
- ulnar deviation
- rheumatoid nodules (elbow)
- popliteal cyst (fluid filled growth behind the knee)
2) loss of physical function and ability to carry out ADL
*subluxation = partial dislocation of joints with bones still touching.
lab findings for RA
1) autoantibodies (not all patients will have, only confirmatory if positive)
- RF
- anti-citrullinated peptide antibodies ACPA using anti-CCP assays
2) acute phase response (active disease/inflammation)
- ESR, CRP increase
3) FBC
- decreased Hg, increased platelets and WBC
4) radiology
- narrowing joint space, erosion, hypertrophic synovial tissue.
diagnosis of RA
AT LEAST 4 of the following
1) early morning stiffness ≥1h for ≥6wks
2) swelling of ≥3 joints for ≥6wks
3) swelling of wrist/MCP/PIP joints for ≥6 wks
4) rheumatoid nodules
5) positive RF and/or anti-CCP
6) radiographic changes
diagnosis of RA based on ACRA guidelines
≥6 out of 10 = confirmed diagnosis
when is disease remission
atleast 6 months with
boolean 2.0
- TJC , SJC ≤1
- CRP ≤1
- PGA using 10cm VAS ≤2cm
INDEXES
- SDAI ≤3.3
- CDAI ≤2.8
- DAS28 <2.6
NSAID use in RA?
normally used before diagnosis/confirmation of RA to manage pain and inflammation
DOES NOT ALTER COURSE OF DISEASE
GC use in RA
low dose bridging therapy
PO PREDNISOLONE <7.5MG/DAY
when initiating DMARDs or changing DMARDs
for up to 3 months (or when bDMARD/tsDMARD started)
with predefined tapering
use of continuous low dose therapy?
use for over 2 years
may be efficacious BUT risk of CV diseases, infections, fractures = not recommended
intra-articular GC use?
can be used to control monoarticular or oligoarticular flares via local injection
repeated q3 monthly
BUT no more than 2-3 times per year per joint due to risk of tendon atrophy and accelerated joint destruction…
what is the first line treatment for DMARDs
start csDMARDs to slow or prevent radiographic joint damage, improve physical function and lower ESR/CRP
For moderate to high disease
- MTX 1st choice
- Sulfasalazine or Leflunomide 2nd choice if MTX contra/not tolerated
For low disease activity
- can consider hydroxychloriquine without poor prognostic factors and other three are contraindicated
STARTED ASAP
frequency of disease monitoring
every 1-3 months
treatment should be adjusted if no disease improvement in 3 months and remission not reached by 6 months
what are poor prognostic factors
high disease activity (DAS28>3.2, SDAI>11, CDAI >10)
high ACPA or RF
high CRP
high TJC or SJC
presence of early erosions
failure of ≥2 csDMARDs
if treatment failure to csdmard?
if no poor prognostic factor
= consider adding another csDMARD or changing to a new csDMARD (can consider triple therapy)
if poor prognostic factor
= add bDMARD (1st choice)
= add tsDMARD (last choice)
MTX dose? + folic acid dose?
initiation: 7.5mg once weekly
increase 2.5-5mg/week every 4-12 weeks OR target 15mg/week in 4-6 weeks
max 25mg per week
ADD ON folic acid 5mg once weekly, taken the day after MTX dosing
sulfasalazine dosing
initiate 500mg OD-BD
increase by 500mg per week
maintenance = 1g BD
max 3g/day
hydroxychloroquine dosing
200-400mg in one-two divided doses
max 5mg/kg/day
leflunomide dosing
100mg/day for 3 days (loading dose)
and
20mg/day maintenance dose
dose adjustment for methotrexate
if AST/ALT >3xULN = 75% of dose
if CrCl 30-50ml/min = 50% of dose
if CrCl <30min/min = avoid use
it is 80% renally excreted unchanged
