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Clin Med - MSK > Lecture 2 - Arthritis > Flashcards

Lecture 2 - Arthritis Flashcards

1
Q

Arthritis

A

disorder of the joint

can be limited to the joint or associated with systemic disease

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2
Q

1 in ___ people have arthritis

A

5

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3
Q

Oligoarthritis

A

< 5 joints involved

Monoarthritis - 1 joint
Polyarthritis - many joints involved (> 5)

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4
Q

Which arthritis are considered inflammatory?

A

RA
gout
spondylarthropathy
septic arthritis

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5
Q

What are the two types of non-inflammatory arthritis?

A

osteoarthritis
or
mechanical injury (like school trauma)

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6
Q

What are the different types of spondyloarthropathy?

A

Chron’s and UC related arthritis
Ankylosing spondylitis
Reactive arthritis
Psoriatic arthritis

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7
Q

How does the pain differ between inflammatory and non-inflammatory arthritis?

A

inflammatory: worse in AM >45min

non-inflammatory (OA): worse in PM <45 min

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8
Q

Which type of arthritis is more likely to have warmth and erythema?

A 
inflammatory arthritis (RA) 
Elevated ESR and CRP and serologic markers also present
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9
Q

How does the WBC level in the synovial fluid differ between inflammatory and non-inflammatory arthritis?

A

inflammatory: >2000/mm3

non-inflammatory: <2000/mm3

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10
Q

When do you get xrays for pts with joint pain?

A

OA: may be used at time of dx but not necessary

RA: you need to get xray at EVERY visit to assess progression of dz

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11
Q

What labs are done when working up and dx arthritis?

A 
inflammatory markers ESR/CRP 
serologic work up rheumatoid factors 
anti CCP antibodies 
HLA b27
synovial fluid analysis
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12
Q

Normal synovial fluid analysis

A

clear
transparent
<200 WBCs
<25% PMNs

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13
Q

Non inflammatory synovial fluid analysis

A

yellow
transparent
<2000 WBCs
<25% PMNs

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14
Q

Inflammatory arthritis synovial fluid analysis

A

cloudy
yellow
200-50,000 WBCs
>50% PMNs

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15
Q

Infectious arthritis synovial fluid analysis

A 
cloudy 
yellow
>50,000
>50%
positive culture
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16
Q

Risk factors for OA

A 
obesity 
female
advanced age 
genetic factors 
occupation 
sports
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17
Q

What is the most common type of arthritis?

A

osteoarthritis (non-inflammatory)

degenerative arthritis

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18
Q

Which joints are most commonly affected in OA?

A 
DIP joint 
knees (weight bearing joints) 
hips 
lumbar/c-spine 
IP joint of the first toe
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19
Q

Bouchard’s Nodes

A

seen in OA

found at the PIP joint

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20
Q

Heberden’s Nodes

A

seen in OA

found at the DIP joint

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21
Q

What do you see on xray with OA?

A

joint space loss

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22
Q

EOA

A

erosive osteoarthritis

radial/ulnar instability (not commonly seen in regular OA)

on Xray you will see “seagull” pattern d/t central erosions

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23
Q

How do you dx OA?

A

clinically
classic sxs
progressive pain that is worse with activities

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24
Q

Classical dx of OA

A

peripheral joints
persistent usage - related joint pain in one or few joints
age >45 years
morning stiffness <30minutes

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25
Q

What is the first step of OA treatment?

A

physical exercise –strengthen the muscles

ideally they lose >7.5% of body weight

if sxs do not improve for mild sxs start on NSAIDs, capsaicin

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26
Q

What is the treatment for moderate to severe OA?

A

low dose NSAIDs, duloxetine, intraarticular steroid, assisted devises, injection every 4 months

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27
Q

What is the appropriate way to use a cane?

A

height should be at the level of the wrist
hold it with slight flexion at the elbow
should be used on the opposite side of the affected limb

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28
Q

Rheumatoid arthritis

A

chronic, systemic, inflammatory disorder

typically symmetrical and usually leads to destruction of joins d/t erosion if untreated

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29
Q

What happens to the synovium in RA?

A

hypertrophied –can become irreversible if left untreated

30
Q

Who is more likely to affected by RA?

A

women

31
Q

What is the typical presentation of RA?

A

polyarticular disease with gradual onset

sxs include joint pain, swelling, warm, and prolonged stiffness

32
Q

Palindromic rheumatism

A

this is episodic, comes and goes on its own

if the pt has rheumatoid factors its probably just best to start treatment

30-60% may progress to RA

33
Q

If a pt comes in with joint pain in just one pain, what must you r/o?

A

tap it to r/o septic arthritis

34
Q

Which joints are commonly involved in RA?

A

C spine
MCP joint
wrists
feet

35
Q

Boutonniere deformity

A

see in RA

flexion at PIP and extension at DIP

36
Q

Swan-neck deformity

A

seen in RA

hyperextension of PIP and flexion at DIP

37
Q

A pt with known arthritis is pre-op, what must you do?

A

neck xrays MUST be done in RA pts before they get intubating

38
Q

RA can be systemic, what manifestations might you see?

A

Heart disease is MC: pericarditis, myocarditis, increased risk of CAD

be sure to manage their DM, HTN, and cholesterol

Bone loss 
Rheumatoid nodules
Anemia
Sjogrens syndrome
Lung disease 
Eyes
Lymphomas
39
Q

Rheumatoid factors

A

present in 70-80% of RA cases

also seen in other autoimmune diseases like lupus

40
Q

Anti-CCP antibodies

A

highly specific for RA

low titers can be seen in smokers

41
Q

Marginal erosions

A

seen on hand xrays in RA

42
Q

Subluxation

A

seen in long standing RA

partial dislocation of the vertebrae

43
Q

When is MSK US done?

A

determine degree of damage

good for early detection of erosions

44
Q

What is the treatment goal for RA?

A

early recognition of disease

goal of remission or low disease activity

45
Q

DMARDs

A

disease modifying anti-rheumatic drugs

traditional vs biologics

Traditional:

  • Methotrexate
  • Sulfasalazine
  • Hydroxychloroquine
  • Leflunomide
  • use of triple therapy

Biologics:

  • Anti TNF therapy
  • T cell targeted therapy
  • B cell targeted therapy
  • Jak Kinase inhibitors
46
Q

Before treating someone for RA, what must be done?

A

CBC
C-reactive protein
Hep B/C test
TB testing

47
Q

Methotrexate

A

Conventional DMARDs

2.5mg tablets (take like 6) once weekly –at the same time every week

these pts need to be put on folic acid 1mg daily

Avoid EtOH

monthly CBC, CMP

Contraindication: pregnancy
MUST BE STOPPED 3 months prior to CONCEPTION

MTX can be continued in the perioperative period

48
Q

Can MTX be used in pregnancy?

A

NO

must be stopped 3 months prior to conception

49
Q

HCQ

A

Hydroxychloroquine

usually used in combo therapy
taken daily

be sure to get a baseline EYE exam for all these pts d/t retinal toxicity

50
Q

Sulfasalazine

A

used in triple therapy

500 mg daily, weekly titration
use with extreme caution in renal and hepatic impairment

contraindication: pregnancy/breast feeding –risk of kernicterus in newborn, NTD

SE: oligospermia (reversible), skin rash, HA

51
Q

Leflunomide

A

10-20mg daily
monthly CBC monitoring
NOT to be used in young pts

Contraindicated in pregnancy

52
Q

Triple therapy in RA

A

MTX + HCQ + Sulfasalazine

53
Q

What needs to be monitored for pts on TNF -inhibitors?

A

baseline CBC and CMP
Hep B/b
TB testing! (can cause re-activation of TB)

live vaccines should be given before the onset of tx

contraindicated in heart failure pts (TNF is used in heart remodeling)

54
Q

Pts with MS and RA should not be given which biologic?

A

anti TNF d/t risk of demyelination

55
Q

Rituximab

A

B cell targeted therapy

IV infused every 6 months

56
Q

How do steroids play a role in RA treatment?

A

as a bridge therapy until the MTX or biologics begins to take affect (about a month)

remember that when on steroids pts need to be on daily calcium and vitamin D

57
Q

Pre-op evaluation for RA

A

C-spine X-ray (both flexion and extension)

NSAIDs: usually advised to stop
Traditional DMARDs: should be continued
Biologics: for elective procedures - surgery should be scheduled at the end of cycle (d/t increased risk of infection) –they can be restarted 2 weeks after surgery

58
Q

For pts on biologics, if they need a live vaccine, what are the recommendations?

A

stope the drugs 1 month prior and 1 month after

59
Q

SpA

A

spondylarthritis

a form of chronic inflammatory arthritis

term used for a family of disorders that can invovled spine or peripheral joints

60
Q

AS

A

ankylosing spondylitis

involving the spine
MC in men

61
Q

With which arthritis do you see genital lesions?

A

reactive arthritis

62
Q

What are distinguishing features of SpA?

A 
inflammation of axial joints 
asymmetric oligoarthritis (exp. LE) 
Dactylitis (sausage digits) 
Enthesitis (inflammation at sites of ligamentous or tendon attachment to bone)
63
Q

Enthesitis

A

seen with SpA

inflammation around the site of insertion of ligaments, tendons, joint

64
Q

Nail pitting is seen with….

A

psoriatic arthritis

65
Q

Syndesmophytes

A

seen on spine xrays in pts with SpA

66
Q

Pencil in cup

A

abnormality

DIP join involvement in psoriatic arthritis

67
Q

What is the treatment of SpA?

A

NSAIDs: use maximum effective dose on regular basis to achieve remission

Sulfasalazine/methotrexate - for peripheral arthritis only

Biologics
Anti -TNF (Humera, Remicade)
Anti IL -17 A monoclonal Antibody (Secukinumab)
Antibody against IL-23/IL-1y axis (Ustekinumab)

68
Q

Dactylitis is a feature of…

A

psoriatic arthritis

69
Q

Rheumatoid arthritis spares which joints?

A

DIP

70
Q

Which drugs for RA can be used in pregnancy?

A

Hydroxychloroquine

71
Q

Before starting TNF inhibitor, what should be checked?

A

TB and hepatitis

72
Q

TNF inhibitors should be avoided in which pts?

A

Heart failure

Clin Med - MSK (10 decks)

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